VALUE
IMPROVEMENT
LEADERS
TOPIC #20
800 words + 2 activities  | 30 minutes (4 to read, 25 minutes for video)
FORCING FUNCTIONS
PRINCIPLE
Human memory is not reliable enough for critical tasks whether routine or rare. 

TOOLS
• Mistake-proofing mechanisms
• Computer automation
• Immediate mistake detection

APPLICATION
Examine your daily life for examples of mechanisms and process techniques that prevent you from making mistakes and think about how you can apply similar techniques in your process.
It Was So Easy That I Forgot To Do It

Every morning you grab your keys and your phone and you go to work. It’s nearly a sub-conscious action. I put my car keys next to my phone charger at bedtime to avoid forgetting my phone the next morning. How do I remember to take my keys? I need them to start my car. I can still forget them but the impact is minimal because I’ll just walk back inside and get them. It’s a much bigger problem if I don’t discover my forgotten phone until I’m at work. Ah! But how do I remember to put my keys with my phone each night? I depend on my memory and my memory is NOT reliable.

Have you ever “memorized” the 3-5 items you needed from the store and arrived back home minus one item? What happened to your system? What was the flaw in your process?
Reactive vs. Cognitive

Routine tasks become “automatized” to borrow a term from the study of human factors. We are at risk for error any time a manual task becomes so common that it is executed with no or very limited cognitive requirement, such as taking your phone to work or shopping with a short list.

You might take offense at the suggestion that you do anything with limited cognitive requirement. Consider driving, specifically steering and braking. These are quite important tasks. They are also so common they’re “automatized” for us… They are “unconscious” actions. Neither term is scientifically accurate, but you get it. They are vitally important AND they are dull. Fact is, steering and braking require our reactive skills rather than cognitive skills.

Don’t mistake talent or knowledge for recall . Heck, memory isn’t even the same as recall . Recall implies the need for a specific bit of information to be plucked from the right synapses at the right moment, given a specific set of circumstances, under stress. When we prescribe the use of forcing functions, no one is calling into question our talents, knowledge, or memory. We are merely acknowledging that some actions are too critical to depend on the fallibility of human recall.
Forcing the Correct Actions

A forcing function is a mechanism designed into the workflow to prevent a specific error or reduce its impact. Put rather bluntly, they force the proper actions to be taken. A shopping list is a basic forcing function. Not all shopping lists are created equal, by the way. 
Another common example is the common three-prong plug. You can’t accidentally plug it in wrong. Nothing’s to stop you from snipping off the ground prong and intentionally plugging it in backwards; forcing functions are not intended to prevent intentional wrong-doing. 

Most processes have many opportunities for error including errors of omission; more than you could possibly prevent with forcing functions so teams must consider the severity, the likelihood, and the detectability of the error. 
Forcing Functions: The High Reliability Cousin to Standard Work
The last article linked to standard work for a central line dressing change . The design team designated the sequence of steps and use of proper materials as critical to a high quality dressing change, as is reflected in the document. The team knew from first-hand observation that these critical process steps were often skipped. 

Among its other benefits, standard work decreases quality errors but it doesn’t force the correct action. The document was designed in good faith but never integrated into the workflow because no one believed it would be used properly in a highly dynamic intensive care unit and so they adopted a forcing function: specialized packaging. (Photo shows the only part of the kit.)
As a nurse unfolds the packaging, the proper materials are revealed in the proper sequence, numbered and annotated with icons and keyword instruction, according to the best practice standard. Nurses can deliberately choose to skip a step in the standard process, but they can’t do so accidentally. Like standard work, forcing functions are designed by and for trained personnel, and neither is designed to thwart deliberate actions of personnel who knowingly deviate from the standard process. 

For a small extra cost, this packaging as forcing function raises the reliability of the process dramatically. As of this writing the packaging is in the final stages of development.
Here’s the Video
This video, called the Cost of Poor Quality is longer than most (25:20). I discuss topics including the costs associated with error prevention, the concept of risk assessment which humans are notoriously bad at, the principles of forcing function design and how to facilitate their design.
LINKS

Quickly locate all course videos, slides, and previous emails here .
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Questions? Email:  kim.mahoney@hsc.utah.edu