Improving guideline compliance and healthcare safety using human factors engineering: The case of Ebola

Consistent compliance with evidence-based guidelines is critical for safe care. Yet, many patients in the United States (US) do not receive the recommended therapies. For example, healthcare-acquired infections can be largely prevented through consistent guideline compliance, but 1 of every 25 patients in US hospitals still develop these infections. ¹

Guideline compliance is also important for healthcare worker (HCW) safety. According to the Bureau of Labor Statistics, HCWs have one of the highest rates of work-related illnesses and injuries among all private industry sector workers, with 552,600 cases reported in 2016 alone. ² Increased compliance with recommended safety guidelines could prevent many work-related illnesses and injuries.

The methods and skills to develop guidelines, such as evidence reviews and clinical wisdom, differ from the methods and skills to ensure that the guidelines are properly used and translated into practice, such as Human Factors Engineering (HFE). HFE is a science that draws from broad theories and methodologies and employs a systems perspective to improve human performance. It focuses on improving both individual well-being and the overall system performance. To accomplish this, HFE experts work with clinicians to investigate the characteristics of an innovation or task using multiple methods (e.g. observations, focus groups, simulations, task analysis). Experts then develop training and instructional materials, and recommend how to redesign the work system to support the clinicians’ work. ³

The 2014 Ebola outbreak highlights the importance of guideline compliance for patient and HCW safety. This epidemic devastated large regions of West Africa, killing more than 11,000 people, a disproportionate number were HCWs. The two Texas HCWs who became infected with the virus while caring for an Ebola patient raised concerns about safety and preparedness in the US.

Compliance with recommended use of personal protective equipment (PPE) greatly reduces infection risk for HCWs. Consistent compliance has proven devilishly difficult, with compliance rates estimated to be under 50%.^4,5 The most common approach to improve HCW compliance has been to review published guidelines, discuss potential consequences of non-compliance, and provide post reminders to be vigilant and careful. This well-intended approach is minimally effective, failing to consider the complexities of human behavior and to draw upon proven HFE principles.

In response to the Ebola outbreak, the Centers for Disease Control and Prevention (CDC) issued guidelines for properly donning and doffing PPE to prevent Ebola virus infections among HCWs. ⁶ Complying with these guidelines is complex and consequential. One slip or lapse can lead to infection, as HCWs discovered in Texas. Warning clinicians to be careful and strictly follow guidelines is, by itself, not a reliable approach.

To provide more effective guidance, the CDC asked the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality to develop a web-based training program that complemented and clarified the newly published PPE guidelines. To develop the training modules, we formed a transdisciplinary team of 40 individuals with expertise in infection prevention, medicine, nursing, instructional design, videography, and HFE. The particularly innovative aspect of this training development effort was the systematic use of HFE principles and methods to help translate the PPE use guidelines into practice, given the realities and constraints of how care could be delivered for suspected or confirmed Ebola virus disease patients. In addition to experts across the Johns Hopkins University, other key stakeholders participated in the initiative, including the Association for Professionals in Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America, Miami University (Ohio), Salesforce Foundation, and Apple Inc.

The goal of the initiative was to help mitigate some of the safety risks associated with putting on and removing PPE. We pursued the following three interrelated HFE strategies to improve guideline compliance: reduce ambiguities associated with the guideline, (re)design the work system to make compliance with the guideline as easy as possible, and improve teamwork among HCWs caring for Ebola patients. The final web-based training program (http://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html?s_cid = cs_021) was viewed more than 320,000 times within one month of its release.

First, ambiguity is a common reason for guideline non-compliance. ⁷ Our team conducted an HFE expert review to assess usability and reduce ambiguity of PPE use. Such an assessment is guided by questions such as: Is part of the guideline unclear? Is the sequence of tasks clear? Who is responsible for what tasks? How and/or where a particular task be conducted? When is it acceptable to deviate from the guideline? Once ambiguities were identified, our team recommended revisions to the guideline and clarified these ambiguities through training. For example, we clarified when and how to put on boot covers with the training modules. Modules also provided clarifications on correct taping of the sleeve and inner glove when donning PPE to prevent separation and potential skin exposure, while also making PPE removal less risky. In addition, ambiguities in the roles of the team members were systematically identified based on HFE analyses, and then were clarified with the help of the training modules.

Second, we evaluated the work system to facilitate guideline compliance, exploring potential failure modes and developing strategies or actions to mitigate risks. For example, we addressed the following questions relative to the recent Ebola outbreak. What if the power air purifying respirator fails in the middle of patient care? What if the ante-rooms are not appropriately designed or configured for the critical doffing process? What if the HCW is extremely fatigued when doffing the PPE? Whenever possible, we included strategies to mitigate these risks in the web-based training modules. Although some mitigating strategies could be included in a training program, it would be better to remove the underlying risks from the work system using HFE principles and methods. Tools, technologies, and work processes should be redesigned to make it easy to follow the recommended guidelines and difficult to deviate from them.

Third, we sought to improve teamwork or the management of interdependencies between HCWs. Throughout the HFE analyses, it became clear that HCW safety relied heavily on core teamwork skills, in which a co-worker closely observed the donning and doffing processes. Since PPE made verbal communication difficult, we incorporated closed loop communication behaviors (wherein the receipt and understanding of critical communication is acknowledged by the recipient and original sender) into training. A high-priority risk in doffing PPE involved HCWs’ rushing the process to remove uncomfortable equipment, a risk-intense situation. Using the closed loop strategy, observers were able to pace the tasks, resulting in a more deliberate and mindful process. There were also several situations when protocol breaks with potentially dire consequences could occur, such as unconsciously wiping the forehead with an unclean hand immediately after removing head coverings. Guidance was developed to encourage observers to proactively identify these risks and provide real-time guidance and reminders to HCWs.

These brief examples highlight the need for broader implementation of HFE principles in healthcare. Similar to the Food and Drug Administration’s requirement for HFE evaluation of new medical devices, ⁸ clinical and public health guideline developers should also have HFE experts evaluate the usability of any new guidelines. Other safety-critical industries commonly use the HFE approach to ensure worker or customer safety. Each year 210,000 to 440,000 patients die and many more are injured because of preventable adverse events in US hospitals. ⁹ Healthcare remains one of the riskiest private industries in America with regard to worker safety. Many patient deaths and injuries can be prevented by using the science of HFE. Yet, most health systems lack HFE experts and few medical students or residents receive any training in the basics of HFE.

Our approach had several limitations. First, we acknowledge that, although the videos received many positive reactions from front-line HCWs and infection prevention and control experts and were viewed widely, this is not the same as systematically evaluating their impact on HCW behavior. Additional research is needed to demonstrate the effectiveness of these HFE-based videos on improving correct use of PPE. Another limitation was that, due to the urgency of the situation during the 2014 Ebola outbreak, the entire training development effort was completed in less than 15 days, including the HFE analyses, instructional design and development of the detailed training content, video recording, and posting on the CDC’s website. While we have identified many opportunities to improve the PPE use guideline within such a short time period, more in-depth research is needed to identify safety risks comprehensively, and to develop mitigating strategies through training and work system redesign. A third limitation was due to the nature of the guideline. The PPE use guideline has been developed primarily to protect HCW safety. Future work should investigate whether developing HFE-informed training for supplementing guidelines that primarily target patient safety would result in similar experiences.

Clear examples of HFE’s success in improving patient and HCW safety exist,^10,11 but HFE remains under-utilized in healthcare. ¹² This needs to change. Healthcare would be well served by supplementing evidence-based medicine with the science of safety, and by integrating HFE and systems-based improvement approaches into both public health and healthcare delivery.