Applied education for safer healthcare: From human factors understanding to systems change

Healthcare has never been more technologically capable or more complex. Ageing populations, multimorbidity, workforce pressures, new models of care and the rapid introduction of digital technologies and artificial intelligence are changing how healthcare is delivered. Yet the systems in which healthcare professionals work are not evolving at the same pace.

The result is familiar to anyone working at the frontline: workarounds, bottlenecks, poorly designed processes and technologies, and risks that are often visible to staff but are consistently challenging to address.

We are getting better at recognising that patient safety problems are rarely attributable to individuals alone, though there is still a long way to go. But recognising that problems are systemic is not the same as knowing how to redesign the systems that produce them.

If we want safer healthcare, we need to move beyond a light touch awareness of human factors towards developing the expertise to deliver meaningful systems change.

Human factors is more than ‘non-technical skills’

In healthcare, Human Factors/Ergonomics (HFE) has sometimes become shorthand for communication, teamwork, situation awareness and other so-called ‘non-technical skills’. These are important, but they represent only one part of a much broader discipline.

HFE is concerned with understanding interactions between people and all the other elements of a system, and using that understanding to optimise both overall system performance and human wellbeing.

That means looking beyond the individual clinician or team and considering the design of equipment and technology; physical environments; staffing and workload; tasks and processes; organisational structures and culture; information flows; regulation and policy and, crucially, the interactions between them.

The distinction matters because interventions focused primarily on individual performance can leave underlying system weaknesses untouched.

Consider a medication administration problem. Training staff to be more vigilant may temporarily reduce errors, but what if the underlying problem involves confusing interfaces, interruptions, poorly designed storage, competing demands or unreliable information flows?

A systems approach would investigate how these factors interact, involve staff and patients in redesigning the process, test potential solutions and evaluate whether changes improve safety without introducing unintended consequences.

The aim is not to help healthcare professionals cope more effectively with poorly designed systems. It is to design systems that make safe, effective care easier to deliver.

From understanding problems to implementing solutions

Healthcare has made considerable progress in adopting systems-based approaches to safety investigation and organisational learning. However, identifying contributory factors is only the beginning.

The harder challenge is translating that understanding into sustainable improvements.

This requires capabilities that extend beyond incident analysis: understanding work as it is actually performed, analysing complex interactions, applying human-centred design, testing interventions, managing organisational change and evaluating their impact.

For example, introducing a new digital system is not simply a technology implementation project. It changes workflows, responsibilities, communication patterns and the distribution of cognitive workload. Without a systems perspective, technology intended to improve safety can inadvertently introduce new risks.

Systems thinking tells us where to look. Human factors and systems methods help us understand what to change. Implementation and evaluation help us establish whether those changes actually work.

Bringing these capabilities together is essential if we are to move from repeatedly identifying problems to systematically designing safer healthcare.

Safety expertise needs professionalisation

This raises an important question: who has the expertise to undertake this work?

Healthcare organisations rightly expect substantial education, assessment and professional development from people taking on specialist clinical roles. Yet responsibility for improving the safety of extraordinarily complex healthcare systems has often been given to enthusiastic clinicians and managers who have acquired their safety knowledge piecemeal through short courses, local initiatives and experience.

Safety remains everybody’s business. But there is an important difference between expecting everyone to adopt principles of safe practice in their day to day clinical work and expecting everyone to have the expertise required to analyse, re-design and implement change in complex work systems.

The work of analysing, re-designing and making change to complex systems demands people educated in systems thinking, HFE, safety science, human-centred design, implementation and evaluation. We need recognised competencies, credible educational pathways and professional standards. HFE in the UK already has such a professional framework through the Chartered Institute of Ergonomics and Human Factors (CIEHF), including pathways towards Chartered status. Healthcare should make much greater use of this existing professional expertise.

Learning from other industries (not just copying them)

There is much we can learn from aviation, nuclear power and other safety-critical industries. HFE has been embedded within many of these sectors for decades, alongside systems engineering, independent safety investigations, simulation and professional safety expertise.

Healthcare has already borrowed successfully from elsewhere. Crisis resource management in anaesthesia was developed from approaches used in aviation, while early critical-incident approaches drew on methods originating in military aviation.

But learning from other industries does not mean copying them uncritically. Healthcare is a complex adaptive system with distinctive characteristics.  For example, the majority of care is co-produced with the patient, rather than simply provided as a service.  Another characteristic unique to healthcare is that many treatments involve known harms, as when we make a surgical incision or administer drugs with a profile of side effects.

These characteristics of patient care make healthcare settings very different from a nuclear power plant, whose customers do not enter the premises, or aviation, where interactions between crew and customer are quite different in nature than interactions between a healthcare professional and their patient.

Clinical work contains uncertainty, variation and competing goals that cannot simply be engineered away. The transferable lesson is not that healthcare should become aviation. It is that safety-critical industries take the science and profession of safety seriously. They recognise that safe performance emerges from the interaction between people, technologies, tasks, environments and organisations rather than from exhorting individuals to try harder.

Building capability through education

This thinking has informed the development of a new postgraduate programme in Healthcare Systems Safety at the University of Oxford, led by clinician researchers and human factors experts in collaboration with colleagues in Engineering Science and Experimental Psychology. The proposed programme brings together HFE and systems thinking with implementation science, human-centred design, safety research methods, simulation and the safe integration of AI and emerging technologies.

Importantly, the ambition is not simply to transmit knowledge. Students will apply systems methods to real problems in their workplaces, learn alongside professionals from different backgrounds and develop a community of practice capable of supporting change beyond the classroom. The programme is also being developed towards CIEHF accreditation, connecting postgraduate education with wider professional recognition in HFE.

Ultimately, education matters because changing how people understand safety changes the questions they ask. Instead of “who made the error?”, we can ask “what made this action make sense in this system?” Instead of “how do we make staff more resilient?”, we can ask “how do we design work processes that support people to succeed?” And instead of treating safety as something we evaluate after care pathways have been implemented, we can make it a fundamental design requirement from the outset.

If healthcare is serious about becoming safer, we need to develop not only safer clinicians and teams, but people with the expertise to understand, design and improve whole systems. That requires education and it requires us to recognise healthcare systems safety as a professional discipline in its own right.