Human Factors Engineering for the Pediatric Hospitalist

HFE, also referred to as human factors or ergonomics, is the scientific discipline devoted to understanding the interactions between people and the systems in which they work and subsequently designing systems that jointly optimize people’s well-being and system performance.⁴  The International Ergonomics Association defines 3 domains of HFE: Physical, cognitive, and organizational.⁴  Each domain has important contributions to make in health care. Physical ergonomics consider the anatomic, physiologic, and biomechanical capacities of people in the design of tasks (eg, the ideal weight that a human can safely lift), tools (eg, dimensions of chairs, grips of surgical instruments), and the physical environment (eg, hospital floorplans, lighting, air quality). Cognitive ergonomics considers the mental capacities of people (eg, perception, memory, reasoning) and their impact on interactions with a system (eg, a health care worker’s workload or the usability of a medical device). Finally, organizational ergonomics or macroergonomics consider a person’s work system (ie, their work tasks, the tools and technologies they work with, and their organizational and physical environments) and how interactions between aspects of the work system shape outcomes (eg, how the quality of patient handoffs or use of the electronic health record impacts patient safety). These domains help to understand specializations and foci of HFE scientists and practitioners, but they interact to shape work and performance; HFE experts must sufficiently consider all relevant HFE factors.⁴  Here, we focus on organizational ergonomics, which can play a pivotal role in understanding and improving complex health care systems, like the pediatric inpatient setting.⁵ 

As mentioned above, understanding the work or sociotechnical system surrounding a person (eg, health care worker, patient, family) is an important part of an HFE approach to improving care. There are multiple frameworks that explicitly account for system components and their interactions to better understand how and why specific outcomes (eg, patient safety) result.⁵  One of the most influential work systems frameworks used in health care is the Systems Engineering Initiative in Patient Safety (SEIPS) model (Fig 1).⁶  SEIPS places people (eg, health care worker, patient, family) at the center of a work system and describes how they use specific tools and technologies to conduct tasks within their organizational and physical environment.⁶  Together, these components and their interactions form the work system which shapes work processes and, ultimately, influences outcomes for patients and caregivers (professional and otherwise). Therefore, to improve outcomes, one must evaluate the various components of the work system and their interactions.

There are many existing tools that can help you better understand the work system for your particular project. Holden and Carayon⁷  outline 7 simple tools to systematically identify important work system components and interactions. One of these tools is the People, Environments, Tools, and Tasks (PETT) scan. This is a simple checklist and documentation tool that can help you identify individual components and interactions that can either hinder or help people do their work effectively. When executed well, the PETT scan identifies the activity of workers (ie, work as done), not only the tasks prescribed in the health system’s policies (ie, work as imagined).^8,9  Once you have developed a deeper understanding of the current work system for your project, you can progress to (re)designing that system.

Human-centered design (HCD) applies HFE principles to develop systems that are “usable and useful by focusing on the users, their needs, and requirements.”¹⁰  The first step in any HCD process is to plan the process, including setting a design objective and selecting the scope (Fig 2, step 1). Often, the design objective and project scope will be influenced by what can practically be studied (eg, a care process that can reasonably be observed) and done (eg, an objective that is likely achievable given the time, money, and expertise of the team).

Second, one must understand the work system or context that will be (re)designed (Fig 2, step 2). Tools such as a PETT scan will help you accomplish this step. An essential aspect of specifying the context is to identify who is involved and should be included in the design process. Depending on the context, the who may include end-users of the design (eg, clinicians, patients) and other stakeholders in the design and/or its implementation (eg, managers or other leaders, information technologists). In the next step in the HCD process, one should articulate the requirements of the different users or people involved (Fig 2, step 3). Frequently, the output of this step holds conflicting perspectives and needs that must be reconciled.^11,12 

One method of approaching the HCD process is to use participatory ergonomics methods,^13,14  wherein the people who will be impacted by the design (eg, end-users, stakeholders) contribute to the process of turning user requirements into potential solutions (Fig 2, step 4). Depending on the context of your project, you may engage people to different degrees; for example, with varying decision-making capacities or at different points in the design process, using methods such as surveys, interviews, or focus groups.¹⁴  Once potential solutions have been identified, they can be developed and evaluated against the user requirements in an iterative process (Fig 2, step 5). Once a design is produced that sufficiently meets user requirements, the design can be implemented (Fig 2, step 6). In practice, iteration happens well into the implementation of a design as the outcomes of the system are monitored. The need for continuous design iteration is especially relevant for ensuring high-quality health information technologies.¹⁵ 

Here, we provide an example of employing a human-centered, participatory design process to redesign family-centered rounds at 1 children’s hospital.¹⁶  Our design objective was to improve the way we engaged families during rounds and, in turn, enhance patient safety (Step 1). From an HFE standpoint, we recognized that any changes we made to rounds would need to be designed for and integrated within our complex inpatient work system. Specifically, we would need to account for the work performed by the multiple people on rounds (eg, parents, physicians, nurses, pharmacists, learners) and how they interacted with tools and technology (eg, computers on wheels, electronic health record, pagers) to accomplish their daily tasks across multiple inpatient units. Changes made in complex, dynamic work systems could lead to unanticipated, negative consequences or new problems.

We first observed and outlined our current rounding process using a PETT scan guided by the SEIPS work system components to identify the work as done (Step 2). We then elicited 21 ideas (ie, user requirements) for improving family engagement during rounds from families of hospitalized children and members of their health care team (Step 3). Using a participatory approach, we gathered a team of stakeholders representing those who participate in rounds.¹³  We surveyed them on their perception of the impact of each of these 21 ideas on family engagement and assembled the highest impact ideas into 3 potential interventions. We piloted each of the 3 interventions and surveyed stakeholders again on the feasibility and sustainability of each. The most feasible and sustainable intervention was identified as a checklist of recommended activities that should be completed during every rounding session (Step 4).

Finally, to evaluate whether the checklist intervention met the design objective, we observed checklist use and stakeholder perspectives after implementation (Step 5). We subsequently demonstrated that performance of checklist items improved family engagement and parent perceptions of safety during their child’s hospitalization.¹⁶  More information about this HCD process, the family-centered rounds checklist, and supporting materials can be found at: www.hipxchange.org/FamilyRounds. Other recent examples of HCD in pediatrics include the development of shared displays to support teamwork during care transitions¹⁷  and the development of a mobile health application to support family-delivered enteral tube care.¹⁸ 

In this article, we introduced one HFE framework, the SEIPS model, to understand the complex interactions in health care systems that shape outcomes for people (eg, parents, physicians, nurses, pharmacists, learners). We then highlighted tools to operationalize the SEIPS model as part of a human-centered, participatory design process and provided an example. We must acknowledge that this is an intentionally abbreviated introduction to the HFE field. The embedded references include additional information outside the scope of this introductory overview; we encourage interested readers to explore them!

Although HFE is increasingly emphasized in medical education and thus has increased the ability of clinicians to incorporate these principles into their work,¹  please note that true expertise in HFE in health care takes years of training and requires an advanced degree. Thus, partnering with an HFE expert may be a more expedient and prudent way to access in-depth HFE experience. In other words, a good physician may not know all the answers, but knows when to ask for help. Do not hesitate to engage an HFE practitioner, scientist, or researcher in your work. And, given that health care systems are increasingly employing HFE experts, there may be HFE experts closer to you than you first imagined. If not, we suggest a variety of resources to identify potential collaborators (Table 1).

HFE provides useful frameworks, approaches, methodologies, tools, and principles to improve quality and safety in health care. In particular, the HFE-based concept of the work system can be useful in understanding the contextual factors that shape care processes and influence outcomes. The SEIPS model, combined with a human-centered, participatory design approach, can guide improvement efforts. However, an important aspect of these models is the feedback loop; as you (re)design the work system and process, you must continue to gather feedback on system performance and iteratively and continuously improve your design. In doing so, you may reach a point that additional expertise is needed; do not hesitate to reach out to collaborate with HFE experts. Together, we can improve systems to keep kids and health care workers safe, healthy, and happy.

• HFE is the science of jointly optimizing system outcomes and people’s well-being.

• The systems that people work in shape health care processes and outcomes.

• Identifying the work system components and their interactions that matter is key to improving health care processes and outcomes.

• HCD is an iterative process that centers the needs of people.

• Ask for help; there are human factors experts who want to collaborate.

We thank Dr Pascale Carayon; in addition to her tireless efforts to improve the safety and quality of health care and important intellectual contributions, she has been an exceptional mentor and advocate for us and others. We also thank Dr Chris Bonafide for his collaboration and contribution to the conceptualization of the adapted SEIPS model for pediatric hospital medicine.