Human Factors and Hernia Repair - What you were not told......

 

I have written about hernia repair and recurrences previously.

A fairly common surgical procedure such as hernia repair involves a number of human factors.

Pause now, think and imagine the human factors involved in a successful routine primary inguinal hernia repair.

 

So I asked AI (ChatGPT)

What are the human factors involved in a successful primary inguinal hernia repair?

Chat GPT answer was:

The human factors behind a successful repair can be summarised as:

Preparation → situational awareness → effective communication → teamwork → appropriate challenge → cognitive flexibility → ergonomic working → fatigue management → reliable checking → reflection and learning.

Claude gave this answer to a similar question:

The dominant human factors challenge is therefore data capture, audit culture, and willingness to have practice scrutinised, rather than technical dexterity alone.

 

If you were a surgeon, or an anaesthetist, or a theatre nurse, or any member of the surgical team, that is exactly what you would have been taught as human factors.

Those would be true for variables that do not have a technology based physical design solution.

One of the important crucial end points of a successful primary inguinal hernia repair is the recurrence rate.

Historically, the recurrence rate was 30% to 40%.

Currently the recurrence rate is 1% (in some research publications) and up to 10% in practice.

Were the surgeons of the past technically incompetent? Has the groin anatomy changed? Were the surgical teams of the past not paying attention to the human factors listed above by Chat GPT?

I don’t think you would say yes to any of those questions.

What made the difference was the introduction of a physical technology based design in the repair of an inguinal hernia – a MESH.

That reduced the recurrence rate.

Every behaviour based  point mentioned above and repeated here, namely Preparation → situational awareness → effective communication → teamwork → appropriate challenge → cognitive flexibility → ergonomic working → fatigue management → reliable checking → reflection and learning; are important as an additional layer on top of the physical design but unlikely to make a significant impact on their own.

 

Healthcare Human Factors is so distorted that we do not readily consider physical technological design as a component, never mind the main component of human factors.

 

I address this issue extensively in my book : “Look for the design – Clinical Human Factors – Humans execute and ‘machines’ guard.” https://www.amazon.co.uk/dp/B0HC4M1ZBT

The above example is not in the book but is a bonus for the readers of my blog.

Give the book a read and let me know what you think.

 

 

https://www.amazon.co.uk/dp/B0HC4M1ZBT 

Guarantees in Healthcare

I would like you to take a moment to think about what is the longest guarantee period offered for a product that you know of. Months, years, decades? What about life-time guarantee? For instance Toyota offers an 8 year guarantee for their Prius battery for the electrical motor part of their hybrid system. Some manufacturers and some body works repairers offer life time rust proof guarantee. Pizza companies say that you can have the pizza for free if it does not reach you within a defined time after your order. Well you can surely name a few more yourself.

Here is a jaw dropping guarantee. 2000 years.

Yes, you read it right The Sweet Little Sugar Softener offers a 2000 year guarantee. Yes that is offered for a product that is very simple. Okay, I am not sure if any of us are going to be around for 2000 years to vouch for this. But just imagine the confidence of the manufacturers in their product that they are able to offer it. It is a product made by simple artisans in rural America, not highly educated, with no great facilities etc


Guarantees in Healthcare

Health care is full of educated, highly intelligent and motivated people. Many if not all clinicians would have two post-graduate degrees. Healthcare managers and insurers are very large players in terms of the total money spent on healthcare especially in the western world. What kind of guarantees can healthcare offer to patients? As far as I know, none. In fact, professional bodies may not look at you very kindly if you started offering any guarantees, they will come down on you with a tonne of heavy scientific bricks and with a high moralistic tone accuse you of potentially misleading patients. Why is that? Why is it that healthcare which consumes so much of our resources unable to offer any sort of guarantees to our patients?

It is high time that we started backing our intelligence, education and skills and experience to think about what guarantees we can offer our patients and how we can make those guarantees work. We then need to put some money to back those guarantees. Doctors should perhaps take the lead on this one. Doctors always claim that they are consistently in the top 2% of the top performers in the society - well that is indeed true. If the top 2% performers cannot guarantee any of the activity they do and back it with some money we do need to either question their performance or their motives.

Healthcare needs some guarantees, patients need some guarantees. Yes, you healthcare folks, time to up your game, I know you cannot yet reach the level of guarantee offered by rural native American artisans but surely you could start with something small. How about no charge for patients if their bowel anastamosis leaked? How about completely free care if you did not meet the expected discharge date? How about paying a penalty to the patient every time you cancel or postpone their appointment/operation/etc.

Healthcare just dazzling and blinding people with asymmetrical power, high intelligence and skills is not simply good enough any longer. It has to be matched with some performance guarantees.

Being the change you want to see - the oft repeated Gandhian saying; on that basis let me go first.


OFFER OF MONEY BACK GUARANTEE IN HEALTHCARE
(possibly for the first time in the world)

One day the whole of healthcare especially doctors including me may be able to offer guaranteed clinical end results; right now it seems we cannot. So what can I guarantee can I give my patients? Before we get into that let me also explain that I work in the NHS on a salaried basis in a surgical department. NHS allows me to do private practice but I am not in regular/routine private practice. I cannot as an NHS doctor offer any individual guarantees to my patients. I am like the rest of the British people, own the NHS but do not run it. However I can offer some guarantees to my potential private patients.

Here are the guarantees I am willing to offer to any private patient who cares to find me and pay me a fee for service (self paying private patients).
Open primary inguinal hernia repair: if you have a recurrence within 3 years I will refund you the my fee i.e. the surgeon's fee.
Colonoscopy: if I do not reach the caecum (provided it was not poor bowel preparation or a confirmed bowel narrowing) and hence you had an incomplete colonoscopy I will not charge you my personal fee for the procedure.
Obviously all other charges will apply, have to be paid for and not be refunded.

As I have already said, right now I am not in active private practice. But if there were any patients who paid me privately for these two procedures that is the money back guarantee I am able to offer. If there were takers for this service/offer I might be stimulated to think of what further guarantees can be designed in healthcare.

What is important is if many others in healthcare provision are able to offer firm money back guarantees in healthcare. That might be a disruptive innovation in clinical provision. Let us go for it.

What are the guarantees that you are able to offer your patients?


Update: 1 Nov 2012: W Fischer informs me that there are guarantees in healthcare at Geisinger, Danville, PA since 2006. Very nice to know. So obviously I am not the first or the only. Here is a write up on their warranty: http://www.ihi.org/knowledge/Pages/ImprovementStories/GeisingerWarrantyonCABGSurgerySignalsCommitmenttoExcellence.aspx There are press stories about it, find it on the net. They do not seem to pay the patients any money back (I suppose that will be an issue for the insurers) but they do not charge the insurer to fix any complications.

©M HEMADRI 

Follow me on twitter @HemadriTweets