does human performance analysis/technology (hpa/hpt) …...performance analysis/technology 2000-...

Does Human Performance Analysis/Technology (HPA/HPT) Have Anything to Offer for Peer Review and OPPE? Session Code: WE04 Time: 8:30 a.m. – 10:00 a.m. Total CE Credits: 1.5 Presented by: Mark Smith, MD

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Does Human Performance Analysis/Technology (HPA/HPT) Have Anything to Offer For Peer Review and OPPE?Mark A. Smith, MD, MBA, FACSOctober 8, 2014

Disclosures

HG Healthcare Associates- Partner

Morrisey Associates, Inc.- Chief Medical Consultant

University of California, Irvine- Clinical Assistant Professor of Surgery, Division of Vascular and Endovascular Surgery

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Agenda

• Peer Review Historically- Source of the Issue • What is Human Performance Analysis/Technology

• How can it be integrated into Peer Review and OPPE

• What is Human Error Analysis (HEA)- a subset of HPA

• How can it be integrated into Peer Review and OPPE

Agenda cont.

• Synthesis of HPA/T and HEA Approaches- Human Performance Improvement (HPI)

• Does it work?• How could contemporary HPT Improve Peer

Review and Performance Improvement• Summary• Questions

Idea- Action- Science

Most ideas have roots in antiquity

Humans have a propensity to translate ideas into action (process) before fully understanding them

Eventually, greater knowledge or fundamental science enters the picture

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Evolution of Evolution

Epicurus 340- 271 B.C.

Anticipated natural selection


Dr. Erasmus Darwin 1731-1802

Medical Practitioner who read Epicurus, promoted theories that anticipated natural selection in his work “Zoonomia” and anticipated evolution in his poetry.


Charles Darwin 1809- 1882 Scientifically developed theory of natural selection; waited 20 years before reporting it in 1858; On the Origin of Species published 1859

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Gravity of Gravitation

Brahmagupta 598- 670 C.E.

Indian mathematician

Discovered the mathematicalconcept of Zero

Described natural properties of gravity


Galileo Galilei1564- 1642

Force acting on falling objects independent of weight


Sir Isaac Newton1642- 1727

Laws of Motion and Universal Gravitation

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Albert Einstein 1879- 1955

Developed Special Theory of Relativity and General Theory of Relativity which contains conception of gravity as distortion of space-time continuum


Need for Unification Theory- Must Unify Relativity with Quantum Mechanics to truly answer reality of gravitation

Peer Review Historically-Source of the Issue

Evolution

– Al- Ruhawi, 9th Century Syrian, Ethics of the Physician

– Ernest Codman, MD, 1916, End Results System

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Evolution

– JCAHO, 1952, Peer Review

becomes a Standard

– Patrick v. Burget, 1986

– HCQIA, 1987, Peer Review Protections and Guidelines

– Florida Amendment 7, 2004, Patient's Right to Know About Adverse Medical Incidents


Gravity

– Peer Review is more than Case Review

– Lack of Standardization

– Events are mixture of system and individual performance

– Ensuring objectivity while using some subjective techniques

– Achieving Performance Improvement rather than Quality Assurance


Where are we at?

• Case Review still the prominent peer review method

• Since 2007, real impetus to be holistic in looking at performance dimensions- General Competencies

• Computer systems are putting improved data collecting systems into general use

• Defensible benchmarks are rare- Better national data bases are coming

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Where are we at?

• Science is applied to data collection methods but not necessarily to performance evaluation methods

• The causal connection between peer review and improved patient outcomes is somewhat fuzzy

• Strong push by society for greater transparency in the peer review process with legal liability undertones

• Peer Review has been left to physicians who are not fundamentally trained in the science of error evaluation

What is Human Performance Analysis/TechnologyThe International Society for Performance Improvement defines

Human Performance Technology as: � “...a systematic approach to improving productivity and

competence, uses a set of methods and procedures ‐‐ and a strategy for solving problems ‐‐ for realizing opportunities related to the performance of people. More specific, it is a process of selection, analysis, design, development, implementation, and evaluation of programs to most cost‐effectively influence human behavior and accomplishment. It is a systematic combination of three fundamental processes: performance analysis, cause analysis, and intervention selection, and can be applied to individuals, small groups, and large organizations."(ISPI, 2012)

What is Human Performance Analysis/Technology

Evolving set of theories and practices to evaluate and improve performance, both system and individual

Started out with training programs in the military beginning during WW II

Moved from instructional emphasis to performance gap analysis and action in the 1950’s to 1960’s

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W. Edward Deming- System of Profound Knowledge

1970’s- Started to systematize in many different fields yielding a number of approaches- Quality Assurance (QA). There started to be a separation of individual and system

1980’s- 1990’s- Further application of methods of QA systematically- Total Quality Management (TQM)

What is Human Performance Analysis/Technology2000- Today- Performance Improvement- changes

emphasis from identifying defects, potential or actual, to bettering the performance outcome

A secondary effect has been to create a unifying theory of performance by reuniting the system and the individual

HPA/HPT is being referred to today as Performance Improvement (PI)


Deming- contributed many ideas including:

– Errors are due to system issues 85- 90% of the time

– Should depend on statistical process control measurements

– Developed the Shewhart Cycle which we know as Plan-Do- Study- Act cycle.

– Quality= Results of Work Efforts/ Total Costs

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Thomas Gilbert (1927- 1995) Psychologist who is considered father of Human Performance Technology

Published in 1978Based on conclusion that trainingor knowledge improvement did notresult in corresponding behavior change or better outcomes


P= BxE P=Performance, B=Behavior, E= Environment

Led to ABC ModelAntecedents lead to Behavior lead to Consequences

Six variables of performance

– information, resources, incentives, knowledge, capacity, and motives

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So, what is HPA/HPT?

It is the field of practice devoted to attaining improved human performance using rational approaches

It derives from general systems theory and is a young discipline still coalescing out of many fields and perspectives


Characteristics of HPA/HPT (Geis, 1986)

– Human performance is lawful; therefore it can often be predicted and controlled

– It is empirical

– It can be applied to any human performance context

– It derives from many sources and is evolving

– The final model construct is yet to be stated


Tosti’s Principles of HPT

– Focus on results.

– Take a systemic view

– Make sure you provide value

– Work in partnership with others to produce the best result

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Measured Reported Results of Efforts in HPT

– Increase in profits

– Increase in productivity

– Increase in customer satisfaction

– Greater work efficiency

– Cost leveraging and total cost savings

What is Human Error Analysis (HEA)- a subset of HPA/HPT

Related to Human Reliability which utilizes a number of analytic techniques under the Human Reliability Analysis (HRA) mantle– Probabilistic Risk Assessment (PRA)

– Cognitive control based techniques

– Failure Mode and Effect Analysis (FMEA)

– Systems Analysis Programs for Hands-on Integrated Reliability Evaluations (SAPHIRE)

Same techniques for errors but needed model to apply them


Development of Human Error Models

Freud- Errors are an expression of unconscious drives

Contemporary thought-– Every human makes mistakes

– Errors are greatly influenced by environment

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Jens Rasmussen- Error System

Knowledge based - “Figuring out what to do next without the benefit of rules or experience”

(3/10) (problem-solving error)

Rule based - “Implementation of a sequence of a pre-established steps” (1/100) (decision- making error)

Skill based - “Repetitive behavior performed many times through experience” (1/1000) (monitoring error)

Based on Jens Rasmussen, 1974


Human error taxonomies

Errors of omission (not doing the required thing)– Forgetting to do it

– Ignoring to do it deliberately

Errors of commission (doing the wrong thing)– slips in which the operator has the correct motivation or

intention, but carries out the wrong execution

• Sequence or wrong order of execution

• Timing: too fast/slow

– errors based in erroneous expectations and schema.

(schema are sensory-motor knowledge structures stored in memory used to guide behavior: efficient and low energy)

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Why do events happen?

• Human errors • Equipment failures • External events start a chain of events

Holes don’t stop the event

Significantevents orinjuries

Based on Dr. James Reason, Managing the Risksof Organizational Accidents, 1997.

Event triggers System barriers to stop event(policies, training, self-checking, etc.)

How many barriers failed if there is a significant event? How many successful barriers are needed to prevent an event?

Generic Error Modeling System-GEMS (Reason, 1990)

The human factors analysis and classification system (HFACS)

Developed in 2003 by Wiegmann D.A. & Shapell S.A.looking for method to evaluate and reduce aviation

accidents.

Based on Reason’s Swiss Cheese model

Created a tool to assist in accident investigation and recommendations

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The human factors analysis and classification system (HFACS)

The human factors analysis and clasiffication system (HFACS)

What is Human Error Analysis (HEA)- a subset of HPA

What tools come out of this work?

Failure Mode and Effects Analysis (FMEA)Root Cause Analysis (RCA)Harm ScalesLeanLean Six SigmaCrew Resource ManagementProbabilistic Risk Assessment (PRA)Tracer methodology

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Evidence of Effectiveness of HPA/T and HEA Approaches

Results are all over the place

Generally, most organizations realize some benefit from application of these techniques

Measurement and analysis is in its infancy which can limit the evaluation process

How could contemporary HPT Improve Peer Review and Performance Improvement

Two general areas of applicability in Peer Review process

Creating objectivity in Peer Review

Creating meaningful evaluation that can lead to performance improvement

Creating objectivity in Peer Review

Standardizing rating scales

Applying error classification to cases

Harm Scales are useful for identifying relative significance of given care event

Probabilistic Risk Assessment can help to separate expected outcomes from areas of potential improvement

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Creating meaningful evaluation that can lead to performance improvement

Using a GEMS or HFACS system to inform an improved method of patient care error analysis- this in turn will lead to better PI action planning

Better understand the interaction of individual and system factors in the peer review analysis

Develop team based performance indicators and clarify individual responsibility within them

Summary

Science of HPA/HPT and HEA is evolving into unified theories of Performance Improvement

Application of these ideas and tools into the peer review process can improve both its objectivity and value of evaluation process

Can start to measure directly the effect of peer review on overall patient care delivery

Questions?

does human performance analysis/technology (hpa/hpt) …...performance analysis/technology 2000-...

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