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
Does Human Performance
Analysis/Technology
(HPA/HPT) Have Anything to
Offer For Peer Review and
OPPE?
Mark A. Smith, MD, MBA, FACS
October 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
Evolution of Evolution
Dr. Erasmus Darwin 17311802
Medical Practitioner who read
Epicurus, promoted theories
that anticipated natural
selection in his work
“Zoonomia” and anticipated
evolution in his poetry.
Evolution of Evolution
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
3
Gravity of Gravitation
Brahmagupta 598- 670
C.E.
Indian mathematician
Discovered the
mathematicalconcept of
Zero
Described natural properties
of gravity
Gravity of Gravitation
Galileo Galilei
1564- 1642
Force acting on falling
objects independent of
weight
Gravity of Gravitation
Sir Isaac Newton
1642- 1727
Laws of Motion and Universal
Gravitation
4
Gravity of Gravitation
Albert Einstein 1879- 1955
Developed Special Theory of Relativity and General Theory of
Relativity which contains conception of gravity as distortion of spacetime continuum
Gravity of Gravitation
Need for Unification Theory- Must Unify Relativity with Quantum Mechanics
to truly answer reality of gravitation
Peer Review HistoricallySource of the Issue
Evolution
– Al- Ruhawi, 9th Century Syrian, Ethics of the
Physician
– Ernest Codman, MD, 1916, End Results
System
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Peer Review HistoricallySource of the Issue
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
Peer Review HistoricallySource of the Issue
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
Peer Review HistoricallySource of the Issue
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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Peer Review HistoricallySource of the Issue
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/Technology
The 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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What is Human
Performance
Analysis/Technology
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/Technology
2000- 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)
What is Human
Performance
Analysis/Technology
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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What is Human
Performance
Analysis/Technology
Thomas Gilbert (1927- 1995) Psychologist who is
considered father of Human Performance
Technology
Published in 1978
Based on conclusion that training
or knowledge improvement did not
result in corresponding behavior
change or better outcomes
What is Human
Performance
Analysis/Technology
P= BxE P=Performance, B=Behavior, E= Environment
Led to ABC Model
Antecedents lead to Behavior lead to Consequences
Six variables of performance
– information, resources, incentives,
knowledge, capacity, and motives
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What is Human
Performance
Analysis/Technology
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
What is Human
Performance
Analysis/Technology
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
What is Human
Performance
Analysis/Technology
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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What is Human
Performance
Analysis/Technology
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
What is Human Error
Analysis (HEA)- a subset
of HPA/HPT
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
Skill based - “Repetitive behavior performed many times
through experience” (1/1000) (monitoring error)
Rule based - “Implementation of a sequence of a preestablished steps” (1/100) (decision- making error)
Knowledge based - “Figuring out what to do next without the
benefit of rules or experience”
(3/10) (problem-solving error)
Based on Jens Rasmussen, 1974
What is Human Error
Analysis (HEA)- a subset
of HPA/HPT
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?
Event triggers
System barriers to stop event
(policies, training, self-checking, etc.)
Significant
events or
injuries
• Human errors
• Equipment failures
• External events
start a chain of events
Based on Dr. James Reason, Managing the Risks
of Organizational Accidents, 1997.
Holes don’t stop the event
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 Scales
Lean
Lean Six Sigma
Crew Resource Management
Probabilistic 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?
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