Human factors that influence the performance of the
Contents
1. Performance difficulties errors failures Why would this happen What might the solutions be Recommends inappropriate equipment Not trained adequately e Training needs to be standardised and reviewed e Trainers need to be given professional support e Trainers need to help assessors understand interoperability issues e Training and awareness of broader product range limited Training out of date e Competency in training to be recognised and assessed Did not have access to relevant information e Manufacturer s information designed to better match the user s abilities needs and the specification of the equipment e Interactive websites for assessors to use to improve their abilities for selecting equipment Equipment provided did not fully meet the needs of the end users Better information and training for assessors Provision of equipment needs regular reviewas changes in circumstances context of use are frequent e Better feedback of the problems and issues encountered to designers and managers Recommends inadequate or non optimal equipment Charging arrangements mean some clients cannot have additional appropriate sensors e Improved understanding to help with commissioning process 14 Source AKTIVE ELA database CIRCLE University of Leeds Human factors that influence the performance of the telecare system Table 7 10 Performanc2. State of science human factors and ergonomics in healthcare Ergonomics 56 1491 1503 HSE 1999 Reducing error and influencing behaviour HSG48 Hollnagel E Woods D D amp Leveson N 2006 Resilience Engineering concepts and precepts Farnham Ashgate Publishing Ltd Jun T Ward J Morris Z amp Clarkson J 2009 Health care process modelling which method when nternational Journal of Quality in Health Care 21 214 224 Keats S amp Clarkson J 2003 Design Exclusion in Inclusive Design Design for the Whole Population 34 pp 576 581 Springer Verlag London Leveson N G 2011 Engineering a safer world Systems thinking applied to safety Cambridge MA The MIT Press Nagpal K Arora S Vats A 2012 Failures in communication and information transfer across the surgical care pathway interview study BMJ Quality amp Safety 21 843 849 Nicolle C Abasca J 2001 Inclusive design guidelines for HCI CRC Press Obradovich J H amp Woods D D 1996 Users as designers how people cope with poor HCI design in computer based medical devices Human Factors 38 574 592 Rasmussen J Pejtersen A M amp Goodstein L P 1994 Cognitive systems engineering New York John Wiley and Sons Inc Reason J 1990 Human Error Cambridge Cambridge University Press Stanton N A Salmon P M Walker G H amp Baber C 2005 Human factors methods A practical g
3. Le akt ve The Role of Telecare in Older People s Daily Lives experiences practices and attitudes Working Papers from the AKTIVE project 2011 2014 AKTIVE Working Paper Human factors that influence the performance of the telecare system Pete Buckle The Robens Institute Guildford and Royal College of Art London Advancing Knowledge of Telecare for Independence and Vitality in later lifE Technology Strategy Board Driv ng Innovatior Published by CIRCLE University of Leeds April 2014 University of Leeds University of Oxford and the author ISBN 978 0 9928741 6 2 Online version http www aktive org uk Also available from CIRCLE Centre for International Research on Care Labour and Equalities University of Leeds Leeds LS2 9JT UK Tel 44 113 343 4872 Web http www sociology leeds ac uk circle Email CIRCLEadmin leeds ac uk Acknowledgements Research analysis and development of the working paper Data discussed in this paper were collected and analysed by the author and researchers responsible for the AKTIVE fieldwork Kate Hamblin and Emanuela Bianchera University of Oxford and Emma Reetta Koivunen and Gary Fry University of Leeds With Sue Yeandle who directed the AKTIVE project and edited the AKTIVE working papers these colleagues also advised on the content and development of this paper The author gratefully acknowledges their contributions Research participants The res
4. As no technology can reach such levels of reliability the industry is confronted with the need to demonstrate the extent to which the quality of the equipment meets the risk perceptions and therefore balance with freedoms of both the user and the carers Currently this does not appear to be happening What has become equally evident in this study is that where equipment does fail the legacy of failure is substantial In particular it may lead to a disproportionate reduction in the perception of reliability While this may not be reflected in the actual failure rate risks perceptions need to be studied more closely to ensure the industry can present data in a way that reassures those who are using buying or are reliant on such technology Such failures are of increasing importance given the advances in technology being made Increased technological capability and complexity albeit often with less transparency will become the norm in such applications Ensuring the humans in the system are comfortable with such advances may yet turn out to be the greater challenge Why failures are occurring at different stages in the process Failure or difficulties in achieving a given task have been studied in depth in many work situations Consistent patterns emerge as to why these exist There is a general consensus that those factors most likely to affect performance are as described in Table 7 15 This component of the AKTIVE study suggests that great
5. This information could be of great use to those who are in a position to investigate the reason for this change In particular it is recognised that changes in medication can lead to behavioural or physical changes Early intervention following warning signs such as increased false alarms to the monitoring centres could promote a proactive investigative response rather than waiting until a response of a more serious nature is required e g following a fall Mapping the information held in this complex network is a further important piece of research that fell outside the scope of the AKTIVE project suitable methods exist however and have been applied successfully in areas of healthcare Nagpal et al 2012 A simplified map has been prepared Figure 7 2 that identifies the key stages in the process of telecare provision This graphic representation of the process has been used to help categorise and present our findings on both the potential for failure and or on errors that occur within the telecaresystem Jun et al 2009 have provided an authoritative review of how such process maps can benefit our understanding of health care and it is important to recognise that they can and should be used in health and social care scenarios such as telecare provision Figure 7 2 Simplified process map of telecare provision Procurement Assessment Installation Client Use amp Monitoring Response 4m 4 Human factors that inf
6. Wilson and Corlett 2005 Stanton et al 2005 We do not believe this approach has been used in this manner with telecare previously and thus the research was ground breaking il Human factors that influence the performance of the telecare system 2 Methods The approaches used to research these elements of the system have been described elsewhere Yeandle et al 2014b and only the findings are reported here However it is worth re iterating that this component of the research set out with the intention of using Prospective Hazard Analysis PHA approaches These are standard practice in many high hazard industries including chemical engineering aerospace and nuclear power generation They allow a predictive and proactive approach and thereby offer potential for identifying problems in existing systems and more importantly opportunities for improving them Increasingly these methods are also being used in health care particularly for patient safety risk assessment Ward et al 2010b PHA is especially useful in developing systematic thinking regarding the identification of risk and the development of improved design of systems Previously PHA had seen only limited use in technology and health social care situations The application of these methods through the AKTIVE research study was therefore novel PHA is not a single method but rather an approach and a range of tools Ward et al 2010 that form a systemic systematic
7. Interviewer Oh so it s like a wristwatch type Mr Hodgkins Yes if I show you Like that right now that will be at the side of my bed and I will pick it uo and then I will have to lay it like that on the bed and then the difficulty is to get that strap through there Mr Hodgkins 70 memory problems living alone Leeds user of telecare package Example 4 Inconvenience I don t wear it overnight because if it sets up the call system it would take me ages to get downstairs even with the lift to speak to them Mr Hodgkins 70 memory problems living alone Leeds user of telecare package Example 5 Design too limited Ive got the thing that goes under the bed That s presumably in case you falls in the night or whatever Yeah I think it is OK but it s very difficult to give them a time when you actually when they say what time do you want it to active particularly in the morning because I think mine goes off at seven Well I mean I m always awake by then but what I tend to do is have a cup of tea and go back to bed So then when I get up about quarter to eight presumably if I fell then I would have to activate the alarm Mrs Wooley 83 falls living alone Leeds user of telecare package Size Im sure they can make it smaller There must be a way that they can design it smaller so that it isn t such a a bit of an eyesore not so uncomfortable for them Do you know where it is actually Daughter of Mr
8. and structured process to support the identification of hazards their potential consequences and hence risk The methods draw both upon existing system performance and failure data and on subjective sources of risk information obtained from those that have experience of the system s being assessed The following steps are usually considered necessary to undertake PHA 1 Describe the socio technical system 2 Generate a process description 3 Identify hazards prospectively i e where is the potential harm where might the system fail 4 Analyse prioritise and or quantify the risk arising from the hazards 5 Recommend mitigation and risk reduction or hazard elimination strategies Assessing the telecare system from this ergonomics human factors perspective has involved extensive system mapping Buckle et al 2010 stakeholder identification through workshops observational work by the research team and drawing on the ELA data and analyses However the complexity of the system only became apparent on completing step 1 i e describing and mapping the system This complexitymeant that it has not proved possible to complete all of the steps for a full PHA Nevertheless a substantive body of results has been compiled and analysed that addresses the first three aspects and enables recommendations to be made for mitigation and risk reduction or for hazard elimination strategies It has not been possible to quantify the risk as the data requ
9. cant Interviewer Al right so you can deal with it but your wife can t Mr Court She won t even change a programme for the telly cause she might press the wrong button and something might happen Mr Court 82 falls living with wife Leeds user of telecare package 7 Human factors that influence the performance of the telecare system AK E Example 4 Lack of crucial knowledge Mr Maveritt And then as soon as I get out of my bed I put this on and then I go wobble in there and get a quick wash And many a time I ve wet it forgetting Interviewer Well you know I think it s waterproof Mr Maveritt Js it waterproof Oh I didn t know that Interviewer Z think so yeah Mr Maveritt Oh I ve been terrified Interviewer Yeah I think they re all waterproof You can wear them in the shower Mr Maveritt OA I never knew that Crikey Interviewer Did they not tell you when they brought it Mr Maveritt No Tve never heard that Oh well Mind you when I think about it you know a person can you do fall in showers and that Mr Maveritt 71 falls living alone Leeds user of telecare package Example 5 Demonstration of how to use equipment 1 Mr Peters Sorry we can t give you more info about the technological gear but I really do need somebody along to just get me up to speed on it And I don t think it honestly I don t think it will be long I suppose we talked so long about sett
10. decision makers and managers Examples of latent failures are poor design of equipment ineffective training inadequate supervision ineffective communications and uncertainties in roles and responsibilities Exemplars of these have been identified and design approaches that may overcome these deficiencies have been presented A new focus is now required on how future developments in telecare might aid activity engagement and quality of life for older people and those who care for them New design initiatives need both to take account of these systematichuman factors risk assessments and to protect users by building appropriate resilience into the system Levenson 2011 Hollnagel et al 2006 Much of the telecare observed in the study appeared to have been introduced to the users at a stage in their lives or illness when problems already existed or were well advanced This presents enormous design challenges The adoption of any new technology is difficult even with those with no impairments and where the benefits are self evident The challenge therefore is to enable familiarity with technology prior to the onset of a specific need Such familiarity is likely to be invaluable in overcoming many of the barriers and problems seen in this study The following quote from a participant in the AKTIVE project illustrates this Mrs Bentley s daughter explained ew things take a while to get used to We thought it was best to kind of start with thing
11. human factors experts and HCI specialists and or a poorly designed e Identify good examples of inclusive user manual instruction manuals Installers and assessors must be aware that the technology may not be fully inclusive of all intended users Cannot use equipment Fail to check user can operate e Ensuring that the users can operate it cont equipment and or that before it is left with is essential e g training instructions given location of the base unit may result sin user are understood users are being unable to hear or respond to the compliant alarms The need for a more resilient system perhaps with additional sound units should be explored Maintenance procedures did not form part of Equipment requires this study but should be reviewed and their maintenance e g carbon potential to include maintenance of user monoxide detector batteries knowledge as well as equipment should be considered e Need to overcome fears and suspicion regarding telecare equipment e Education and empathy to overcome Fear stubbornness lack of paziy Re barriers to use understanding or suspicion Will not use equipment Failure to use as aesthetically displeasing stigmatizing and e Reliability of the equipment will also be an important element in overcoming such barriers uncomfortable e Take opportunity to engage with the design community to improve the aesthetics of future telecare devices Assesso
12. may depend on the locality in which the service is provided For example currently training may be bundled with the equipment provided by manufacturers Because as shown in the AKTIVE study it sometimes fails to consider how one piece of technology links to and interacts with other pieces of technology within the system such training is often of limited value When telecare services in a locality have been fragmented for example through a commissioning process these problems are exacerbated Interoperability between equipment remains a major challenge The use of interoperability standards has worked in other sectors and it may be that further investigation of their potential application is required In addition keeping end users up to date with new advances in technology may require a resource that is readily available to all Currently such a resource would have to reside as a web based domain perhaps with an opportunity for end users to provide feedback on their experiences with specific items of equipment Initiation of reviews for clients has emerged as an important and urgent area to be addressed The longitudinal nature of the AKTIVE study has shown that changes in the circumstances of telecare users occur and that these can be both negative and positive They can also change abruptly or remain stable for long periods This presents a challenge for those who must review client user need One output from this study might be to make
13. ave any indication Interviewer Theres no like beep What s this Mr Lindsay No there s no beep or anything You just you just press it and there s nowt there laughs You know that s basically it Interviewer Yeah So really if it s attached to your belt and you re not looking at it you it could actually expire without you knowing it Mr Lindsay 65 memory problems living with wife Leeds GPS device user Example 2 Comfort Interviewer So are you still wearing it on your wrist every day Mrs Barnard Yes ldo Ihave been taking it off occasionally because it was beginning to yes Interviewer Itch Mrs Barnard Yes it was really It was beginning to get Interviewer Zs that when it s warm outside is that when it s warm Mrs Barnard J think it s just when it s on it s on for a long time so I think that I m better to take it off a few times Mrs Barnard 89 memory problems living alone Leeds user of telecare package 5 Human factors that influence the performance of the telecare system rl Example 3 Difficult to put on Mr Hodgkins t s not easy to put on because it may be my slight trembling but the difficulty is getting the strap threaded through and trying to control it at the same time So I ve found the only way I can do that is to lay it on the bed and put the strap on and try and adjust it and get it through It s getting it through the metal clasp initially
14. e difficulties errors failures Incorrectly installed Fail to check user can operate equipment Fails to check electrical integrity of equipment Fails to train user carer appropriately Fails to train user carer appropriately care home Fails to check that training in understood and users compliant Faulty equipment 15 Installation Difficulties Why would this happen Technical faults in system Installer not trained adequately Deficiencies in design and operating documentation Installer not trained adequately Installer not trained adequately Installer not trained adequately Installer not trained adequately Installer not trained adequately Manufacturer procedures if new Installers service engineers do not check equipment if reconditioned What might the solutions be Checklist for ensuring that technical faults are not overlooked Basic training for installers is required with a certificate of competency The quality of the documentation should be designed inclusively Those with visual impairments need to be considered Experts in inclusive design e g equipment instructions should be consulted Basic training for installers is required with a certificate of competency Equipment check to ensure that users can operate the equipment in an appropriate and timely fashion Basic training for installers is required with a certificate of competency Basic trainin
15. earch team is extremely grateful for the contribution made to the study by the older people who took part sometimes in difficult circumstances who allowed us into their homes gave generous and thoughtful interviews permitted us to observe their living situation and assisted us by completing diaries taking photographs and in other ways helping us gain a full picture of their everyday lives We also wish to thank their family members home care workers and others involved in their care who agreed to be interviewed or observed or who completed questionnaires These contributions were vital to the study which would not otherwise have been possible To protect the confidentiality and privacy of those who took part all names and some identifiable details have been changed Funding of the AKTIVE project The main funding for AKTIVE was provided by the Technology Strategy Board TSB which developed the scheme through which the project was funded in collaboration with the Economic and Social Research Council ESRC and the National Institute for Health Research NIHR AKTIVE industrial partners Tunstall Healthcare UK Ltd and Inventya Ltd also contributed resources to the project AKTIVE was originally funded under the name The Potential of Assisted Living Technologies for Older People at Home creating a knowledge base for businesses developing technology for dementia and falls contract reference number 400215 2592 25185 Human factors that inf
16. er attention needs to be paid to how each of these factors might adversely affect the performance of the current system Those factors shown in the table may and perhaps should be integrated into assessment forms installation instructions training of assessors and installers and management training 22 Human factors that influence the performance of the telecare system Table 7 15 Performance influencing factors Task factors Individual e factors Organisational e factors Clarity of signs signals instructions and other information System equipment interface is well designed labelling alarms error avoidance tolerance Difficulty complexity of task has been considered Routine or unusual tasks have ben identified Divided attention is avoided Procedures inadequate or inappropriate have been identified and rectified Preparation for any task is appropriate e g risk assessments checking when installing equipment Adequate time available required Tools appropriate for task Communication with others such as monitoring centres carers colleagues is adequate Working environment is appropriate noise heat space lighting ventilation Physical capability and condition has been considered Cognitive capability and condition has been considered Fatigue acute from temporary situation or chronic is recognised Stress morale issues of all members of the telecare system are noted Competence to deal w
17. es identified in this human factors perspective of telecare systems failures and risks 25 Human factors that influence the performance of the telecare system Yu References British Standards Institute 2005 BS 7000 6 Design management systems Managing inclusive design Guide UK British Standards Institute 2010 BS EN 31010 Risk management Risk assessment technique Buckle P Clarkson P J Coleman R Bound J Ward J amp Brown J 2010 Systems mapping workshops and their role in understanding medication errors in healthcare Applied Ergonomics 41 645 656 Buckle P 2012 Systems approaches to risk assessing healthcare how far have we come Work 41 Supplement 1 3847 3849 Carayon P Hundt A S Karsh B T Gurses A P Alvarado C J Smith M amp Brennan P F 2006 Work System Design for Patient Safety The SEIPS Model Quality amp Safety in Health Care 15 50 58 Embrey D E 1994 Guidelines for reducing Human Error in Process Safety Center for Chemical Process Safety New York American Institute of Chemical Engineers Haigh R 1993 The Ageing Process A Challenge for Design Applied Ergonomics 24 9 14 Hamblin K 2014 Lifestyles in Later Life identity choice and stigma AKTIVE Research Report Vol 2 Working Paper 6 Leeds CIRCLE University of Leeds available at http circle leeds ac uk Hignett S Carayon P Buckle P amp Catchpole K 2013
18. f she had to push the button would she have the strength to do it That s a concern Daughter of Mrs O Carroll 86 both falls and memory problems living alone Oxfordshire user of telecare package Physical condition actually physically put it wrist worn pendant on it s not easy to put on because it may be my slight trembling but the difficulty is getting the strap threaded through and trying to control it at the same time so I ve found the only way I can do that is to lay it on the bed and put the strap on and try and adjust it and get it through Mr Hodgkins 70 memory problems living alone Leeds user of telecare package Vision But you know when you get these documents I mean it was about a three page document they always do say Tf you want any help ring But it must be very hard For people who cant follow them or haven t anybody to turn to to process them really And the other thing at the weekend I had two friends who are partially sighted with me and they both had all these documents that needed and I spent my time going through the documents And I thought how difficult for them it was And by the time you ve requested it in large print which I mean we re very good at in this country often the appointment s come and gone you know by the time it arrives Mrs Woolley 83 falls living alone Leeds user of telecare package Example 3 Hearing ability 2 Mrs Robinson is deaf and called me to say s
19. ference So actually the bigger button is more of a problem because it might be set off accidentally Mrs Cooper Well yes The other one was more indented This one you d only have to touch it because it s flatter Now if went like demonstrates across my arms I d probably set it off So I ve got to be careful Interviewer So the indented one was better Mrs Cooper I think so Mrs Cooper 68 falls living alone Leeds pendant alarm user Example 2 Ease of accidentally triggering fall detector I d taken the telecare off and I d actually popped it into my trouser pocket and as I was taking my trousers off sort of slung them Nothing happened and then all of a sudden I could hear the telephone going down here so I had to come down to communicate with her to apologise and to say it was all my own fault Mr Hodgkins 70 memory problems living alone Leeds user of telecare package Example 3 Need to cancel false alarm From ELA researcher notes The cord is very loose and she does not know who to call she asked me which button to press to tell them she needs a new cord It is clear that if she did press the alarm she not only would she not know how to cancel it she also cannot get to it as it is in the front room which she can no longer access Mrs Richardson 93 living alone falls Oxfordshire pendant alarm user Example 4 Accidental triggering during sleep and consequences He has had a false alarm
20. g for installers is required with a certificate of competency Basic training for installers is required with a certificate of competency Basic training for installers is required with a certificate of competency Training instructions and information for clients to be clear and simple Note this aspect not explored in this research but should be assessed by service providers and appropriate checks if not already in place put in place to prevent errors Note this aspect not explored in this research but should be assessed by service providers and appropriate checks if not already in place put in place to prevent errors Human factors that influence the performance of the telecare system e Need for training closely aligned to the Installation of complex equipment e g fixing to walls or ceilings requires a assessment and the context into which the Cannot be installed equipment is to be installed referral to an engineer e Better environmental assessments of what is feasible and or practical in each setting Source AKTIVE ELA database CIRCLE University of Leeds Table 7 11 Problems relating to the review process Performance difficulties Why would this happen What might the solutions be errors failures The review system needs to be improved and perhaps standardised Lack of information re when Review not timely review is needed Monitoring centres could lead in initiating a review based o
21. he d been having problems with her ivi pendant which was part of her upgrade She said she must keep accidently pressing it because it keeps going off I explained that as it has a falls detector inside it she might be accidently setting it off if it swings around or is knocked She said she would be more careful with it but I received an email trom her daughter saying the problem persisted and her mother was put of wearing it at all Researcher fieldwork notes on Mrs Robinson 77 living alone falls Oxfordshire pendant and fall detector user Source AKTIVE ELA database CIRCLE University of Leeds 12 Human factors that influence the performance of the telecare system Addressing these problems has been an important challenge in this study The following section considers the challenges that emerge from the data collected and how solutions may be found or generated A series of tables Tables 7 8 to 7 14 show where such failures occur considerations as to why such failures occur and possible remedies or solutions to these problems Each element of the process map of telecare has been considered separately but it is recognised that errors or problems arising in one part of the process may only become apparent further along the process line For example a faulty assessment of the capability of the end user may lead to the provision of a device that cannot be operated This may appear as an end user problem but an
22. important root cause of this failure had occurred much earlier in the process where there had been a failure to train the assessor correctly Table 7 8 Procurement difficulties Performance difficulties Why would this happen errors failures Lack of appropriate manufacturer information Inappropriate equipment purchased Lack of appropriate knowledge within purchasing team Complex interoperability issues Too long time delays between purchasing decisions relative to change in technology What might the solutions be e Better training for procurers e Manufacturer s information designed to better match the user s abilities needs and the specification of the equipment e Improved interactive websites for accessing and selecting equipment e Trip advisor style website enabling comments and feedback to be readily posted e Better training e Manufacturer s information designed to better match the user s abilities needs and the specification of the equipment e Improved interactive websites for accessing and selecting equipment e Trip advisor style website enabling the posting of comments and feedback e Review of and adherence to standards e Speedier decision making as part of commissioning brief Source AKTIVE ELA database CIRCLE University of Leeds al Human factors that influence the performance of the telecare system er Table 7 9 Assessment difficulties
23. ing it up that when it came to the very quick demonstration Interviewer About actually using it Mr Peters That was a little bit that I didn t have to the forefront of the mind Husband of Mrs Peters 67 memory problems Leeds user of telecare package Example 6 Demonstration of how to use equipment 2 Interviewer So you were in hospital when they installed the device Mr Eaves Yeah So this one it s got the little button on it it s got the little I don t know what that thing is but apparently I m not going to test it now if I press that somebody will respond Mr Eaves 77 falls living alone Leeds user of telecare package Source AKTIVE ELA database CIRCLE University of Leeds 8 Human factors that influence the performance of the telecare system Yu Table 7 3 False alarms and accidental triggering leading to inappropriate use Example 1 Size and location of pendant button Interviewer Does that happen often when it goes off accidentally Mrs Cooper Well it s the first time with this one although I think it s going to be easier to set this one off than the old one Interviewer Why is that Mrs Cooper Because there s more of that to press Interviewer Oh more button Mrs Cooper Last night it was there and my ashtray was balanced there and that s what set it off Interviewer But does it make it easier to use when you need it because it s bigger or does it make no dif
24. ing on other TSB ALIP research studies Yeandle et al 2014 Mapping proved to be a powerful tool in understanding the system contextualising the research and interpreting the findings It is recommended that this approach to researching complex care and health systems is used more regularly as it is both simple to undertake and engages with a wide number of stakeholder groups allowing easy access to their experiences successes and failures Buckle et al 2010 The system complexity presents both opportunities and challenges For example the information held within this system is immense and potentially vital to improve the quality or performance of telecare Human factors that influence the performance of the telecare system AK E Identifying those with this information and establishing the nature and content of this information proved complex however and beyond the scope of the study What has emerged is a complex picture involving many stakeholders for whom little has previously been documented on their needs abilities or wants The implications of this have been that too often important information is held by one stakeholder that could help others but this is either not recognised or not appreciated Call centres for example have records of calls from telecare users that might through increased frequency or the nature of the call s be an important indicator of the changing physical or mental state of the user involved
25. ired were not readily available 2 Human factors that influence the performance of the telecare system A ave 3 Managing risk The map of those engaging with the development and delivery of telecare is complex Figure 7 1 represents the key components we identified from a combined set of workshop inputs within Oxfordshire and Leeds the two study locations It is probable that additional variations exist in other localities Figure 7 1 Map of those engaged with the development and delivery of telecare Local Auth Gov Procurement ADASS Age disability Carers NGOs Nurse OT GP Physio Chirop GP reception Mem falls clinic Adult Telecare User gt Shopkeepers Mobility Monitoring Z Academic R amp D Warehouse Call Centre Neighbours Age UK Family not Industry R amp D supplier resident amp friends Household Com Equip member Equipment stores Manufacturers On line Equipment designers Age UK McM Nurse Hospice at home Meals wheels Hairaresser Marketing Venture capitalists Housing assoc Telecare services assoc Homecare asst TSB services Purchase stock The workshop mapping exercises demonstrated the complexity of the system that currently exists for both the development and delivery of telecare This map was compiled during a series of workshops covering a wide range of interest groups including those work
26. it easier for those that are in a position to observe changes in user need to trigger a review Those who might observe such changes could include those operating monitoring centres those called to respond or where a caring network exists around the telecare user could include its members The essence of telecare must be to prevent outcomes of a serious nature To provide a system that is performing optimally requires regular reviews of clients This might be standardised or could be responsive The latter would require readily understood and easy access to an alerting system to trigger such a review 20 Human factors that influence the performance of the telecare system A cve 5 Discussion of Results Risk assessment The need for a fuller risk assessment of the system has emerged This might benefit from current thinking in socio technical systems research in other areas such as healthcare The Health and Safety Executive HSE 1999 and Risk standards British Standards Institute 2005 2010 for example have long recommended such an approach A simple model see figure 7 3 illustrates how important this is in establishing a the context within which risks are evaluated b the need for consultation with all parties and c the need for monitoring and review Telecare is a work system and the needs of all the social partners must be met for the system to perform optimally While the emphasis in the AKTIVE research has been on the wellbei
27. ith circumstances with appropriate training available Motivation vs other priorities has been established as adequate Work pressures are controlled Level and nature of training supervision leadership is of sound quality Communication wihtin and between organisations is optimised Manning levels are reviewed Clarity of roles and responsibilities is recognised Consequences of failure to follow rules procedures are appreciated Effectiveness of organisational learning learning from experiences is prioritised Organisational or safety culture is monitored Source AKTIVE ELA database CIRCLE University of Leeds Further categorisation of the diffculties errors and failures encountered using a simple approach such as that in Table 7 16 would enable designers and those responsible for the integrity of the system to rapidly prioritise allocation of resources for system improvement Many of the issues could be addressed through a contemporary inclusive design approach to interface design e g Nicolle amp Abasca 2001 This predictive approach has been advanced by others e g Predictive Human Error Analysis PHEA Embrey 1994 23 Human factors that influence the performance of the telecare system AK ri Table 7 16 Human Factors Failure Modes Action Failures A1 Operation too long short A2 Operation mis timed A3 Operation in wrong direction A4 Operation too little too much A5 Operation too fast or too slo
28. luence the performance of the telecare system 1 Introduction The AKTIVE research study has afforded a unique opportunity to study how frail older people and those who support or care for them are interacting with today s telecare systems Those studied include not just the end users of the telecare service but also the care support groupwhich may be involved with them e g relatives friends neighbours those working in monitoring and response centres assessors and reviewers of end user requirements and even those who install and maintain the equipment and services The in depth nature of the study has enabled the social dimensions of the system to be observed and explored providing rich in depth data that has not before been gathered These data form the basis for this working paper on the human factors that influence the performance of the system where difficulties or failures have or could occur and how improvements might be made Telecare may be considered as an example of a complex socio technical system The human factors aspects of socio technical systems have been extensively studied the past and more recently in a number of healthcare scenarios Buckle 2012 Carayon et al 2006 Hignett et al 2013 However there is little evidence that this approach has previously been undertaken to investigate performance and failure issues with respect to telecare services We have presented here the research component of the study
29. luence the performance of the telecare system rl 4 Discussion Independence control and risk management a balancing act Performance Difficulties Errors and Failures Problems that result in potential failures within the current telecare system can occur through procurement assessment of client needs installation of equipment review of equipment client use at monitoring centres and even in response settings While it has been difficult to quantify or even prioritise the scale of these failings it is nevertheless apparent that significant problems exist These problems have frequently emerged in discussion with stakeholders throughout the system and in particular through the ELA The data arising from the ELA provide a rich set of insights into the challenges facing those providing telecare services Tables 7 1 to 7 7 illustrate the concerns identified from the social research team s work with telecare users and those who care for or support them They have provided a great deal of evidence to support the need to improve a number of components of this socio technical care system They have also helped establish that solutions can only be found through co operative participative design consultation if the true needs of end users are to be met Table 7 1 Physical Equipment Design Issues Example 1 Battery design Interviewer So when the battery actually expires you cant use the system at all Mr Lindsay No no No but you don t h
30. ly there s no way of actually communicating with them Great niece of Miss Chester 89 falls living alone Leeds user of telecare package 10 Human factors that influence the performance of the telecare system Krv Example 2 Alarm cancelation when away from communication box in garden Miss Chester s great niece Again that s the thing If you had a false alarm in the garden telecare people would contact you But it being here you wouldn t hear it So then it would raise all the emergencies again S erviewer Jt would raise yes lt iss Chester t s difficult that because I mean the three of my falls have been in the garden a iss Chester s great niece Well yes So in that case itd be good because then we would get somebody out to you But that s why I just think it would be good if you coula you know even if you just heard something whether it just be a beep or something that then you could cancel you can push a button sort of thing to say Oh no cancel that don t need it Miss Chester 89 falls living alone Leeds user of telecare package Example 3 Alarm cancellation when away from communication box in house There are issues around false alarms Daughter says this is because her mother cannot hear it but mother says it is because she cannot get to the alarm box in time it is in the front room where the telephone point is Very hard to get to quickly Lots of f
31. n client demands and behaviours e Routine reviews maybe a more effective Lack of resources nee approach to avoiding untimely events e Routine reviews maybe a more effective Review not completed Lack of resources ee approach to avoiding untimely events Database enhancement at the monitoring centres may help avoid missed reviews Review not completed Client in hospital e May require additional information on the client being made available to the monitoring centre Source AKTIVE ELA database CIRCLE University of Leeds Table 7 12 Problems arising with client use Performance difficulties Why would this happen What might the solutions be errors failures e Industry should work more closely with Not appropriately designed inclusive designers human factors experts and human computer interface specialists Cannot use equipment e Installers and assessors must ensure that Not user tested the end users can both operate equipment and fully understand what it is achieving 16 Human factors that influence the performance of the telecare system Installers and assessors must be aware that the technology may not be fully inclusive Not appropriately assessed of all intended users Ensuring that the users can operate it before it is left with is essential Deficiencies in design and e The industry manufacturers should work operating documentation more closely with inclusive designers only verbal instructions
32. ng of the end user of telecare the evidence generated has shown the importance of risk assessing the system as a whole if sustainable improvements are to be made Figure 7 3 from Risk management Risk assessment techniques British Standard 2010 BS EN 31010 2010 21 Human factors that influence the performance of the telecare system Advances in technology have to be seen in the context of how useful and how trusted they are to those that rely on them Thus an automatic fall pendant that may contain state of the art technology may never achieve its full potential This can occur for example if the user fails to appreciate what the technology is doing and how to use it Similarly if there are too many false alarms these generate difficulties and embarrassment for the end user and their carers and may well lead to reluctance to use telecare at all There is also an important debate still needed regarding the relationship between how telecare helps to manage risk and how its reliability may in turn influence the perception of risk This debate needs to address the impact of behaviour with respect to the perception of risk by relevant stakeholders For example the telecare user wearing a GPS tracker may feel he or she is empowered to move and travel more widely outside of the home than would be the case without such a device However a relative or carer may only be persuaded that this is the case if the equipment is considered 100 reliable
33. nterviewer What are these buttons for The red ones for Mr Hodgkins dont touch them at all I daren t touch them in case owt goes wrong So I just leave them as It Is Mr Hodgkins 70 memory problems living alone falls Leeds user of telecare package Example 2 Information provision and design Interviewer So you can actually request what you need explain what you need Mr Hodgkins Probably would do When I got that I didn t get no literature or anything like that with it You know I Just got a bit of paper that tells you like you press and all that but it didn t give you no bookletsof what happens you know Interviewer Like a little guide or something Mr Hodgkins Yeah Interviewer Do you think that d have been hejptul Mr Hodgkins a dnt get nothing like that Interviewer Do you think that would have been helpful Mr Hodgkins t would have been yeah because you know what to do and that lot yeah Mr Hodgkins 70 memory problems living alone falls Leeds user of telecare package Example 3 Complexity of use Mr Court My wife s got one medication dispenser but we ve no idea where it is and the reason she won t use it is because it s what one would say technicalities it s too technical too clever It s got more than one button Interviewer So it s different it s more complex than this one Mr Court There s nothing complicated about it but it s just too much for her she
34. omething about alarms and things that go off that you know they re a bit disturbing because you wonder if you re going to be able to switch them off kind of thing Mrs Wooley 83 falls living alone Leeds user of telecare package Example 2 Medication reminder system She also had a medication reminder system but it Grove her crazy as she couldnt shut it off Mrs I s daughter said it was overly complicated and she also struggled to understand how to adjust it Researcher fieldwork notes on Mrs Inigo 76 living with daughter memory problems Oxfordshire former pendant alarm reminder system and GPS device user Example 3 Pendant Mrs Inigo likes the pendant alarm but did not like the reminder system as she could not remember how to shut it off once she had taken her medication Researcher fieldwork notes on Mrs Inigo 76 living with daughter memory problems Oxfordshire former pendant alarm reminder system and GPS device user Source AKTIVE ELA database CIRCLE University of Leeds Table 7 5 Design ideas arising from telecare users Example 1 More communication stations It s probably too impossible a technical thing to do I m not sure But I do think it would be good if you could talk into the hand thing as well because obviously if she s downstairs maybe even in the kitchen she can talk you know If the problem if she was in the kitchen she could still talk to them But upstairs obvious
35. p and then not be contactable as help with the phone you see You see in that situation now let s suppose that these two hadn t been turning up I would have got into here without anybody here I might have got to the phone and rang up carer s name But really if I can t respond to the box and tell them why I ve pressed it they ve got to send somebody out Mr Watson 87 falls living alone Oxfordshire pendant alarm user 11 Human factors that influence the performance of the telecare system Krv Example 3 Feedback on Bed sensor that could be more helpful But the lack of communication from the response centre is proving challenging Unless the response team go out the family had no idea the bed sensor was going off as much as it was Mrs Ramsey s memory problems mean she cannot remember it has happened to tell them Researcher fieldwork notes on Mrs Ramsey 96 falls and memory problems living alone Oxfordshire user of telecare package Source AKTIVE ELA database CIRCLE University of Leeds Table 7 7 Problem of design for those with other impairments Example 1 Hearing ability 1 As she is deat she cannot hear the telecare box and though she has a hearing dog Mrs Robinson 77 living alone falls Oxfordshire pendant and fall detector user Example 2 Physical strength The only thing I ve worried a little bit about because she is so frail now and not much strength in the fingers is i
36. rg uk web www aktive org uk CIRCLE School of Sociology and Social Policy University of Leeds LS2 SUT UK ca tweet to AKTIVEproject AK r v E partners circle SInveEntTvA RESEARCH ON CARI LABOUR amp
37. rs do make allowances but frequency of reviews amp how such reviews Does not understand the are initiated must be addressed State of health equipment The role of monitoring centres in helping with this process should be explored as a matter of priority 17 Human factors that influence the performance of the telecare system Too complicated design Use was not made clear to all Does not understand the users Who needs to know equipment cont what and why Deficiencies in design and operating documentation Too complicated instructions Faulty equipment Aaa maintenance Use was not made clear to all Client becomes frustrated the users who needs to know upset with equipment what and why No routine checking or Industry to work more closely with inclusive designers human factors experts and HCI specialists There is good ergonomics advice on how to design equipment that facilitates ease of use All the users and or their caring networks e g family friends neighbours care workers need to understand how to use the equipment what is does and what to use when Instructions must include the links connection between pieces of equipment and other partsof the system e g the monitoring centre response centre and installation assessors Equipment that facilitates ease of use is required There is very good and clear advice on how to design inclusively e Industry to work more closely
38. s Inigo 76 living with daughter memory problems Oxfordshire former pendant alarm reminder system and GPS device user Example 6 Design of tablet dispenser Interviewer And the tablet dispenser works OK and you haven t got any Daughter of Yes well other than dad tips it on its side to get the tablets out but then leaves it on its side And it Mr Carlson doesn t like it very much it likes to be fat Well because he hasn t turned it over It s designed when you turn it over He leaves it stood up so when the tablets come through they just drop out And then he phones us and tells us that it s beeping all the time So then we ve come over and we ve checked it it s Just been he s not tilted it Daughter of Mr Carlson 80 memory problems living alone Leeds user of telecare package and GPS device Example 7 Design of timer interface That was just couldn t suss it out to work out the timer on it and it was just so complicated Really complicated So I do think some of the things they ve got just think Gosh Daughter of Mrs Inigo 76 living with daughter memory problems Oxfordshire former pendant alarm reminder system and GPS device user Source AKTIVE ELA database CIRCLE University of Leeds 6 Human factors that influence the performance of the telecare system A K E Table 7 2 Fear of use by the end user resulting from poor design and poor understanding Example 1 Interface design I
39. s and accents need to be intelligible to the telecare user Source AKTIVE ELA database CIRCLE University of Leeds What might the solutions be Routine audit of the data maintained within the client database This may be achieved through providing the client or the carer with a regular electronic datasheet to amend e Responders may need to be given additional support perhaps through Internet based resources to ensure they are fully aware of their responsibilities and of how equipment may have changed Monitoring centres could undertake regular reviews of incidents that have arisen from inappropriate or incorrect responses Use a standardised analysis of why events occurred e g root cause analysis or consider prospectively where failures may occur Better understanding of how users see the role of the monitoring and response centre would help in providing better information about what it can cannot do and the nature of the response service Better information education training needed for all carers and users Source AKTIVE ELA database CIRCLE University of Leeds Note This table applies to all those involved in the delivery and use of telecare not only the end user of the service 19 Human factors that influence the performance of the telecare system Problems related to client users have demonstrated that a large number of difficulties may be encountered These have important implications throughou
40. s now so that at least in the future she s got knowledge of what to do So it s not necessarily that she needs it now cause we think she s going to fal but potentially in the future if it happens It seems likely that the best future technological designs will be those that are wanted by users because of their benefits In much the same way that mobile and now smart phones and tablet computers such as the iPad have captured the imagination and wants of a global audience so adoption of other assistive technologies should build on the desirability of technology This needs to occur before it is deemed a health or care requirement for any given individual For this to happen there must abe full recognition of the need for contemporary design using current thinking and methods These must involve the end users be inclusive and utilise co operative design processes BSI 2005 Haigh 1993 Keats et al 2003 Woods 2003 Obradovich and Woods 1996 Without such an approach there are likely to remain too many instances of poor design leading to errors and an under performing system In future designers of telecare systems or any component of them might like to address two key questions Namely who is this feature not designed for and secondly what happens when it goes wrong In this way all technological advances and most other changes to the system will have had to consider many of the major issu
41. t the system For example false alarms are a common cause of complaint They take up a large amount of time at monitoring centres lead to distrust of equipment by end users cause distress to the older people involved and where applicable those who form their caring network and can lead to a complete lack of use of the equipment Understanding and correcting the root cause of these faults is essential to drive better design improve assessment inform reviews and help provide better information to those operating the equipment Monitoring centres are particularly well placed to review call data and to classify these issues in a manner that would inform and potentially enhance the performance of their business Routinely studying the nature and origins of a false alarm and seeking a probable cause for example would provide valuable information that could be shared with designers and others to prioritise interventions The time saved in dealing with false alarms could be better spent providing other client services such as online support to address social isolation issues initiate reviews or observe trends in behaviour that might be indicative of a client needing a proactive intervention to prevent a more serious outcome During the course of the study it became clear that better training embracing new technology is required for many users within the system The training provided to assessors appears to be fragmented and idiosyncratic and
42. that investigated where and how telecare systems might fail generate errors or under perform Undertaking such analyses is standard practice in many industrial socio technical systems They are all based on an understanding of factors that influence human performance and the likelihood of human error Reason 1990 Rasmussen et al 1994 In many industries HSE 1999 and particularly in the health sector Ward et al 2010a they have proved immensely helpful both in reducing the likelihood of errors notably human errors and in enhancing the performance and quality of the system This is because the methods used often indicate where improvements to the design of the system may be beneficial in optimising human performance These design improvements are not limited to the physical elements of the system e g in the case of telecare the pendant alarm or bed detector but may also address shortcomings in the design and flow of information training programmes and even the design of the service itself During the AKTIVE project we have also considered the idea of individual risk and freedom afforded by telecare from a number of perspectives Yeandle 2014a Hamblin 2014 The context and findings presented in Hamblin s paper provide a useful context within which failure of technologies human error and design limitations may be understood This element of the study has used human factors also known as ergonomics approaches to identify risks
43. uide for engineering and design Farnham UK Ashgate Publishing Ltd Ward J R Clarkson P J Buckle P Berman J Lim R amp Jun G T 2010 Prospective hazard analysis Tailoring prospective methods to a healthcare context Department of Health Patient Safety Research Portfolio Report 26 Human factors that influence the performance of the telecare system AK r v E Ward J R Buckle P amp Clarkson P J 2010 Designing packaging to support the safe use of medicines at home Applied Ergonomics 41 682 694 Wilson J R amp Corlett E N eds 2005 Evaluation of Human Work A Practical Ergonomic Methodology 3rd Ed London Taylor amp Francis Woods M 2003 Design in a Digital World in Inclusive Design Design for the Whole Population 34 pp 576 581 London Springer Verlag Yeandle S 2014 Frail older people and their networks of support how does telecare fit in AKTIVE Research Report Vol 2 Working Paper 2 Leeds CIRCLE University of Leeds available at http circle leeds ac uk Yeandle S Buckle P Fry G Hamblin K Koivunen E R amp McGinley C 2014 The AKTIVE project s social design and prospective hazard research research methods AKTIVE Research Report Vol 3 University of Leeds available at http circle leeds ac uk 27 Human factors that influence the performance of the telecare system aktive phone 44 0 113 343 5003 email contact aktive o
44. urniture to navigate The location of the box is a big problem cannot get to it quickly enough to cancel However daughter s account is that she can t hear it to know she s accidently activated it Daughter That s right yes because my cousin said to me You should get that relocated but I don t think they could relocate it Researcher fieldwork notes on Mrs Richardson 93 living alone falls Oxfordshire pendant alarm user Source AKTIVE ELA database CIRCLE University of Leeds Table 7 6 Links to monitoring centre Example 1 Updating information Mrs W has had two questionnaires about the telecare service a customer satisfaction questionnaire and a client update form She has found none of the questions to be relevant In terms of liaising with the service provider Mrs W called up once to change the name of a contact and they said it was very difficult Researcher fieldwork notes on Mrs White 78 falls living alone Oxfordshire pendant alarm user Example 2 Need to communicate directly with telecare user Because how can they respond to me I mean clearly it has the advantage it will be where lam They would have to telephone carer s name that s the only thing they can do But if they don t have a conversation with me they don t know whether I ve broken a bone or what I ve done so in fact an alarm without something that they can reply to doesn t really do the job It s not sufficient to say hel
45. w A6 Misalign A7 Right operation on wrong object A8 Wrong operation on the right object A9 Operation omitted A10 Operation incomplete A11 Operation to early or too late A12 Operation in wrong order A13 Misplacement Checking failures C1 Check omitted C2 Checking incomplete C3 Right check on wrong object C4 Wrong check on right object C5 Check too early or too late Information retrieval failures R1 Information not obtained R2 Wrong information obtained R3 Information retrieval incomplete R4 Information incorrectly interpreted Selection failures S1 Selection omitted S2 Wrong selection made Information communication failures I1 Information not communicated I2 Wrong information communicated 13 Information communication incomplete 14 Information communication and clear Planning failures P1 Plan omitted P2 Planning incorrect Violations V1 Deliberate action Note See Embrey 1994 Source AKTIVE ELA database CIRCLE University of Leeds 24 Human factors that influence the performance of the telecare system 6 Recommendations The study found that design of telecare needed this in depth analysis of the existing systems to identify risks of failure and opportunities for design improvement Latent failure types were commonly identified during the study Latent failuresare made by people whose tasks are removed in time and space from operational activities e g designers
46. when he was sleeping and pressed button accidentally so he now does not wear the pendant when he sleeps He also does not wear the pendant during the day he says that he as he has the lifeline in the living room he can press that if anything happens although if he fell e g in kitchen it wouldn t work Researcher fieldwork notes on Mr Whittaker 77 falls living alone Leeds user of telecare package 9 Human factors that influence the performance of the telecare system crv Example 5 Accidental triggering during noisy activities and consequences She recently tested the pendant and it worked well she also accidently set the fall sensor off while cleaning because she was hoovering she didn t hear the call and her daughter came out But the call centre was able to tell her that it was the fall detector which had gone off so she knew it was unlikely to be a real emergency as her mother rarely wears it if it was from the pendant she would have been more worried Researcher fieldwork notes on Mrs Robinson 77 living alone falls Oxfordshire pendant and fall detector user Source AKTIVE ELA database CIRCLE University of Leeds Table 7 4 Design of reminders and alarm checking Example 1 Sound of alarms In fact I think that s one of the things I m very remiss about I don t check in as I should do I don t like it because I don t like the loudness of it you know When you there s sort of s
47. with inclusive designers human factors experts and HCI specialists Industry to work more closely with inclusive designers human factors experts and HCI specialists The role of monitoring centres in helping with this process should be explored as a matter of priority Need for a participatory approach to the design selection and use of the equipment False alerts lead to distrust and need to be minimised through better design and review Other issues such as overly loud ringing can also be improved with an inclusive design approach Source AKTIVE ELA database CIRCLE University of Leeds 18 Human factors that influence the performance of the telecare system Table 7 13 Monitoring issues Performance difficulties Why would this happen errors failures Poor faulty Communication failures communication between between the older person telecare user and call possibly in distress and the centre call centre Table 7 14 Response issues Performance difficulties Why would this happen errors failures Incorrect data in database Not trained adequately Incorrect response Incorrect information given by telecare equipment Perceived incorrect End users shocked worried response when responder arrived What might the solutions be e A fuller understanding of how end users see the role of the monitoring centre would help in providing better information about what it can and cannot do e Voice
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