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1. Care Quality

What is quality healthcare?

The Provincial Perspective
Health Quality Ontario (HQO)
● is a provincial agency that advises the government and healthcare providers regarding
strategies to “support high-quality care, to support improvements in quality, and to
monitor and report to the public on the quality of healthcare provided in Ontario”
(MOHLTC, 2010, p. 1).
● The agency received this mandate through the Excellent Care for All Act (ECFAA),
2010.
● The goal of ECFAA “... is to transform the healthcare system by creating greater public
accountability, increasing the focus on quality, bringing patient satisfaction to the
forefront and basing patient care decisions on the best scientific evidence available.”
(MOHLTC, p. 1 ).
HQO (2017a) has identified six elements of a quality care system. These words used to
describe these elements are:

● Safe
● Effective
● Patient-centred
● Efficient
● Timely
● Equitable

“Safe Care”: I will not be harmed by the health system – physically, emotionally or
otherwise.

The care my patient receives does not cause the patient to be harmed, nor will I be at risk of
injury or accident while providing care.

“Effective Care”: I receive the right treatment for my condition, and it contributes to
improving my health.

The care I provide is based on best evidence and produces the desired outcome.

“Patient-centred Care”: My goals and preferences are respected. My family and I are
treated with respect and dignity.

Decisions about my patient’s care reflect the goals and preferences of the patient and his or
her family or caregivers.
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“Efficient Care”: The care I receive from all practitioners is well coordinated and efforts
are not duplicated. The value of my time is respected.

I deliver care to my patients using available human, physical, and financial resources
efficiently, with no waste to the system.

“Timely Care”: I know how long I have to wait and why, to see a doctor or for tests or
treatments I need. I am confident this wait time is safe and appropriate.

My patient can receive care within an acceptable time after the need is identified.

“Equitable Care”: No matter who I am or where I live, I can access services that benefit
me. I am fairly treated by the healthcare system.

Every individual receives high quality care that is fair and appropriate to them, no matter
where they live, what they have, or who they are.

The nurse’s role in quality

The healthcare system is complex, and it will take all of us in the system to create changes that
will improve the quality of care that is delivered. It is no longer the responsibility of just the
formal leaders to create change. Given that nurses are the largest group of healthcare providers
and have the most contact with patients, nurses are in an ideal situation to observe and address
quality gaps. Furthermore, nurses’ participation in any improvement process can be critical to
the ongoing efforts to improve the quality and efficiency of our healthcare system.
How can YOU be involved in ensuring and improving quality care?

● Be aware of quality standards of care (developed by your organization and/or

professional organizations).
● Speak up to your colleagues and manager when quality standards are not followed.
● Speak up to your colleagues and manager when quality gaps are observed.
● Participate in the development and revision of quality standards.
● Include the patient/family’s perspectives about gaps in quality.
● Become involved in unit-based or organization-wide initiatives to improve quality.

The science of quality improvement includes specific skills, tools and processes that this set of
modules will focus on. Each of the subsequent modules will help you to learn these skills at a
foundational level.

● Nurses and Quality Improvement: What does it look like?

○ Acute Care Setting
Reducing nursing interruptions to prevent medication errors.
○ Long Term Care Setting
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Reducing unplanned hospital re-admissions from long term care homes through a community-
based geriatric team.
○ Community Care Setting
Increase hospice, pain management, and advance-care planning for palliative clients in the
community.
○ Public Health/Primary Care Setting
Increase the numbers of new clients seen by the Diabetes Care Program, by identifying and
addressing barriers to referrals and booking.
○ Rehabilitation Centre Setting
Improve patient and family education across the continuum of stroke care using a Stroke
Passport.

Patient engagement
Given that patient-centred care is a key element of care quality, healthcare providers need to
understand how to engage with patients in ways that will meet their unique needs at the
individual, unit, organization and system levels.
● Providing individualized patient-centered care includes getting to know the patient, their
story, family context, needs and goals and then co-designing a plan of care to meet their
goals and values.
● To accomplish patient-centered care, you will have “engaged” the patient and their
family by listening, learning together, empowering them to make decisions about their
care and being responsive to their needs.
Beyond engagement at the level of direct care, the concept of “patient engagement” has
evolved to include the active collaboration with patients and their families at the unit,
organization and system level to capitalize on their experiences to improve care delivery. For
example, a 42-year-old patient named Mr. Lewis was asked to attend a pre-operation
educational session to help prepare him for upcoming cataract surgery. At this session, the
participants (mainly seniors) were asked to view a video. Mr. Lewis provided feedback to the
team to let them know that the video was not an effective strategy for individuals with poor sight
and hearing. As you can tell from this example, patients and their families, as consumers of
health care services, are in an ideal position to provide feedback on opportunities for
improvement.
● Why is Patient Engagement Important?

Patient engagement has been shown to result in:

● Improved patient experience and self-management (Rathert et al., 2013)

● Better health outcomes for patients (Hibbard & Greene, 2013)
● Decreased cost of care (Charmel & Frampton, 2008; Smith et al., 2013)

“...putting patients in positions of real power and influence, and using their wisdom and
experience to identify issues and to inform and redesign care to improve processes and
systems, provides the most important force for driving change and has the greatest potential for
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achieving long-term transformation of the healthcare system.” (Reinertsen et al., 2008 cited in
Baker et al., 2017, p. 18)
● How can patients/families be engaged in their care?

Patients and families bring a unique perspective of their experience that can be used to inform
or co-design improvements in care delivery. Engaging the patient/family can occur at various
levels to answer the following questions:
Direct Care: What care works for me?
Program/Organizational Level: How should care be designed and delivered for all
patients like me?
System Level: What services should be available, for whom and in what way?
(Baker et al, 2017)
Health Quality Ontario (HQO) has developed a framework to help healthcare providers identify
ways in which engagement activities can be planned and implemented.
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Heal
th Quality Ontario’s Patient Engagement Framework (2017b)
Source: Health Quality Ontario

● Long Description

The ”Guiding Principles” found to be critical to successful engagement were based on

consultations with over 1,000 individuals across the province including patients, families and
healthcare providers. As you review the principles, consider how you could apply these
principles when interacting with patients to develop their plan of care.
These six principles are:
Partnership: Meaningful patient engagement requires authentic, timely and
mutually beneficial relationships forged between patients, their family members,
other informal caregivers, health professionals and the organizations they work
with.
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Learning: All participants in patient engagement should expect to learn – about

each other’s perspectives and experiences, about facts about the issue at hand,
and about how things may improve and be better.
Empowerment: Patients and their caregivers need to feel empowered to openly
express their needs, perspectives and concerns without fear of reprisal, and to
make informed decisions with confidence.
Transparency: This means that healthcare professionals and organizations are
honest about their apprehensions, resource limitations, and knowledge gaps when
it comes to engaging with patients and caregivers.
Responsiveness: Being responsive means that healthcare professionals and
organizations act upon the voices of patients, their caregivers and the general
public in ways that demonstrate the positive impact of this input.
Respect: Healthcare professionals and organizations demonstrate respect for their
patient and caregiver partners by actively showing signs of appreciation for their
time, ideas, lived experiences, various worldviews and cultural locations.
(Health Quality Ontario, 2017).
● Patient Engagement in Action!

Kingston General Hospital created a Patient and Family Advisory Council (PFAC), where
members were involved in annual organizational planning. They received regular reports on the
hospital’s progress related to the plans, including critical-incident reports and patient satisfaction
surveys. To support direct care, the PFAC developed five core standards to support
partnership and improved communications, safety and risk reduction at bedside. The standards
include:

1. Identification badges to be worn at the chest level to facilitate patients identifying who is
engaging with them.
2. Purposeful hourly rounds to ensure minimal assessment and comfort measures on a
regular and predictable basis.
3. Effective communication (Communicate with H.E.A.R.T. program).
4. A bedside communication/whiteboard updated every shift with key information that staff
and patients/family want to share.
5. Patient-led feedback forums where former patients share their hospital experience with
their providers. Staff then co-design and conduct quality improvement cycles.

Two Worthwhile Goals

The figure below shows the link between the goals of quality improvement and and patient
safety. In quality improvement, you are trying to “raise the ceiling”, or enhance the quality of
care delivered to patients to increasingly higher standards. On the other hand, the goals of
patient safety are to “raise the floor” or raise the minimum standard for what constitutes safe
WK 5 notes

care. Overall, efforts to enhance quality and reduce risk are intertwined for the benefit of the
patients and the healthcare system.

Relationship between quality improvement and patient safety

2. Defining patient safety

Risk Management

● To achieve quality, it is critical to also prevent adverse events and manage risks inherent
in providing patient care – risks that can have an impact on both the patient and the
nurse.
● Risk refers to a potential threat or vulnerability that can lead to an uncertain or
unexpected negative outcome i.e. an adverse event such as medication errors, patient
falls, nosocomial infections, etc.
● Risk management, complementary to quality management, focuses on the systematic
identification, assessment and prioritization of risks and the implementation of
strategies to reduce the occurrence of adverse events (Folse & Wong, 2015). The
goal of risk management is to prevent harm and promote patient and worker
safety.
● A healthy work environment is one strategy to improve quality and reduce risks. e.g.
adequate staffing (Kane et al, 2007).
● In the systematic review conducted by Kane et al., an increase in nurse staffing was
associated with lower patient mortality, length of stay and failure to rescue (death after
the development of a treatable complication). Improved patient and nurse outcomes
were reported in hospitals where there was support for ongoing development, support
from nursing leaders and good nurse-physician relationships (Kutney-Lee et al., 2015).
● Types of Risk

A few types of risk-related adverse events you should know about:

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● Never events: Errors that are preventable and have serious consequences e.g.
surgery on the wrong body part, mismatched blood transfusion, medication error
that results in significant patient complications.
● Sentinel events: A serious unexpected death or harm (physical/psychological)
e.g. patient suicide, infant abduction.
● Near miss: An error that could have resulted in harm but was intercepted before
harm occurred.

In each of these cases, the high-risk situation is studied to determine what could/did go wrong
(e.g. a root-cause analysis, which is discussed further in Module 4) and what strategies could be
put in place to reduce the risk of occurrence in the future. The use of incident reports for
medication errors, patient falls, needle-stick injuries, etc. are one of the tools that can be used to
identify data trends and opportunities to reduce future risk. Incident reporting should not be
punitive to the individual, but instead be used to identify weaknesses in care processes that can
be improved (i.e. it’s not you, it’s the system you are working in). Input from nurses is key to
analyzing and preventing these risks. The focus of this series of modules is the tools and
techniques that can be used to engage in process improvement and enhance both quality care
and worker safety.

Patient safety competencies

The Canadian Patient Safety Institute (CPSI) has created a framework to describe the
necessary abilities or competencies expected of students upon graduation. “The Safety
Competencies can be used as a framework to support the evolution of quality
improvement processes for patient safety (p. 33).” For detailed background on the
competencies framework, refer to the full report listed in the recommended reading for this
module
Highlights of the Safety Competencies Framework are provided below. As you review each
competency and related definition, consider what nursing actions you could engage in to
demonstrate this competency. Once you’ve considered these nursing actions, click to reveal
some possible examples.
Patient Safety Competency #1: Contribute to a culture of patient safety.
Definition: A commitment to applying core patient-safety knowledge, skills and attitudes to
everyday work, to promote well-being of patients and staff, minimize harm, reduce risk of
adverse events and communicate safety concerns.
Examples of Nursing Related Actions

● Ongoing knowledge development about patient safety.

● Recognize and respond to unsafe situations.
● Work within own limitations and seek assistance when needed.
WK 5 notes

● Learn policies and procedures that support safe practice.

● Analyze errors to identify system issues.
● Advocate for system improvements.

Patient Safety Competency #2: Work within interprofessional teams to optimize patient safety.
Definition: Collaborative patient-centred team practice is designed to foster safe and effective
patient-, family- and community-centred health outcomes.
Examples of Nursing Related Actions

● Understand roles, responsibilities and scope of practice for each discipline and team
member.
● Timely and clear communication of patient care using a shared patient record to promote
continuity of care.
● Debrief after a close call.
● Manage and prevent conflict.
● Shared decision-making and leadership.
● Demonstrate respect and professionalism.
● Meaningfully engage patients in their plan of care.

Patient Safety Competency #3: Communicate effectively for patient safety.

Definition: High-quality and safe care depends on the ability of healthcare providers to
communicate well with patients and with other professionals. (Fast Fact: In a U.S. Joint
Commission report of sentinel adverse events [2004 to 2015], errors in communication were a
frequent root cause. Source: Joint Commission. Most commonly reviewed sentinel event types
(1995-Q2-2016)
(Opens PDF document)
. Oakbrook Terrace, IL; 2016 Aug 1. Sentinel event data—event type by year.)
Examples of Nursing Related Actions

● Demonstrate effective verbal and non-verbal communication abilities to prevent adverse

events.
● Communicate effectively in special high-risk situations to ensure the safety of patients
e.g. urgency of a clinical situation, SBAR.
● Use effective written communications for patient safety.
● Assess patient/family understanding.
● Use appropriate communication to provide safe transfers and transitions in care among
providers.
● Apply communication technologies appropriately and effectively to provide safe patient
care.
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Patient Safety Competency #4: Manage safety risks.

Definition: Anticipating, recognizing, and managing situations that place patients at risk. Design
the healthcare work system in a manner that anticipates and recognizes situations that place
individuals and groups at risk.
Examples of Nursing Related Actions

● Recognize routine situations and settings in which safety problems may arise e.g.
correct safety problems.
● Engage in safety practices that reduce the risk of adverse events e.g. hand hygiene,
aseptic technique, medication administration protocols.
● Systematically identify, implement, and evaluate context-specific safety solutions e.g.
checklists, evaluate system failures.
● Anticipate, identify and manage high-risk situations.

Patient Safety Competency #5: Optimize human and environmental factors.

Definition: Managing the relationship between individual and environmental characteristics to
optimize patient safety.
Examples of Nursing Related Actions

● Describe the individual and environmental factors that can affect human performance
e.g. work-life balance, sleep deprivation/sleep debt, fatigue, physical and emotional
health.
● Avoid work-arounds.
● Apply techniques in critical thinking to make decisions safely e.g. recognize common
types of cognitive biases.
● Appreciate the impact of the human/technology interface on safe care.
● Describe principles of workflow analysis to enhance care.

Patient Safety Competency #6: Recognize, respond to and disclose adverse events.
Definition: Recognizing the occurrence of an adverse event or close call and responding
effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence. Adverse
events and close calls should be considered learning opportunities to reduce system failures
and improve professional performance.
Examples of Nursing Related Actions

● Recognize the occurrence of an adverse event or close call e.g. provide honest effective
communication of adverse event.
● Mitigate harm and address immediate risks for patients and others affected by adverse
events and close calls.
WK 5 notes

● Disclose the occurrence of an adverse event to the patient and/or their families as
appropriate and in keeping with relevant legislation.
● Report the occurrence of an adverse event or close call.
● Participate in timely event analysis, reflective practice and planning for the prevention of
recurrence e.g. advocate for system change.

Safety culture
The first patient safety competency on the previous page refers to a “culture of safety”.
● Culture refers to the way things are done within the organization that reflect underlying
values (i.e. what behaviours are encouraged, rewarded, and expected).
● The Agency for Healthcare Research and Quality (AHRQ) has adopted the definition
of safety culture from the Health and Safety Commission of Great Britain:
“The safety culture of an organization is the product of individual and group values,
attitudes, perceptions, competencies, and patterns of behavior that determine the
commitment to, and the style and proficiency of, an organization’s health and safety
management. (Health and Safety Commission Advisory Committee on the Safety of
Nuclear Installations, 1993).”
Sammer et al. (2010) conducted a review of the literature on properties of a patient-safety
culture within American hospitals and identified the properties or subcultures listed below.
Accreditation Canada has developed a series of Required Organizational Practices (ROPs)
to support patient safety. Examples of ROPs have been added to the examples provided by
Sammer et al., in the table below.
The patient safety competencies on the previoun reflect individual responsibilities while the
properties of a patient safety culture reflect organizational responsibilities. Similarities between
the two lists should be apparent.
Properties of a patient safety culture, with examples

Accreditation Canada
Property* Example*
Patient Safety ROPs**

1. Leadership: Leaders align

vision/mission, staff ● Accountability ● Accountability for
competency, and fiscal and ● Commitment quality
human resources from the
● Executive rounds
boardroom to the frontline.
● Resources
● Role model
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● Vigilance

2. Teamwork: A spirit of
collegiality, collaboration, and ● Mutual respect
cooperation exists among ● Psychological safety
executives, staff, and
independent practitioners.
● Readiness to adapt
Relationships are open, safe, ● Supportive
respectful, and flexible.

3. Evidence-based: Patient
care practices are based on ● Best practices ● Antimicrobial
evidence. Standardization to ● High reliability stewardship
reduce variation occurs at every
● Outcomes driven ● Heparin safety
opportunity. Processes are
● Standardization ● High-alert
designed to achieve high
medications
reliability. ● Protocols and
guidelines
● Hand-hygiene
compliance
● Technology
● Reprocessing
(Sterilization
processes)
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4. Communication: An
environment exists where an ● Assertive, speak up ● Client-safety
individual staff member, no ● Safety quarterly reports
matter what his or her job briefings/debriefings ● Adverse events
description, has the right and the disclosure
● Communication
responsibility to speak up on
structure techniques ● Adverse events
behalf of a patient.
such as SBAR reporting
● Infection rates
● Client and family
role in safety
● Dangerous
abbreviations
● Information transfer
● Medication
reconciliation at
care transitions
● Safe-surgery
checklist
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5. Learning: The hospital learns

from its mistakes and seeks new ● Awareness ● Hand-hygiene
opportunities for performance ● Informed education and
improvement. Learning is valued training
● Data driven
among all staff, including the ● Client safety
medical staff. ● Education education and
● Learn from mistakes training
● Mentor
● Proactive
● Root-cause analysis
● Share lessons learned

6. Just: A culture that

recognizes errors as system ● Blame free
failures rather than individual ● Disclosure
failures and, at the same time,
● Non-punitive reporting
does not shrink from holding
individuals accountable for their ● Analysis of system not
actions. just individual
● Trust
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7. Patient-centered: Patient
care is centered around the
patient and family. The patient is
not only an active participant in
his own care, but also acts as a
liaison between the hospital and
the community.
● Grassroots
involvement
● Compassion/caring
● Empower patients and
family and participate
in care
● Patient stories

Other: Worklife/Workplace
(Accreditation Canada) ● Client safety plan
● Equipment
preventive-
maintenance
program
● Workplace violence
prevention
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Other: Risk Assessment

Falls-prevention
(Accreditation Canada)
strategy
Home-safety risk
assessment
Pressure ulcer
prevention
Skin and wound care
Suicide prevention
Venous
thromboembolism
(VTE) prophylaxis

What Happens When Competencies and Culture Break Down?

To pull together the concepts of quality and safety, review the following video. The case
described in the video below is troubling and emotional. As you listen to the important story that
is being told, take time to reflect on the following:

1. Identify factors that contributed to avoidable patient harm, even at a renowned

organization.
2. Consider how patient-centered care can help prevent adverse events.
3. List specific things you can do to make patients feel respected and included in
decisions about their health care?
a. Identify factors that contributed to avoidable patient harm, even at a renowned
organization.

This case is an example of “failure to rescue”, where a death arose from a treatable
complication but the team missed key red flags that the patient was deteriorating. Some of the
factors that influenced this outcome are as follows:

● Communication: the nurses should have paid attention or even double checked when
the mother was showing concern. When the parent or patient refuses or questions an
order, the nurse should recheck with physicians and review existing orders. The
healthcare team did not transcribe orders in the chart regarding holding the narcotics.
WK 5 notes

● The nurses didn't assess the patient in greater detail, nor did they notice that the patient
was so dehydrated. They did not assess the patient and picking up on physiological
cues of dehydration including lab work.
b. Refer back to the chart on patient safety competencies:
● Work within your own knowledge limitations and seek assistance when needed.
● Meaningfully engage patients in their plan of care.
● Use effective written communications for patient safety.
● Identify individual and environmental factors that can affect human performance e.g.
work-life balance, sleep deprivation/sleep debt, fatigue, etc.
● Apply techniques in critical thinking to make decisions safely e.g. recognize common
types of cognitive biases (i.e. “everything will be fine”).

From a patient-safety culture perspective, the nurse needs to be assertive and speak up when
safety concerns arise e.g. a deteriorating patient.

c. Consider how patient-centered care can help prevent adverse events.

As noted above, if the nurse valued the parent as a key contributor to the plan of care, more
attention would have been paid to her voiced concerns. According to the principles of a patient
safety culture, patient-centred care involves compassion/caring, empowering the family to
participate in care, and to listen and learn from patient stories.

List specific things you can do to make patients feel respected and included in decisions about
their health care.

● Listen to the concerns of the family.

● Assess the situation further to address their concerns and rule out anything untoward
that may be happening (e.g. review the chart and labwork, additional patient physical
assessment).
● Communicate back to the family what actions you have taken.
● Encourage the family to discuss any further observations or changes with the next shift
of nurses.
● Facilitate an opportunity for the family to speak with the physician to have their questions
answered in more detail.
● Document the concerns and your actions in the patient record.

3. Better Work means better care: A system’s model for patient safety and quality
care
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In this segment, a foundational framework, along with two related models that describe the work
system will be introduced to help you see beyond the tasks and understand how work-
environment factors have an impact on quality care and patient safety. The required reading by
Karsh, Holden, Alper and Or offers an introduction to “systems” thinking. Take time to review the
key ideas in this paper before proceeding with this section and the following section on human
factors..
● The Donabedian Framework
○ Based on systems theory, Donabedian’s conceptualization of a “system” includes
the following components (1988):
○ a health care organization that wishes to develop quality will organize or structure
itself for quality. Quality client care does not just happen. It must be planned.
Quality is the result of assessing client needs and delivering care to meet those
needs.
○ 3 Elements:
Structures: The context within which care is delivered (e.g. roles, reporting relationships,
worker characteristics, etc.) that influence how care is provided (also referred to as “inputs” or
the “socio-technical work system”).
Processes: Transactions or work processes that are undertaken to deliver care (e.g. admission
process, medication administration process, discharge process, etc.).
Outcomes: Effects of the care provided or products of the system that are influenced by the
structures in place and the work processes used to deliver care (e.g. patient outcomes,
symptom management, satisfaction, readmission rates, falls, etc.), nurse outcomes (job
satisfaction, commitment, health) and organization or system outcomes (cost, quality e.g. length
of stay, turnover rates, etc.).
This framework has been used extensively to examine health services and evaluate the quality
of healthcare. Each factor in this model can be designed to achieve the intended outcomes for
patients, professionals and for the healthcare organization as a whole. Poor design in the
system will compromise performance and outcomes. As a healthcare professional, you will
experience many different efforts to improve aspects of the healthcare system. It is crucial that
in these efforts, that whatever part is being changed, will still work seamlessly with all the other
elements. For example, if a new technology is difficult to use, or doesn’t match the current
procedures, then errors may occur once the technology is implemented. Front-line healthcare
professionals can see where these problems emerge, and should be part of helping to ensure
that any change will not have an inadvertently negative impact on care delivery.
● The Systems Engineering Initiative for Patient Safety (SEIPS) Model
○ The Systems Engineering Initiative for Patient Safety (SEIPS) model is an
extension of the Donabedian framework and was conceived to also include
concepts from engineering science related to improving performance, and also
human-factors engineering to consider not only the patient but the healthcare
professional in the system, thus making the model “person-centred”. (Human
factors will be described in more detail in the next section.) According to Holden,
Carayon, et al. (2013), “efforts must be taken to support people through the
design of work systems that fit their capabilities, limitations, performance needs
and other characteristics.” This model can be used to inform process
improvement so that better work systems can be designed.
WK 5 notes

Please study the model depicted in the image below and tour through the details in the
description that follows. As you read the description of the model, consider how these factors
would influence your ability to perform or deliver care.

The Systems Engineering Initiative for Patient Safety Model (SEIPS) 2.0
First, the work system refers to structures/inputs or the context within which the professional
works. Each of these factors can be designed to optimize the performance of the healthcare
provider. The work system is comprised of the following components:

● Tasks: Attributes or characteristics of the task (e.g. difficulty, complexity, variety,

ambiguity, etc.)
● Tools and technology: Supplies, equipment, medical devices (e.g. usability,
accessibility, functionality, etc)
● Organizational factors: How your time, space and activities are organized (e.g. work
schedules, patient assignments, training, staffing levels, etc.)
● Internal environment: Physical environment (e.g. temperature, lighting, noise, etc.)
● Personal factors: Skills and behaviours (e.g. education level, age of workforce,
teamwork, etc.)
● External environment: Social, political and economic context (e.g. provincial budget,
professional regulations)

Each of the components of the sociotechnical work system influence your ability to perform and
deliver care. For example, if you do not have enough infusion pumps or they are malfunctioning,
your will be less able to manage medication administration in a timely manner which could then
impact patients if their medications are not received when scheduled.
Next are the work processes that include physical, cognitive and social/behavioural
components that impact performance. Examples of work processes are as follows:
WK 5 notes

● Professional work: Work specific to the scope of practice for each professional (e.g.
medication administration, physical assessment)
● Collaborative work: Care processes that involve many disciplines collaborating
together (e.g. patient rounds, care planning)
● Patient work: Active engagement of the patient/family and the nurse is minimally
involved (e.g. managing medications at home, independent deep breathing and
coughing exercises)

Finally, outcomes refer to products of the work processes and may be performance indicators.
Examples are provided below:

● Patient: Quality of care, patient satisfaction, survival, overall health quality of life, errors,
etc.
● Professional: Stress, fatigue, illness, job satisfaction, etc.
● Organizational: Within budget, meet ministry performance targets, staff turnover,
absenteeism rates, etc.

● The Healthcare Innovation Model

○ Currently, most process-improvement approaches aim to improve the quality of
care (including patient safety) and to achieve efficiencies (reduce cost and
enhance productivity).
○ By applying the SEIPS model, we are advocating that a third aim of process
improvement should be optimizing a healthy work environment. In this way,
system design (re-design) can be more person-centred and will be more likely to
achieve positive outcomes for the patient/family, the nurse and the organization.
○ To guide process-improvement work, we have developed a model that applies
the concepts in the SEIPS framework. The Healthcare Innovation Model below
indicates that a human-centred approach to system design and improvement
must always address the aims of care quality, efficiency and work environment
as complementary rather than competing goals. If a patient-care unit is designed
to optimize the work system and work processes, then there is increased
likelihood of positive outcomes for the healthcare provider e.g. (the nurse) and
the patient. Outcomes relevant to the healthcare provider might include pain,
workload, psychosocial, knowledge utiilization, job satisfaction and project
engagement, while outcomes relevant to the patient might include care quality,
patient satisfaction, resource use, and care time received.
WK 5 notes

Healthcare Innovation Model to Guide Process Improvement

Source: Neumann & Purdy (2016). Unpublished.

The feedback loop proposes that “healthcare provider” outcomes can influence the patient care
unit and, in turn, can impact patient outcomes.
Here is an example to make this proposition clearer.

As you work you will gain experience and knowledge; these will improve your ability to deliver
care and avoid errors in care delivery. If however, you become overly fatigued or stressed, for
example, then the quality of care delivered will decline and the chance you will make an error
will increase. These effects act as a feedback loop in the healthcare system, which, as time
goes on, can gradually improve or compromise care quality.

Another example ... if you develop back pain from patient handling (and we hope you don’t!)
your ability to deliver safe care will be compromised and your patients outcomes may also
degrade. It is important to ensure that health hazards and workloads for HCPs are improved
with every process improvement effort. Engaging in the improvement process is therefore
important both for your own wellbeing, as well as that of your patients. You owe it to your
patients to be healthy and feeling well at work.

In summary, if a better work system can be created, better care can be delivered. This
relationship and the value of the SEIPS model will become even clearer as you review the final
section on human factors.

4. Human Factors and Patient Safety

What are Human Factors and Ergonomics (HFE)?

WK 5 notes

● “Human Factors or Ergonomics is the scientific discipline concerned with the

understanding of interactions among humans and other elements of a system, and the
profession that applies theory, principles, data and methods to design in order to
optimize human well-being and overall system performance.” (International Ergonomics
Association).
● The important concept is that the design of the healthcare system affects how people
act, what their injury risks are, and how well they perform their duties.
● Recall from the SEIPS model that we use the term “system” to refer to any aspect of
delivering care, including the organization of work, the use of technology or other
devices, etc. HFE (Human Factors and Ergonomics) impacts the worker’s well-being and
impacts performance. If you are sick, injured, or working in pain then your ability to
deliver high quality care will be compromised.
How a person interacts and responds with the environment can be thought of as a continuous
loop of information, beginning with perception, followed by cognition or processing of the
information and deciding on an appropriate response, and then responding (see the video
below). The external environment, be it a machine (e.g. heart monitor) or another person (e.g.
patient or family) receives the response via a physical, verbal, or visual means of
communication. The information is then processed and then a response is displayed visually,
audibly, or physically. The person perceives this information and the cycle continues.

*Perception, Cognition and Responding are core of all human factors

How Organizational Factors Impact Human Factors

The three stages (perception, cognition, motor response) introduced in the video on the
previous page are the core of all of human factors. Problems can occur in any one of the three
domains resulting in missing critical information, misunderstanding or misinterpretation of a
signal, or errors in executing a care delivery task.
Individual performance can also be impacted by organizational factors such as organizational
structures, policies, and processes. Examples include: communication, work design, shift length
or schedule, teamwork, and telework.
The stages and interactions introduced in the video can also be used to help with diagnosing
system problems. Understanding where in the chain of information and action that the problem
occurred can help to reach the root cause of a problem, understand the mechanism behind the
problem, and then design an appropriate control to prevent it from happening again.
Overload in any aspect of the caregiver’s perception, cognition, and motor demands in care
delivery can lead to fatigue, errors or even injury. For example, a misperception of the
information written in a small font can lead to the wrong decision and response. Similarly a
complicated decision making process requiring holding information in your head can result in an
incorrect response. Likewise, poor motor control and execution of the necessary motor output
can mean a typing error or mishandling of a tool or perhaps inability to support a heavy patient.
The organization of the healthcare system can have many different effects on the caregiver and
the quality of care delivery.
WK 5 notes

What conditions could be impacting your perception, processing and decision making, or motor
response?

● Hunger
● Fatigue (difficult to concentrate)
● Stress (work overload, personal issues on your mind)
● Anxiety (unsure of skills, being observed or tested)
● Overstimulation (noise)
● Interruptions (lose pattern of thought)

HF and Caregiver Health: Psychological and Physical Job Demands

Psychosocial factors and stressors

Stress and burnout are serious problems for healthcare professionals. In a 2007 study of over
68,000 RNs in the United States, a high degree of burnout (emotional exhaustion) was
experienced by 35% of hospital nurses, 37% of nurses working in long-term care and 22% of
nurses working in other settings (McHugh et al., 2011). Laschinger and colleagues (2013) found
severe levels of burnout in an Ontario sample of new graduate nurses, and burnout levels
among experienced nurses was even higher. Critical aspects at work include the psychological
demands of the work, including time pressure and task complexity. The level of monotony of
work, our level of control over work, and the extent to which we can influence how we do the
work can also increase or decrease our stress levels.
Stress can have many unwanted effects. It can affect your health negatively with symptoms
ranging from muscle tension and digestive tract problems, sleep disturbances and illnesses
leading to more serious heart disease problems.
Stress also increases your probability of error. If you are not feeling well, if you are sick, if you
are tired, then your ability to deliver quality care is diminished. Presenteeism is the term used
to refer to employees who come to work when they are ill, and proceed to work at less than
100% capacity. Presenteeism is associated with decreased work performance, efficiency loss,
and declines in care quality.
Stress at work can be counterbalanced by a good social support system from your colleagues
and supervisor. Even your support at home from family and friends, and exercise and lifestyle
factors can affect your stress levels.
Experience: With experience a person improves physical and mental skill competence.
Increased competency allows tasks to occur more naturally and with less mental effort.
Experience also provides a person with exposure to a range of situations which improves their
ability to adapt to unexpected circumstances. With minimal experience, tasks happen less
naturally and require more effort to complete, which can put someone in a state of feeling
overwhelmed. The mental requirements of a task can also seem like it takes more of an effort,
meaning that an inexperienced person could feel more fatigue relative to a more experienced
WK 5 notes

worker. If a nurse is injured at work, the replacement caregiver may not have the same
experience as the injured nurse, with possible declines in care quality as a result.
Work design should also include appropriate psychosocial support, meaning a person will feel
that they are contributing valuable, meaningful work with appropriate time demands, and that
their efforts are both rewarded and supported by colleagues and the organization. These
considerations ensure an appropriate level of stress, are less likely to cause an employee to
experience burnout, and improves their sense of worth to the organization.
Physical job demands

Effective design of work systems minimizes the physical risk exposure to the worker and
maximizes psychosocial factors for well-being. When work systems are effectively designed, the
person’s work tasks will provide the proper amount of work and recovery to offset unhealthy
levels of fatigue and the location of work will position the person to maximize their strength and
reach capabilities to reduce the risk of injury. In the figure below, note the potential for strain on
the lower back and shoulders using different lift positions.

Lifting from a) Floor, b) Appropriate height with moderate reach, c) With far reach
Source: Toronto Metropolitan University 2017
Physical job demands are a function of not only the loads that are moved or the force required
for a task, but are also a function of the postures that are needed, the frequency of tasks and
the length of time an exertion is held. Looking again at the image above, combinations of force,
repetition, and time of exertion can make any of those postures challenging and with an
elevated risk of injury.
HFE, Care Quality, and Patient Safety
WK 5 notes

Care quality and patient safety are paramount in health care. High levels of both can only be
attained through high levels of care delivery, which means that healthcare practitioners need to
have a work environment that allows optimal performance. Often that might not be the case.
Fatigue

Fatigue is a naturally occurring phenomena in the cycle of stress and relaxation of material or a
biological system. There is little consequence to fatigue below a threshold level when there is an
appropriate balance between stress and recovery. However, if there is inadequate recovery
then problems can arise and the system can become damaged or impaired. Mechanically, it
means things break, which for a person means an injury like a strain or sprain. Physiologically, it
means the performance capability is reduced, such as not being able to continue with a task
because you are running out of energy to effectively move and think. The impact of fatigue in
the latter case can create effects similar to intoxication (Dawson and Reid, 1997) – not ideal if
you are late on your shift or starting your shift at a care facility. What should not be overlooked
then is how fatigue can contribute to physical and mental errors.
It is important to note that fatigue is multidimensional for people, and has mental and physical
implications. Åhsberg et al. (1997) identified five different dimensions in their questionnaire
assessing fatigue. The dimensions were:

1. Lack of energy
2. Physical exertion
3. Physical discomfort
4. Lack of motivation
5. Sleepiness

These dimensions reflect the general (dimension 1), physical (dimensions 2 & 3), and mental
(dimensions 4 & 5) factors of fatigue.
Fatigue is an outcome of actions being taken and work being done. The action and work
required are a result of what the environment dictates. A work environment that properly
accounts for the demands imposed on the people interacting with the system should effectively
consider the implications of fatigue on system outcomes.
Errors

● error of commission when providing care, like inserting a needle incorrectly into the
patient. You might also make an
● error of omission – when you forget to perform a task. This can happen when you are
too busy in your shift with too many patients and forget, for example, to change a
dressing on a patient. There are many different factors that contribute to both kinds of
medical error.
Recall the human interaction video from earlier. Remember that a person perceives the
environment, creates a plan on how to respond, and then executes a response. Conceivably, an
error can occur in any of these steps. For example, someone could incorrectly perceive the
WK 5 notes

colour of a colour-coded vial or incorrectly read crowded or messy text on a chart. They could
also incorrectly remember the steps required to execute a treatment or miscalculate a medicine
dose for a patient’s weight. Even with successful perception and planning, they could still poorly
execute a task such as miss the glass while pouring water or missing the vein with the needle.
Sometimes errors occur in isolation, other times they can be a series of errors. Often, people
want to classify mistakes as “human error”. However, when you get to the true root cause of the
error, you will find that the error is due to the system and the way it was designed. The error is a
reflection of how the response of the person to information that the system presented or
predisposed them to, which, at its core, is a function of the design. In future modules we will get
more into approaches to root out these sources of errors and methods on how to evoke good
change. In the meantime, take a minute to reflect on something you have experienced where a
mistake, or near mistake, that you have made was an error brought on by poor design and poor
inclusion of HFE, and then proceed to the exercise that follows.
Recall the human interaction video from earlier in the module. If you remember, errors can
come from perception, cognition, and/or execution, meaning how someone interprets their
environment, chooses a response and then executes the response.
● perception error could be made due to the font size used in the design of labels. The
font could be difficult to read, which could slow down a process or cause someone to
interpret the information incorrectly.
● cognition error could be a simple math error, such as when incorrectly converting a
person’s weight from pounds to kilograms. It could also be from having to remember
multiple pieces of information to transfer information from one system and re-enter it in
another. Systems that are not designed to easily “talk” to each other and require the
manual transfer of data increases the chances of someone misremembering potentially
important information.
● execution error could be when someone is re-entering or transcribing information into a
system and mistypes characters.
For each of the errors described below, identify the error as an error of perception, cognition, or
execution.
Perception, Cognition, or Execution?

● Missed medication due to frequent interruptions from staff/visitors when preparing

medications

Cognition

● Incorrect medication dosage due to infusion pump alarm conditions that the nurse could
not hear from her work station
WK 5 notes

Perception

● Lower back strain arising from frequent bending/twisting to plug machines into outlets at
floor level

Execution

● Unreliable blood sugar readings due to forgetting proper procedure to calibrate and
operate a glucose meter

Execution

● Drop and contaminate a sterile piece of equipment

Execution

HFE in Healthcare System Design: How Can HFE Benefit Performance?

Much like the design of the work environment can reduce the risk of injury, the same
considerations can help to maximize a person’s performance. A properly designed physical
environment positions and stresses a person in a manner that is sustainable throughout the
work day or event. Task locations are situated to allow for the person to use the appropriate
muscle groups necessary for strength or control and do not overtax the person so that they are
fatigued. If a person needs fine motor movements, then the task allows for hand dexterity and
fine movement control. Tasks that are repeated or sustained for long periods are designed to
prevent unnecessary fatigue. Otherwise, fatigue may reduce movement capabilities which leads
to either task errors or a reduced ability to complete the task. Likewise, task complexity and task
time requirements are designed at a level that does not overwhelm the person cognitively,
reducing the chance of task errors from difficult or rushed tasks.
Key highlights:

● Quality care: It is the nurse’s role to provide care that is safe, effective and patient
centered. The organization is responsible for designing workplaces that enable efficient,
timely and equitable care.
WK 5 notes

● Nurse’s role: It is the nurse’s role to use their expertise to help improve care delivery to
meet this definition of quality care.
● Patient engagement: Patients and families need to be engaged to help improve the
system through sharing their care experiences, providing feedback and collaborating
with the healthcare team to design improvements.
● Patient safety competencies: Explicitly define the ways in which nurses can fulfill their
obligations to contribute to a safe workplace for patients (e.g. manage safety risks,
optimize human factors that impact safety, etc.).
● Better work, better care: Refers to the importance of creating work conditions that are
safe for the healthcare professional and thereby enable quality care to be delivered. The
SEIPS model offers a systems perspective to guide how work environments can be
designed to improve quality care, efficiency and healthy work workplaces.
● Human factors: Refers to the how humans interact with their environment with the goal
of optimizing well-being and performance. This interaction includes perception, cognition
and a motor response. Problems can occur in any of these domains leading to injury or
error.