The Medical Human Performance Improvement Movement

custom_pill_pack_16502Do you know what is happening in the field of medicine to improve outcomes? Have you been as curious as I have been? I have only seen a small peek inside this huge community that truly cares about getting this right. Dr. Kristin Klein (from the University of Michigan College of Pharmacy and Health System) and I started collaborating on the subject of Pediatric Pharmacy Error Reduction in November 2015 and developed a living presentation (constantly being updated with new data) with intentions of writing a white paper. Since January 2016, it has been presented to over 500 workers in the field of Pharmacy (pharmacy technicians, pharmacy residents, pharmacy students, pharmacists, etc.) most with specialty in pediatric pharmacy. We also shared an update on our research with a poster presentation at a patient safety conference in early April. The goal of this project is to determine event prevention best practices and see if introducing interventions like human performance tools are valuable to the medication use process, which sure seems like they would be.

The Medication Use Process

The medication use process has only five (simplified) layers to the system, yet pieces of it are cause for the error that leads to events that may involve our children. We’ve been asking the right people where the system is most susceptible to error and seeking recommendations to prevent events.

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This is always personal

As far as I know, I have never specifically been involved in a medication error other than having a doctor give me so many different prescribed meds, that my heart started palpitating and I soon after found a new physician. I have also been involved in communication errors that were devastating to me emotionally, but not physically – both being errors where the medical staff assumed I knew the person I loved was already passed away, and in both completely different situations, I had to figure it out in person. This obviously gets very personal, and we all have our own stories, because we all need medical care at different points of time in our lives. So, can you imagine the amount of possibility for error that exists on a daily basis in this enormous field with language barriers, long hours, lack of qualified personnel (because these jobs should pay more), and a myriad of other factors that contribute to error.

Some numbers to educate, scare, and caution you

Hospitalized patients, regardless of age, are susceptible to one medication error per day, and 1999 data shows that the third leading cause of death in the United States is preventable medical errors that account for 44,000 to 98,000 people dying each year.

What is PPAG?

The Pediatric Pharmacy Advocacy Group is an international, nonprofit, professional association representing the interests of pediatric pharmacists and their patients. They are dedicated to improving medication therapy in children. Their sole purpose is to promote safe and effective medication use in children through communication, education, and research.

Our presentation starts:

 Dr. Timothy Todd introduces us:DSC_0353


Rights are Tools

Geared towards nurses in the administration process, the video links below explain 10 “rights” which actually represent human performance tools:

10 Rights of Medication Administration

  1. Right Patient
  2. Right Medication
  3. Right Dosage
  4. Right Route
  5. Right Time
  6. Right Documentation
  7. Right Client Education
  8. Right to Refuse
  9. Right Assessment
  10. Right Evaluation

Video 1

Video 2

We actually are speaking a similar language

Medical professionals call a “Sentinel Event” what nuclear power stations would consider a “Site Clock Reset.” Both terms hold groups of errors that lead up to events of significant consequence, but Sentinel Events will typically involve a legal aspect, as well, which is rarely the case in commercial nuclear power, because asset damage or shutdowns may not involve human harm at all.


The road to improvement starts with care, and everyone I’ve ever spoken with in the field of pharmacy cares about patient safety. “Caring” alone, certainly isn’t enough to bring about enough change, unless people in the right positions care enough to prioritize advances in those areas most susceptible to error. Unfortunately, it seems as if pharmaceutical providers feel like the entire medication use process holds opportunity for mistakes.

9 Questions and Answers for New Human Performance Practitioners

woman_interview_hand_shake_12435Full-time equivalent (commonly called FTEs) positions in this field sometimes rotate through without spending more than 2 or 3 years in a given Human Performance Practitioner position. Some of us figure out that this has the opportunity of becoming a life-long passion and will stick with it for the long-haul, but that is definitely a small community. This role can be like opening your eyes to a new perspective on how people work individually, and as a group. You will hear that it is all about behaviors, but that is not entirely true – it is also about the pressures and the processes in place when work is being performed or prepared, and the systems that people work within and put up with day to day.

1 – What is my position title at other companies?

I’ve been doing this since 2007 and these are the titles I’ve come across, all with the same major goals and functions in mind:

Human Performance and/or Work Observation:

  • Program Owner
  • Coordinator
  • Manager

Sometimes the word “Station” or “Department” is in front of that title, as well. This role could be known as “Resilience Engineering,” as well! My last director and I preferred to call it Event Prevention over Human Performance.

2 – What is my mission?

Well, this may sound weird, but this role is specifically designed to help organizations prevent events, and everything that doesn’t support that function is useless noise. Some facilities, even commercial nuclear power, use this role as a dumping ground for investigation backlog or implementing corrective actions that really will have no value to your overall goal, but so be it – “other duties as assigned” applies here. Unfortunately, if you are under leadership who doesn’t really understand your true purpose to the organization, and you don’t put your foot down, you will end up in an almost entirely administrative role, and not really accomplishing your position’s true mission – preventing events.

3 – What should my elevator speech be?

This is one of the hardest things to consider the enormity of when just starting out, and a lot of us in these niche roles have a hard time quickly explaining to others our primary function. It is difficult to sum up what we do, but I think this covers most of it:

“My job is to help organizations detect, prevent, and correct events related to human error. I do this by measuring and analyzing data, assessing vulnerabilities, making and implementing corrective recommendations, and teaching management and the workforce about event prevention.”

4 – How should I assist in a Root Cause Evaluation?

You are there to cover the human side of an event. Understanding the system the workers were working within, and why their actions made sense to them at the time they made them may require some great interviewing skills, and certainly the ability to build and earn trust and rapport with the workers and leadership team members.

You also can teach the RCE team about human systems, types of errors, and aligning proper corrective actions that will actually work – for example, Knowledge-based errors require a Knowledge-based fix, etc. Also, that the human error corrective actions are in fact, SMART. You should also get the team to pay attention to controlling “antecedents” in order to affect behavior change. If you don’t know about Aubrey Daniels, read his book, “Bringing Out the Best in People.”

You should not be part of the RCE team, EVER. You should be an aide to them, this way your time is not dominated by the RCE mission, which basically requires you to drop everything else and focus on their primary goal, which takes you away from the rest of the organization.

5 – What do I need to know about metrics?

This is the most difficult area to discuss, since your organization most likely follows a  weak, but extremely popular model:

(number of events for last 18 months x 10,000)/ total worker-hours for that 18 month timeframe

Note: 18 months is regarding a fuel cycle for nuclear plants, so that number wasn’t arbitrary.

This number is unfortunately used by INPO to compare nuclear plants against each other for overall event performance, and has a full list of qualifiers for what constitutes an event, ideally, so no one nuclear plant can have a similar event and have it not coded as an event. Some stations even have a “management decision clock reset” that is designed to bring awareness to a station event, even though it didn’t meet the normal criteria. These events are not included in comparative data.

We know that there are two types of indicators:

Lagging – Measures of results or outcomes which represent where you are and what you have accomplished, but do not necessarily predict future accomplishments, and

Leading – Measures of system conditions, which provide a forecast of future performance; measures of organizational “health,” which can predict results and achievements.

We also know that excellent performance is about the PRESENCE of defenses, NOT the ABSENCE of events, which really reminds us that lagging indicators like the primary one used in our profession above are extremely disappointing and rarely a true representation of actual performance. New leading human performance indicators are necessary in our field for it to thrive.

6 – Who are my primary customers?

This may seem like a surprise to you, but the management team, starting with the 2nd level managers. Get them on board, and they will help you get the 1st line supervisors on board, and then they will help you get the workers believing that this program is not going away, and that performance improvement is a culture shift and new way of doing business in your company. It’s much easier to promote change with a smaller crowd of great influence. You will absolutely fail if you start with the workforce and try to promote the shift upwards. You will also fail by just working with 1st line supervision, because you most likely will be adding to their workload, instead of relieving some of it, and it’s hard to build rapport in that environment.

7 – What about Human Performance Tools?

These are ONLY used as a line of defense. The system should be resilient enough to withstand someone forgetting to use a tool. Note that NOT using a tool or lack of situational awareness should NEVER be a cause of any event, EVER. Know these tools inside and out (which are designed with two things in mind: obtaining and maintaining situational awareness), and remember that they are only to be used when they matter the most. I really disagree when I hear anyone (especially a practitioner) state that they are to be used every day, hour, minute, and second. You should disagree, too.

8 – How is this different than safety?

A lot of people struggle with having different roles in these lead areas, safety and human performance. Safety deals with knowing OSHA rules for many given situations, and qualifying people to use protective equipment and special tools like fall protection and oxygen sniffers. Safety falls under the umbrella of Human Performance and as a practitioner you should form an alliance with your safety team, and as a side note if you have an employee concern program, become acquainted with the manager of it.

I used to preach the notion that safety is about protecting people from the plant/grid and human performance is about protecting the plant/grid from the people. I don’t fully see it like this anymore. Industrial safety is about you going home the same way you came into work, and human performance is exactly the same thing. If you broke human performance up into two negative outcomes, personnel accident prevention (safety) and unanticipated system failure (operational upset where nobody gets hurt) I think you’ll understand my comment on the umbrella of human performance a little better.

9 – Do I need to be a good at training?

No, you need to be GREAT at it, and you need to be a great public speaker, too. It’s difficult to get there, but aim for a reputation where people can’t wait to come to your training or hear you speak on a topic. Get to be amazing at story-telling, and expose your passion for the subject material using many references to either case-studies, or your own personal experiences. I have seen people passionate about Human Performance Improvement, but not effective trainers or practitioners. So, if you love this work as I do, read and collaborate with as many past and present practitioners as possible. Find other people at other places that do what you do, and be one of the best of us.


Can you tell me about the Culture Speaker and Affective Survey you developed?

speaker_headphones_pc_4517Everyone I have shown the human performance “Culture Speaker” to gets a little excited about the presentation and the theory in the background. They even get more excited and start asking a lot of questions about the survey I designed that supports the input to it. I promised colleagues I would share some if it one day, and this post is the culmination of a lot of work, and my commitment to those conversations.

What is the Culture Speaker?

The culture speaker is the physical manifestation from the results of an Affective Survey. I created it with one goal in mind: to explain in one simple to follow picture the results of education theory as it applies to your culture’s attitude toward your existing Human Performance Program. Using a “Likert Scale” and knowing that a program is made up from a finite number of elements, survey questions are tailored to surmise leadership and personnel attitudes towards human performance at the time the survey is administered.

Okay, so what the heck is an Affective Survey?

Adults learn in three realms: head, hands, and heart, otherwise known as, the Cognitive, Psycho-motor, and Affective realms. If you have been a long-time follower of this website, the Affective realm had a lot of research and development work done by Krathwohl, and I have mentioned him and this realm in previous posts. A lot of people I have spoken with about creation of learning objectives in training consider Benjamin Bloom as the father of all learning taxonomies, but he lords over the Cognitive realm, specifically, as far as I can tell, and NOT the Affective, also known as the “Attitude” realm.

My survey has been used both in commercial nuclear power and transmission and distribution companies. The amount of survey questions range from 25 to 125 depending on the areas of your program and what you are focusing on, and take anywhere from 10-45 minutes to complete. For example, with a nuclear plant, I administered the 125 question survey in October and November, determined focus areas, and then followed up 10 months later with a 25 question survey – only covering areas that the organization was strategically trying to improve from the baseline.

The survey dives into the taker’s attitude towards parts of the existing Human Performance Program, or lack thereof. Areas of focus can reveal themselves and it helps kick off your strategic plan by knowing what areas need immediate attention, and using leverage from areas already working well.

Survey says


This is what it looks like – a speaker with sound coming from the middle. The louder the sound, the more the culture values that element. Quickly translate the survey results data to see that certain areas in this culture need to be turned up, so the organization is all at the same high-level of value. This depiction shows at a glance that Work Observations are already valued at this company, but human performance training, performance indicators, and an effective reward program are in need of enhancement, if improvement in these areas is desired. The goal of this was to keep it simple to look at and understand, without revealing all the theory of why it’s such an accurate model of culture value.


How are you tracking your improvement in value towards your Human Performance Program? My guess is you aren’t at all. I’ve never heard of anyone else doing that, yet. The best metrics in my opinion measure the strength of your event prevention defenses, and anything that helps you understand how the program is working and what areas are being valued or not. This is an avenue to help measure a baseline and any improvement that the organization attempts, and then to come back again after a certain amount of corrective actions have been put in place to see if things are actually changing.

Quick side note

If you are wondering (and you probably aren’t) why I would give this proprietary idea away to friends, colleagues, and competitors, I really don’t see it that way. My mission is to help companies have less events, and my profession has people that can be a major part of that goal. Some of us have a hard time figuring out where to start an assessment, and this gem is an awesome place to start. Also, I should point out for my own interests, the sanctity of the actual question content, and the theory behind how they transfer into the culture speaker are still protected.

Helpful Links:

How to create a Likert Scale

How to score a Likert test

Affective Context

Note for first-time visitors

I truly appreciate you stopping by and please don’t forget to click on the pictures… any picture in any post will always take you somewhere worthy, and usually to an applicable video.

14 Best practices of a conference poster presenter


Now you are a “poster presenter” – not only are you an attendee at a conference, but you have taken the time to put together a “call for posters” reply and it was accepted. First of all, congratulations for getting your thoughts and body of research in front of a peer audience! This most likely included an abstract and information about you and your background.

So, now what? What comes next? If you’ve never done this, the process can be very intimidating, but it doesn’t have to be. Identifying the constraints and limits of what you’re allowed to put together should be clear up front by the conference presenters. This process could basically be called a science fair for adults, and yes, your poster needs to rock with a market strategy if anyone is going to take a moment to check it out and care about it.

The following is a list of tips for the amateur or expert poster presenter to consider when putting a poster together.



Tip #1: Abstracts should contain something the conference audience would care about, not just the poster presenter.


  • Purpose
  • Introduction
  • Motivation
  • Problem Statement
  • Approach
  • Results
  • Conclusion

If you don’t know the answers to these questions, then your poster idea probably isn’t ready for your audience:

  • Why do we care about this problem?
  • What are you doing about it?
  • What was the result?
  • What are the implications?
  • How are you using this data learned?
Tip #2: Find the best software to meet your needs.

Figure out how big your poster needs to be and the best software to use to make it. MS Power Point works very well if you find a template. You have to zoom in to work on the design elements, but the product looks great when put together properly.

Tip #3: Plan your printer ahead of time.

Know where you’re going to have your poster printed. Use a great paper quality, and you probably should forgo lamination so you can roll it up for travel.

Tip #4: Plan your backing board.

Find out if they will be supplying backing board, and if not, purchase the backing board and have it delivered to the hotel where you are staying. Sometimes, conferences will give you some wall space, but you don’t want to be that person who looks unprepared.

Tip #5: Plan how you will attach the poster to the backing board.

Purchase backing board velcro tabs that stick one side to the other. Put them on the backing board first and use a friend to lay the poster on top and slowly rest your poster on top. Do not remove your poster until after the conference. You can roll up the poster and leave the tabs on for reuse if desired.

Tip #6: Know how you will travel with your poster.

Chances are that you may be on an airplane to get to the conference, so this is a definite consideration. Don’t forget to purchase a poster tube for travel! Plastic ones (approx. $25 from amazon for one that also telescopes for larger sizes) protect more against elements, and often come with a strap, which makes it easier for travel, as well.

Tip #7: Know how your poster will be displayed.

Easel stability matters. Find out if the conference location will be providing easels or purchase a collapsible one that is easy to travel with for about $16 from Amazon. I thought adding brochures and business cards to one of the legs under the poster would be a great way for people to literally take something away from the poster.

Tip # 8: Choose great eye-catching colors and stick to a theme.

If you’re supporting a school or college, considering using their colors. If it’s a business, consider playing off of the logo colors.

Tip #9: Use friendly fonts, and please not too many different ones.

Nothing appeals less to a poster visitor than blurry content, or something you cannot read.

Tip #10: Font sizes matter.

How far back from your poster should average vision people be able to read your large content or your smallest text? Consider this when creating text space on your poster.

Tip # 11: Use graphs and pictures to illustrate points.

People are visual and thats what a poster should be! If it doesn’t appeal to you and your friends, then why would it appeal to anyone else?

Tip #12: Be bold and make your poster interactive

QR Codes are pretty fun to play with and send poster viewers to a website or survey. You could be even more amazing (if your crowd was a little tech-savvy) and you directed them to download a free Augmented Reality (AR) App and have parts of your poster come alive! This may require some extra funding on your end, but AR is DEFINITELY coming!

Tip #13: Stand next to your poster so you can discuss it with visitors

This may not always be possible, but at conference break times and when people are up and looking at posters, try to be there to answer questions and show how committed you are to the content.

Tip #14: Do research on YouTube

There are tons of video ideas that will spark your creativity and help you get the most effective message across to your visitors.


Best of luck on your project, and feel free to send a picture of your poster! Here’s a recent pic from a Center for Patient Safety Conference in St. Louis, MO, of a poster depicting the research Dr. Klein and I have been doing.

Note the QR codes, brochures and business cards.


Human Performance Tool Spotlight: OOPS – Outside Of Procedure, Parameters, or Process – STOP

hands_time_out_signal_15943Holy cow, a Human Performance tool called, “OOPS?” Well, not really. It’s only an addition (or interpretation) to Stop When Unsure and Questioning Attitude. Using a Questioning Attitude (holding off on my argument that SWU and QA are not even tools at all, because these should be used all the time, and tools only when they matter the most) while performing work and you find a reading or situation off normal, STOP. This seems pretty simple and to the point. Staying engaged and thinking about the work.

So, let’s evaluate OOPS and why it’s possibly more effective than Stop When Unsure. The keyword being “Unsure” – it sounds like the worker doesn’t know what they’re doing – lacking training or knowledge to perform the task. This sounds accusatory and perhaps even with a little blame. What I’ve come to learn about people and Human Performance Programs are that words matter, and more people participate in a Good Catch program, than in a Near Miss one… even if the rules and avenues of capturing them are identical. We humans are a fickle bunch.

So, do workers have the authority to STOP work?

Every place I’ve ever been or interacted with, people have told me that they don’t always have this authority, yet one hundred percent of leadership team members I’ve spoken with have told me that everyone has the right to STOP work to resolve safety or potential Human Performance issues. If you are a leader, make it clear to your workforce that they have this authority and you expect them to use it. I am positive there is a disconnect in some companies on this point.

What is a Time Out?

Some workers and leadership team members do not like this verbiage, because it sounds childish. [Suggestion from a friend on LinkedIn: Jeffrey Meade, P.Eng. re: Time Out… If you use this, present it with sports imagery to remove the childish/punishment vibe.] Call it whatever you want, but make sure the job stops to get issues resolved. This is where the performance improvement happens. No need to rush through and get something wrong, or hurt someone. Here is the description:

  • A time out is a brief stoppage of work to allow workers, their supervisor, or other knowledgeable persons to discuss and resolve the issue(s) such as uncertainty, doubt, confusion, or if questions persist before resuming the task.
  • Every person has the responsibility and authority to STOP work when uncertainty exists, even if it seems simple and straightforward.
  • Once the issue(s) have been resolved satisfactorily, it seems most pertinent if the person that called for a time out should be the one to then call time in so work may resume.
When to STOP

–When encountering conditions inconsistent with procedures

–When outside bounds of key parameters

–If conditions are different than expected from your pre-job brief

–When inexperienced or lacking knowledge of task

–When uncertain or confused

–If beyond scope of the plan or process

–When unexpected results or unfamiliar situations are encountered

–When something expected does not happen

–When someone else expresses doubt or concern

How to STOP

If you find yourself Outside of Procedures, Parameters or Processes – STOP – and CONTACT your supervisor. Errors can be prevented by properly using written procedures. OOPS is a strong method that can be used effectively to prevent errors due to proceeding in the face of uncertainty.

From this point on I’m going to share some nuclear procedure “Stop Work Criteria” which involves when to stop, the leadership approved response, and when to start work back up. This may seem like overkill, but when trying to explain this in a very regulated world, this helps it all make sense and also protects the sanctity of the worker’s authority to stop any job.

Stop Work Criteria:

Stop work and contact supervision whenever a stop work criteria condition is encountered. There are any number of things that should cause one to stop work and get help from supervision. The following are (a long list of) examples:

Job surrounding issues:

  • Unusual noise, smell, heat; insufficient lighting, etc.
  • Unexpected job hazard is present
  • Unexpected configuration control bumping hazards are present

As-found equipment conditions:

  • Components are not in expected condition
  • Component labels are not applied or are confusing
  • Component label does not match controlling document (ie: clearance,
  • EDT/EST or Danger Card on equipment to be tested/worked on
  • Work can not be performed as planned/briefed
  • Deficiencies are found in WO package (or instructions are unclear)
  • Procedure can not be followed as written
  • Plant drawings and components disagree

Work performance issues:

  • Unanticipated energy (pressure, voltage, etc.) is encountered
  • Equipment does not respond as expected
  • Loss of pre-established communications
  • Unusual component wear, FME, etc., is observed
  • Need for expanded scope or manpower is identified
  • Test equipment, tooling, parts, etc., do not perform as expected
  • Deficiency identified during rounds on safety-related components

Changes occurring during work performance:

  • Plant/radiological changes in the vicinity of the job
  • Audio/visual alarms (Emergency Plan, Area/Plant Fire)

Event occurrence:

  • Mispositioning of a component
  • Clearance process issue
  • Spill or significant housekeeping issue
  • Vehicle accident
  • Injury
  • PMT performance issue
  • PMT cannot be performed as specified
  • Insufficient resources (including required observers)

Any time you find yourself outside of process or procedure (OOPS) or are uncertain

Supervisory Response:

The following guidance outlines expected actions for supervisors to help ensure an effective response to an OOPS notification.

Thank the individual for stopping work to ask for your help. Questioning attitude and involving supervision are two keys to preventing events should be positively reinforced.

Ask the individual:

  • How did you discover the condition?
  • Why did the condition occur? (Clarify goals)
  • What does your controlling document state? Show me the document.
  • What is your recommendation?

Ask yourself:

  • Does the documentation need to be changed?
  • What expertise do I need to help the condition? (Eng, Maint, etc.)
  • Do I need to use the Operations Decision making model?
  • If there is an equipment deficiency, should we just stop and get it fixed?
  • Am I too close to the issue?
  • What is my recommendation? Who will challenge me? (peer or SM)
  • Do we need to stop and re-brief?
  • Where will we document this?
  • Are my standards high enough?

Consider positive reinforcement for the individual. It is important to reward the behavior of stopping if you want it to happen again. The positive reinforcement can offset the negative reinforcement of having to do more work to ensure events are prevented.

Resuming Work:

Work/testing should not resume until authorized by supervision, which shall ensure the following:

  • Any job surrounding issues have been corrected or addressed. Noise, heat, etc., issues explained satisfactorily and/or corrected. Bumping hazards removed or compensated for.
  • Components which are not in expected condition (or which contain EDT/ESTs) are dispositioned by Operations. New labels are applied. Component label or controlling document is corrected, or supervision has approved continuing with work activity.
  • WO’s, procedures, drawings are corrected/clarified.
  • Clearance is addressed as necessary. Operations/Engineering dispositions unusual equipment response, wear, or out-of-spec conditions, etc. Communications systems are corrected. Test equipment, tooling, parts issues are addressed. Work Management/Planning is notified of expanded work scope/manpower needs.
  • Plant condition/radiological condition changes are reviewed with Operations/RP, and work is re-authorized/re-briefed, as required.
  • Immediate help is acquired, as needed. Management is notified. IR’s generated. Department head approval is obtained before resumption of task.
  • PMT is corrected. All specified resources required to satisfy PMT requirements are on hand.
  • All other open-ended issues related to the concern are addressed.

I dug into some of my archived old Human Performance nuclear procedures and some of the training I’ve put together over the years to develop this post with no particular reference to anywhere other than commercial nuclear industry procedures. Thank you.

Click here for a pretty amazing safety video I found while doing research for this post. 

Click here for a video on Stop Work Authority.

Click here for another video on Stop Work Authority.