A recent orientation class had newly minted EMTs and paramedics look inside the driver’s compartment of the ambulance they would be working in. It had the normal vehicle dashboard, a navigation system, a mobile data terminal, three radios, a smartphone, a drive cam and the controller for the emergency lights/siren.
While the students were trying to figure out where they were supposed to stash their Big Gulps in this morass, the instructor was telling them to “make sure the MDT computer has responded when you push the on-scene button or the CAD will say we were late,” and “we want the driver to notify the stroke-receiving hospital with an urgent short form report on channel 2 as soon as you start transport so they can get the CT scan ready.” You could see the smoke coming out of their ears as their brains blew cognitive overload fuses.
In a previous article we discussed the importance of resilient design for our complex, high-consequence work environment. The two simple definitions for resilience in Webster’s Dictionary are, “the ability of something to return to its original shape after it has been pulled, stretched, pressed, bent, etc.,” and “the ability to become strong, healthy or successful again after something bad happens.” Resilient design doesn’t just mean that the equipment should be designed so that it rarely breaks or can still function in a raging blizzard. Resilient design also means including features that are easily managed by people, allow for quick recovery when an error is made and, most importantly, provide a design that helps, not hinders, when people have a high cognitive load.
Comprehensive resilient design includes equipment and the design of the system itself. Schedules, work rules, production goals, performance measures, compensation systems including rewards, deployment strategies, education, training, radio systems, policies, procedures, etc., all contribute to the system that people work in to care for folks in your community.
The pressure to do more with less is rampant in the healthcare and public safety industries. People who conduct incident investigations and event analyses have known for years that the more work we put on frontline employees and the more complete we make their environment, the more errors we see. Many, if not most, of these errors have cognitive failure as a primary cause. Most operations are designed for efficiency first, not for thoroughness and resilience. All day, every day, employees are told overtly or covertly that everyone needs to be more efficient. Then when something goes wrong, the first thing that happens is the employee gets blamed for not being careful or thorough.
Innovative healthcare institutions are now practicing a few simple strategies to help them proactively mitigate risk around high cognitive loads. One concept that is taught in the Collaborative Culture of Safety Model is to ask the following question before putting any new system, rule, responsibility, or expectation in place for frontline staff: “Will the new expectations or system components have any adverse impact on the employees’ ability to achieve current expectations or priorities?” In other words, what work will an employee have to trade off to get the new thing done? What shortcut will he or she devise?
Resilient design isn’t just a waterproof and shockproof drug case. It’s designing our system around known human limitations and behaviors, and working hard to anticipate when and where staff might run into cognitive overload. If we want to be resilient, we need to be honest about human limitations and discuss potential impacts with frontline staff prior to implementing new policies, procedures or systems. By listening carefully and then designing reasonably, we might mitigate the next mess.