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To Build a Culture of Safety, Use Human Factors Engineering
Amish Aghera, MD, Emergency Medicine Physician and the Director for the Center for Clinical Simulation and Safety and the Simulation Fellowship at Maimonides Medical Center, explains the necessity of creating tools to help keep humans from making mistakes. In recent years, many have pointed to systems issues as the cause of adverse events. Recognizing that healthcare workers are human and subject to human fallibility is critical in developing a culture of safety. Thus, developing decision support tools, medical early warning systems, and other similar programs is an essential element in keeping patients safe. Simulation is yet another tool to help clinicians develop skills without impacting patients directly.
Featuring:
Amish Aghera, MD
Amish Aghera, MD, is an Emergency Medicine Physician and the Director for the Center for Clinical Simulation and Safety and the Simulation Fellowship at Maimonides Medical Center in Brooklyn, New York. Dr. Aghera’s interests include leveraging simulation to improve patient safety through experiential education, professional development, systems integration, team training, and research. Transcription:
David Feldman MD, MBA, FACS (Host): Patient safety and high reliability continue to be elusive goals in healthcare. Creating a culture of safety that will allow us to achieve these goals requires a number of important elements. In this series, we'll address what we believe are the essential ingredients in developing such a culture; mutual respect, teamwork and collaboration, human factors engineering, and just culture.
I'm David Feldman, MD, Chief Medical Officer for The Doctors Company and Healthcare Risk Advisors, part of TDC Group. On today's episode, we're delighted to welcome Amish Aghera, emergency medicine physician and the director for the center for clinical simulation and safety and the simulation fellowship at My Monities Medical Center in Brooklyn New York. Today, Amish will discuss the necessity of creating tools to help keep humans from making mistakes. In recent years, many have pointed to systems issues as the cause of adverse events, recognizing that healthcare workers are human and subject to human fallibility is critical in developing a culture of safety.
Thus developing decision, support tools, medical, early warning systems, and other similar programs is an essential element in keeping patients. Simulation is yet another tool to help clinicians develop skills without impacting patients directly. This is the leading voices in healthcare podcast. So let's begin Amish, as an ED physician, what kinds of events have you seen that may have inspired you to be so involved in simulation in human face?
Dr. Amish Aghera: Yeah, thanks for inviting me to do this podcast. Yeah, I guess my interest in simulation and human factors has kind of evolved, along with my interest in education and learning about how people think. When I first started getting involved in education, it was mostly with residents and medical students. And at that time we were doing what a lot of programs were doing, which was, giving people a lot of long PowerPoint lectures. And so some of these lectures, I would think to myself, wow, this is a pretty long having a hard time staying focused. So, I thought to myself, along with a few of our team members who are involved in education, is there a way that we can just improve the impact of these lectures?
So we started doing, this thing called a testing after the PowerPoint lecture. So we'd ask ASCO residents to fill out a short quiz. After their lecture, just a couple of minutes long to help them maybe solidify the key points of the lecture. And, we turned it into the study. We called it testing to improve knowledge retention or TIKR.
David Feldman MD, MBA, FACS (Host): Good for an ED doc. Right? You'd think a cardiologist with that name.
Dr. Amish Aghera: Well that's right. Well, you know, we were maybe having a little bit of study envy with how we were. So, we found that it actually worked it. We got a 10% improvement in how our residents were doing when we tested them again a couple of weeks later. But what we found was they only really improved from 45% to 55%. So at that moment, I kind of had this existential moment. I was like, what is going on that. Our residents who were teaching like bread and butter topics are only remembering a little more than half of what we're teaching them. So I thought, am I just bad at this thing?
Are our residents bad? And you know, the truth was neither. It just has to do with how we think as human beings. This sort of led me down the track of simulation and, trying to do types of training that keep people engaged. And it was clear, from the very beginning that, you're working with people in smaller groups, they're really engaged in what you're doing, because the activities are relevant to their day-to-day practice. And they learn things and people will come back and say, Hey, you know, that case that we did in SIM lab, that's exactly what happened. Everything played out smoothly unlike, maybe in the simulation where they may have been some hiccups.
I think, when we think about human factors, a lot of it is just understanding how human beings think we're not perfect. We're not machines. You know, we're gonna make mistakes. And I think this understanding that you know, understanding that we're not going to absorb every piece of information that's given to us. I think it's important realization, that's sort of what inspired me to get more and more involved in this area.
David Feldman MD, MBA, FACS (Host): Interesting, fascinating that the, that you came out of through an education lens, which is really amazing. But it does, speak to the fact that now, especially here we are, a couple of years into this pandemic and people don't want to be lectured to anymore. They want to be involved. They want to be participants. And you've got some great data to show that, that really helps people retain things right. By actually participating in these things sitting in a lecture hall just doesn't work anymore. So great insights. Great insights. Tell me why do you think it's been so difficult? I mean, you obviously get this and obviously people that you work with, get it, but why is it so difficult to get other clinicians, especially physicians interested in these kinds of programs? You go around the country and you look at SIM programs and there's a lot of residents and nurses, but where are the doctors? Why is that so hard?
Dr. Amish Aghera: Well, it's a paradigm shift and a. You know, it's hard for people to change, right. Again, it's sort of, it's ironic, right? Like understanding human factors that has to also do with understanding that we're just not good at getting uncomfortable, and change is uncomfortable. A lot of doctors go into medicine because of, maybe things that are a little sexier, you know, as an emergency physician, you're talking about resuscitation and critical skills training and airway management. And it's really easy to get people to talk about that or review the latest journal article. Right. learning about handoffs, even though that's what, makes up a larger percentage of your day. You know, it just, it doesn't excite people. So figuring out how we can get people excited about this, I think is helpful.
David Feldman MD, MBA, FACS (Host): Yeah, interesting point too, right? The difference between these so-called technical skills, I'm a surgeon. That's the things that we always focus on, but the non-technical skills are equally, maybe in some cases, even more important when we try and think about how to make things safer and reduce the number of adverse events. And it is much more difficult. You know, it sort of reminds me when we started working with ED physicians like you years ago in the simulation space. And we said, well, really we'd love to work on handoffs and all these sort of non-technical skills.
But I think you and I talked about this years ago, it's just going to be too hard to engage people. Let's start with some of the technical stuff, right? Like the intubations and the central line placements and the chest tubes and so forth. But you were really instrumental in helping me get these things off the ground. How were you able to lead a program across multiple large institutions that we worked with? How did that go for you?
Dr. Amish Aghera: Well, I think for one thing, it helps to have, people on your side and especially, you know, the quote unquote stakeholders, right. Actually I'd like to thank you because you are part of that process. I guess, you know. I think sometimes it's, the more I do this, the more I appreciate Kotter's change model, and thinking about, okay, who are the people who are going to get things moving at a higher administrative level, but then it's also about, you know, who are you going to work with? who's that working coalition, so to speak? You can't really lead a group of people if people aren't interested, finding those like-minded individuals is super important.
And then, y ou alluded to it, you know, starting with the technical skills, trying to find projects that people are excited about. And that was a great way for us to start, getting people into the simulation center. Something they've never done before. starting with things like, you know, airway management, right. They realize like, Hey, this is really useful. And then when they come back, you can do communication training. You could do things like clinical event debriefing. Cause they've kind of bought into the process. They've started to get this idea of reflection and thinking about how they practice it.
And that's part of what human factors is about. Right? It's about thinking how we think, and then putting systems in place to help augment that.
David Feldman MD, MBA, FACS (Host): It makes a lot of sense. just switching gears a little bit here Amish, you're aware that one of the first programs that we didn't, we put into place to address human factors was the institution of radio-frequency chips in the surgical soft goods, you know, the lap pads and sponges and so forth. And this is almost 10 years ago at all of our institutions. And we're publishing an article coming out now in the Journal of the American College of Surgeons that details the significant reductions we saw as a result in retain surgical items. Do you think there are other applications of this kind of approach in areas beyond surgery, like in the ED how can we make use of this kind of technology and approach and in reducing events in places where you work?
Dr. Amish Aghera: Oh, that's a great question, I think we'd love to get RFID tags into our ED or different places in our hospital. There's a few different applications for them, above and beyond tracking equipment, like routine sponges, one is thinking about putting them on your patients and understanding flow, how quickly they move through the hospital system. Thinking about putting tags on patients that can't advocate for themselves, thinking about that patient with Alzheimer's, who's sitting in the corner of your emergency department you know, they can't answer for themselves if their name is called out. You can use it as an extension for two factor identification, right.
For doing timeouts you know, for doing giving people, medications. There was an interesting article I read about putting RFID tags on staff and thinking about strategically placing sinksand hand sanitizing stations based on t routes people are walking in their clinical You know, it's much easier for people to keep their hands clean, which we know is so important for infection control, if they're just not anywhere near a Purell or a sink. So, definitely lots of opportunities to help sort of augment the way we're using a little bit of technology that's out there.
David Feldman MD, MBA, FACS (Host): It's really great when you think about it, think about how busy EDs like yours and all the others in, well, probably everywhere, but especially in places where you work in New York city. And it's such a crazy place, where our people to have an idea and know where everybody is. Where's the patient is, is the patient in cat scan or are they back yet? And without having to go anywhere there it is for you on a screen. I love the idea of patients who can't advocate for themselves, literally advocating for them. Like, Hey, this patient's here and nobody's been buying a while.
Let's make sure that they're okay. And where are we in their workup, if you will. I think that's a wonderful idea. So as we put all this together Amish, lots of our listeners are thinking like, what would I do if I'm a hospital, patient safety leader, and I want to start developing these kinds of programs and human factors and simulation, what's the first step they should be taking? Where do they start?
Dr. Amish Aghera: Well, part of it is thinking, carefully about how they're going to start and picking projects that seem relevant to those on the front line, the kit, your care providers. We know that there's always going to be a certain programs that are. maybe higher risk, but thinking about just starting off with that lower hanging fruit, and getting people kind of bought in the thing that I see a lot in the simulation spaces is hospitals invest in building full of equipment. If I was to quote one of the fathers of simulation and anesthesiologists, who, originally practiced in Stanford, David Gabba, talked about simulation as a technique and not a technology. So I for institutions to invest in people to know how to leverage, things like simulation-based training, having people who really understand and are experts in safety science to help modify your clinical spaces with things like RFID tags, right. Building a better work environment. I think that's a great way to start thinking about this and maybe a little bit of a paradigm shift for us as well.
David Feldman MD, MBA, FACS (Host): Yeah, great points. Great points. Thank you so much, Amish for joining us today and thank you all for listening to our Leading Voices in Healthcare podcast. Visit our This email address is being protected from spambots. You need JavaScript enabled to view it. to learn more about the services we provide to healthcare professionals.
David Feldman MD, MBA, FACS (Host): Patient safety and high reliability continue to be elusive goals in healthcare. Creating a culture of safety that will allow us to achieve these goals requires a number of important elements. In this series, we'll address what we believe are the essential ingredients in developing such a culture; mutual respect, teamwork and collaboration, human factors engineering, and just culture.
I'm David Feldman, MD, Chief Medical Officer for The Doctors Company and Healthcare Risk Advisors, part of TDC Group. On today's episode, we're delighted to welcome Amish Aghera, emergency medicine physician and the director for the center for clinical simulation and safety and the simulation fellowship at My Monities Medical Center in Brooklyn New York. Today, Amish will discuss the necessity of creating tools to help keep humans from making mistakes. In recent years, many have pointed to systems issues as the cause of adverse events, recognizing that healthcare workers are human and subject to human fallibility is critical in developing a culture of safety.
Thus developing decision, support tools, medical, early warning systems, and other similar programs is an essential element in keeping patients. Simulation is yet another tool to help clinicians develop skills without impacting patients directly. This is the leading voices in healthcare podcast. So let's begin Amish, as an ED physician, what kinds of events have you seen that may have inspired you to be so involved in simulation in human face?
Dr. Amish Aghera: Yeah, thanks for inviting me to do this podcast. Yeah, I guess my interest in simulation and human factors has kind of evolved, along with my interest in education and learning about how people think. When I first started getting involved in education, it was mostly with residents and medical students. And at that time we were doing what a lot of programs were doing, which was, giving people a lot of long PowerPoint lectures. And so some of these lectures, I would think to myself, wow, this is a pretty long having a hard time staying focused. So, I thought to myself, along with a few of our team members who are involved in education, is there a way that we can just improve the impact of these lectures?
So we started doing, this thing called a testing after the PowerPoint lecture. So we'd ask ASCO residents to fill out a short quiz. After their lecture, just a couple of minutes long to help them maybe solidify the key points of the lecture. And, we turned it into the study. We called it testing to improve knowledge retention or TIKR.
David Feldman MD, MBA, FACS (Host): Good for an ED doc. Right? You'd think a cardiologist with that name.
Dr. Amish Aghera: Well that's right. Well, you know, we were maybe having a little bit of study envy with how we were. So, we found that it actually worked it. We got a 10% improvement in how our residents were doing when we tested them again a couple of weeks later. But what we found was they only really improved from 45% to 55%. So at that moment, I kind of had this existential moment. I was like, what is going on that. Our residents who were teaching like bread and butter topics are only remembering a little more than half of what we're teaching them. So I thought, am I just bad at this thing?
Are our residents bad? And you know, the truth was neither. It just has to do with how we think as human beings. This sort of led me down the track of simulation and, trying to do types of training that keep people engaged. And it was clear, from the very beginning that, you're working with people in smaller groups, they're really engaged in what you're doing, because the activities are relevant to their day-to-day practice. And they learn things and people will come back and say, Hey, you know, that case that we did in SIM lab, that's exactly what happened. Everything played out smoothly unlike, maybe in the simulation where they may have been some hiccups.
I think, when we think about human factors, a lot of it is just understanding how human beings think we're not perfect. We're not machines. You know, we're gonna make mistakes. And I think this understanding that you know, understanding that we're not going to absorb every piece of information that's given to us. I think it's important realization, that's sort of what inspired me to get more and more involved in this area.
David Feldman MD, MBA, FACS (Host): Interesting, fascinating that the, that you came out of through an education lens, which is really amazing. But it does, speak to the fact that now, especially here we are, a couple of years into this pandemic and people don't want to be lectured to anymore. They want to be involved. They want to be participants. And you've got some great data to show that, that really helps people retain things right. By actually participating in these things sitting in a lecture hall just doesn't work anymore. So great insights. Great insights. Tell me why do you think it's been so difficult? I mean, you obviously get this and obviously people that you work with, get it, but why is it so difficult to get other clinicians, especially physicians interested in these kinds of programs? You go around the country and you look at SIM programs and there's a lot of residents and nurses, but where are the doctors? Why is that so hard?
Dr. Amish Aghera: Well, it's a paradigm shift and a. You know, it's hard for people to change, right. Again, it's sort of, it's ironic, right? Like understanding human factors that has to also do with understanding that we're just not good at getting uncomfortable, and change is uncomfortable. A lot of doctors go into medicine because of, maybe things that are a little sexier, you know, as an emergency physician, you're talking about resuscitation and critical skills training and airway management. And it's really easy to get people to talk about that or review the latest journal article. Right. learning about handoffs, even though that's what, makes up a larger percentage of your day. You know, it just, it doesn't excite people. So figuring out how we can get people excited about this, I think is helpful.
David Feldman MD, MBA, FACS (Host): Yeah, interesting point too, right? The difference between these so-called technical skills, I'm a surgeon. That's the things that we always focus on, but the non-technical skills are equally, maybe in some cases, even more important when we try and think about how to make things safer and reduce the number of adverse events. And it is much more difficult. You know, it sort of reminds me when we started working with ED physicians like you years ago in the simulation space. And we said, well, really we'd love to work on handoffs and all these sort of non-technical skills.
But I think you and I talked about this years ago, it's just going to be too hard to engage people. Let's start with some of the technical stuff, right? Like the intubations and the central line placements and the chest tubes and so forth. But you were really instrumental in helping me get these things off the ground. How were you able to lead a program across multiple large institutions that we worked with? How did that go for you?
Dr. Amish Aghera: Well, I think for one thing, it helps to have, people on your side and especially, you know, the quote unquote stakeholders, right. Actually I'd like to thank you because you are part of that process. I guess, you know. I think sometimes it's, the more I do this, the more I appreciate Kotter's change model, and thinking about, okay, who are the people who are going to get things moving at a higher administrative level, but then it's also about, you know, who are you going to work with? who's that working coalition, so to speak? You can't really lead a group of people if people aren't interested, finding those like-minded individuals is super important.
And then, y ou alluded to it, you know, starting with the technical skills, trying to find projects that people are excited about. And that was a great way for us to start, getting people into the simulation center. Something they've never done before. starting with things like, you know, airway management, right. They realize like, Hey, this is really useful. And then when they come back, you can do communication training. You could do things like clinical event debriefing. Cause they've kind of bought into the process. They've started to get this idea of reflection and thinking about how they practice it.
And that's part of what human factors is about. Right? It's about thinking how we think, and then putting systems in place to help augment that.
David Feldman MD, MBA, FACS (Host): It makes a lot of sense. just switching gears a little bit here Amish, you're aware that one of the first programs that we didn't, we put into place to address human factors was the institution of radio-frequency chips in the surgical soft goods, you know, the lap pads and sponges and so forth. And this is almost 10 years ago at all of our institutions. And we're publishing an article coming out now in the Journal of the American College of Surgeons that details the significant reductions we saw as a result in retain surgical items. Do you think there are other applications of this kind of approach in areas beyond surgery, like in the ED how can we make use of this kind of technology and approach and in reducing events in places where you work?
Dr. Amish Aghera: Oh, that's a great question, I think we'd love to get RFID tags into our ED or different places in our hospital. There's a few different applications for them, above and beyond tracking equipment, like routine sponges, one is thinking about putting them on your patients and understanding flow, how quickly they move through the hospital system. Thinking about putting tags on patients that can't advocate for themselves, thinking about that patient with Alzheimer's, who's sitting in the corner of your emergency department you know, they can't answer for themselves if their name is called out. You can use it as an extension for two factor identification, right.
For doing timeouts you know, for doing giving people, medications. There was an interesting article I read about putting RFID tags on staff and thinking about strategically placing sinksand hand sanitizing stations based on t routes people are walking in their clinical You know, it's much easier for people to keep their hands clean, which we know is so important for infection control, if they're just not anywhere near a Purell or a sink. So, definitely lots of opportunities to help sort of augment the way we're using a little bit of technology that's out there.
David Feldman MD, MBA, FACS (Host): It's really great when you think about it, think about how busy EDs like yours and all the others in, well, probably everywhere, but especially in places where you work in New York city. And it's such a crazy place, where our people to have an idea and know where everybody is. Where's the patient is, is the patient in cat scan or are they back yet? And without having to go anywhere there it is for you on a screen. I love the idea of patients who can't advocate for themselves, literally advocating for them. Like, Hey, this patient's here and nobody's been buying a while.
Let's make sure that they're okay. And where are we in their workup, if you will. I think that's a wonderful idea. So as we put all this together Amish, lots of our listeners are thinking like, what would I do if I'm a hospital, patient safety leader, and I want to start developing these kinds of programs and human factors and simulation, what's the first step they should be taking? Where do they start?
Dr. Amish Aghera: Well, part of it is thinking, carefully about how they're going to start and picking projects that seem relevant to those on the front line, the kit, your care providers. We know that there's always going to be a certain programs that are. maybe higher risk, but thinking about just starting off with that lower hanging fruit, and getting people kind of bought in the thing that I see a lot in the simulation spaces is hospitals invest in building full of equipment. If I was to quote one of the fathers of simulation and anesthesiologists, who, originally practiced in Stanford, David Gabba, talked about simulation as a technique and not a technology. So I for institutions to invest in people to know how to leverage, things like simulation-based training, having people who really understand and are experts in safety science to help modify your clinical spaces with things like RFID tags, right. Building a better work environment. I think that's a great way to start thinking about this and maybe a little bit of a paradigm shift for us as well.
David Feldman MD, MBA, FACS (Host): Yeah, great points. Great points. Thank you so much, Amish for joining us today and thank you all for listening to our Leading Voices in Healthcare podcast. Visit our This email address is being protected from spambots. You need JavaScript enabled to view it. to learn more about the services we provide to healthcare professionals.