1:30 - 3:00 pmSunday, September 29
LK 101
Leadership and influence: enhancing human performance in medicine
LK 101
Leadership and influence: enhancing human performance in medicine
Founder/CEO, Practicing Perfection Institute, Inc.
In spite of advances in technology, the safety and reliability of day-to-day medical operations continues to depend upon human interface and associated human behavior.   Any attempts to achieve long-term sustainable... Read more


In spite of advances in technology, the safety and reliability of day-to-day medical operations continues to depend upon human interface and associated human behavior.   Any attempts to achieve long-term sustainable performance improvement must therefore take this into consideration.  Unfortunately, methods by which to substantially and sustainably improve human behaviors continue to pose stifling and confusing challenges for most.
Ultimately, the human error challenge has three distinct elements:
(1) Human beings are fallible, which means on any given day, any person can make a mistake.  Even the best workers make mistakes.
(2) Despite organizational efforts to create, install, and reinforce both physical and administrative safety elements into structures and systems (known as barriers or defenses), few (if any) of these are perfect.  The “holes” in these defenses are referred to as landmines and/or human error traps, and create “setups” that promote both the frequency and severity of mistakes.
(3) All human motivation is internal.  External efforts to modify behaviors typically have short-lived results.

Human Fallibility
Numerous studies have been conducted regarding human fallibility and the statistical probability for human error in a variety of situations/circumstances.  These studies have been quite conclusive: give a human being enough opportunities, and he/she is likely at some point to make a mistake.

For example, when doing simple/routine tasks, it is generally accepted that a person will average one mistake out of every 10,000 actions taken. Elevate the complexity of the task or the stress level under which the action is taken, and this number can elevate to one out of ten.  In complex problem solving situations, the number can be as high as one out of two.

An interesting way to look at this is to consider the potential for error-free performance when working at a 99% accuracy rate.  On the surface, we would consider 99% to be a relatively high level of accuracy; however, when we do some very simple math (as shown in the equation below), we can see that at such an accuracy rate, the potential for completing a 100-step process 100% correctly is only 37 percent!

Barriers and Defenses
To safely and efficiently handle complex systems and operations, defenses (also known as barriers) are built into equipment design, systems, processes, and organizational structures and expectations. As shown below, there are four basic types of defenses, which provide layers of protection against accidents/events.

When it comes to the operation/maintenance of complex systems, the first layer of protection against an accident/event lies in Administrative Defenses.  These include medical policies, procedures, work instructions, and the requirements / guidance contained therein.

Physical Defenses include engineered safeguards, physical barriers and interlocks.  These defenses can be as simple as a handrail along a staircase, and as complex as integrated logics in control systems requiring multiple verifications prior to actual completion of a desired action/response.

Oversight Defenses are provided through management/supervision observation and engagement of workers and the tasks they are performing. These include both actual and implied expectations, as well as recognition (or the lack thereof) of specific behaviors.

Behavioral Defenses typically offer the last and final barrier between a human taking an action and an accident/event occurring.  Such defenses should include (1) a validation by the individual that an intended action is the correct action to take under the conditions present, and (2) that the actual action being taken is the action intended.

As shown in Figure 1, each of the layers of defense is typically less than perfect, meaning that there are “holes” in the intended protection.  These holes are created by two distinct vulnerabilities present within any system:
(1) Landmines (also known as Latent Organizational Weaknesses), and
(2) Human Error Traps

As indicated by arrows A, B, and C in Figure 1, these holes typically do not align, and even though one or more barriers may be penetrated, a subsequent barrier prevents an accident/event from occurring. Unfortunately, from time to time the holes do align, and this is typically when disaster strikes.

It is important to note that the last/final barrier is the human and his/her behaviors under the conditions present.  These behaviors can greatly influence the robustness and accuracy of action(s) taken / not taken, and play a significant role in the potential for an fatal accident/sentinel event to occur.

Landmines and Traps

The majority of time human error results in an accident/event, one or more things/conditions is generally present that has promoted the action taken and/or elevated the significance of its consequences.

Landmines are physical things present within procedures, documentation, labeling, equipment design, etc. that cause confusion, promote unintended actions, and/or create safety hazards and above all can be a great risk to the patient life

Human Error Traps are conditions of the work environment that make human error more likely.  The most predominant human error traps present in the workplace include:
• Time pressure
• Distraction/Interruption
• Multiple Tasks
• Overconfidence
• Vague or Interpretive Guidance
• First Shift / last Shift
• Peer pressure
• Change / Off-Normal
• Physical Environment
• Mental Stress

In reality, every organization is chock-full of landmines.  Taking a look at the list of the most predominant human error traps, it is obvious that most (if not all) of these are present during any given day on the job.  This combination regularly sets the stage for potential catastrophe, underscoring the importance of proper and robust human behavior while performing tasks.

Tim Autrey's presentation will include some case studies and introduction to The Medical Error Elimination Tools ™. These tools when used uncompromisingly can virtually eliminate any potential errors from happening. Tim's presentation clearly communicates that substantial reductions in human error across an enterprise cannot be achieved or sustained by any mechanism other than through changes in human behavior. Changes in human behavior can only be sustained through discretionary effort, where organization members are adopting new behaviors because they want to. The collective behaviors and interactions of organization members combine to create the culture of the organization. Organizational culture determines organizational results. Tim is an outstanding presenter and his interactive presentation will surely address main ideas mentioned above.

In short, as we can see what Tim addresses through these presentations is huge. The most important aspect to understand is that since we all know that humans play a strong role within any organization be it electrical, nuclear rail or Medical. It is very important to understand human psychology underneath this and how to influence it for better results in any organization such as Healthcare. Through Interactive demonstration, case studies, examples Tim creatively weaves these with the Healthcare industry and people who are working in it.

Tim Autrey has been a student of human behavior since the age of ten. He has spent over a year of his life aboard a nuclear powered submarine, studying human behavior. Following his Navy tour, he then completed a 20+ year career in the US commercial nuclear power industry, where his primary responsibilities were the reduction of human error and management of risk.

In February of 2005, he stepped away from his commercial nuclear career, following orchestration and completion of an “experiment” at the Vermont Yankee Nuclear Power Plant that resulted in an 87.5% sustained reduction in human error rate. He did so to found the Practicing Perfection Institute, Inc., and make the lessons learned from this experiment available to the rest of the world.

Since 2005, PPI has worked with tens of thousands of workers in some of the largest organizations on the planet, helping them to achieve next-level performance. Example results now include:

• A 72% sustained reduction in human error rates
• A 74.6% reduction in outage-to-outage human error rates
• Reductions in union grievances of 75%
• A 60% reduction in site clock resets

As Founder/CEO of the Institute, he has taken his insights to China and Russia, has put together an elite team of human error reduction professionals, and has helped to develop affiliate organizations in Canada, Belgium, and South Africa. In addition, he is the author of EPRI’s latest Report on human error reduction, and has published several Special Reports and video broadcasts, and has been seen on CBS, NBC, ABC, and FOX networks.


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