Cognitive Biases and Improvement Science

Swiss Cheese Model

A model created by James T Reason used in risk analysis and risk management likening human systems to layers of swiss cheese which have holes (i.e. weaknesses) of different shapes and sizes in each slice. The layers prevent most single points of failure, however the ‘holes’ may very occasionally align, and the risk materialises. Essentially, mistakes in human systems only occur when there are several failings at multiple levels of the system.

How can we improve a human system?

• It must support the fixing of mistakes, rather than punishing people when mistakes happen.

• Reduce the factors that increase the risk of human errors.

• Prevent resistance to change through supporting staff.

• 4 lenses of improvement.

• Make the system do the work.

• Continuous improvement - it can always be better.

What are the 9 factors that increase the risk of human error?

• Heavy workload

• Fatigue

• Stress

• Shift work

• Reliance on memory

• Reliance on vigilance

• Noise

• Distractions

• Unnatural workflow

Why do humans resist change?

• Fear of the unknown.

• Loss of control.

• Distrust in leadership.

• Comfort with the status quo.

• Poor communication.

• Cultural misalignment.

• Negative past experiences.

Hazards of resistance to change

• Implementation delays

• Reduced productivity

• Escalated costs

• Damage to morale

How can resistance to change be reduced?

• Transparency and good communication

• Building trust

• Collaborative approaches including staff

• Providing support and resources to staff

• Address concerns

• Minimise disruption (e.g. gradual change, adjusting expectations etc.)

• Incentivise staff (e.g. footstep stickers to hand wash area in a hospital)

• Go to the inconvenienced minority and work with them first.

• Behavioural change wheel

4 lenses of improvement

Concept created by W Edwards Deming to improve human systems. They are:

• Appreciating a system - looking at what a system is currently doing, considering all the interactions with it. This can allow planning of change and ideas while considering the potential unintended consequences of these.

• Understanding variation - reducing unnecessary variation that come come from outwith or within a system. This considers both behavioural and statistical variation .

• Psychology - looks at what people do within the system, what people think about the system, what motivates people and how people respond to change. This is necessary to facilitate successful change.

• The theory of knowledge - relates to the theories around why the system looks like it does, as well as any theories as to why proposed change ideas would work. It is important to understand why these theories are held by people, including those introducing and affected by change.

Why is understanding improvement science and psychology so important to healthcare systems?

They are extremely complicated systems, involving lots of people and processes, and needing lots of co-ordination and management. Mistakes can lead to fatalities, so improving these systems and recognising failings is crucial.

How can a system be made to ‘do the work’?

It recognises that humans make mistakes, and tries to prevent them from happening in the first place through failsafes such as:

• Education and awareness

• Audits and feedback on performance

• Inbuilt decision aids and reminders

• Personal memory aides and checklists

• Reducing unnecessary variation and complexity within a system

• Fostering a collaborative and safe working environment where feedback, positive change, and improvement is encouraged.

How can human error be reduced?

• Education.

• Reduce and share workload.

• Provide adequate rest time.

• Reduce noise and distractions in the workplace as much as possible.

• Foster trust, collaboration, open communication, and improvement rather than punishing staff who make mistakes.

• Make the system do the work (automation and failsafes), especially reducing reliance on memory and vigilance.

• Audits and checks.

• Clear processes and guidance.

• Mental health support for staff.

Behavioral change wheel