The better work, better care framework: 7 strategies for sustainable healthcare system process improvement.

Healthcare systems are under pressure to control costs and improve performance. Efforts to apply improvement trends such as "Lean" and other industrial engineering approaches have led to degradation of the working environment for healthcare professionals. Research is increasingly demonstrating how poor working environments contribute to declines in care quality and has led to calls for a "quadruple aim" with a focus on the working environment alongside quality, cost, and patient experience factors. This paper contributes to the debate by using a "systems" perspective to propose seven strategies by which healthcare systems might be improved without compromising the working environment. This article presents a rationale for these strategies based on current organisational psychology and human factors research and how these strategies might be deployed in practice. The authors argue that better working conditions leads to better care for patients and presents a viable approach for both practitioners and researchers to pursue the "Better Work, Better Care" agenda.

An ergonomics action research demonstration: integrating human factors into assembly design processes.

In action research (AR), the researcher participates 'in' the actions in an organisation, while simultaneously reflecting 'on' the actions to promote learning for both the organisation and the researchers. This paper demonstrates a longitudinal AR collaboration with an electronics manufacturing firm where the goal was to improve the organisation's ability to integrate human factors (HF) proactively into their design processes. During the three-year collaboration, all meetings, workshops, interviews and reflections were digitally recorded and qualitatively analysed to inform new 'actions'. By the end of the collaboration, HF tools with targets and sign-off by the HF specialist were integrated into several stages of the design process, and engineers were held accountable for meeting the HF targets. We conclude that the AR approach combined with targeting multiple initiatives at different stages of the design process helped the organisation find ways to integrate HF into their processes in a sustainable way. PRACTITIONER SUMMARY: Researchers acted as a catalyst to help integrate HF into the engineering design process in a sustainable way. This paper demonstrates how an AR approach can help achieve HF integration, the benefits of using a reflective stance and one method for reporting an AR study.

Ergonomics action research II: a framework for integrating HF into work system design.

This paper presents a conceptual framework that can support efforts to integrate human factors (HF) into the work system design process, where improved and cost-effective application of HF is possible. The framework advocates strategies of broad stakeholder participation, linking of performance and health goals, and process focussed change tools that can help practitioners engage in improvements to embed HF into a firm's work system design process. Recommended tools include business process mapping of the design process, implementing design criteria, using cognitive mapping to connect to managers' strategic goals, tactical use of training and adopting virtual HF (VHF) tools to support the integration effort. Consistent with organisational change research, the framework provides guidance but does not suggest a strict set of steps. This allows more adaptability for the practitioner who must navigate within a particular organisational context to secure support for embedding HF into the design process for improved operator wellbeing and system performance. PRACTITIONER SUMMARY: There has been little scientific literature about how a practitioner might integrate HF into a company's work system design process. This paper proposes a framework for this effort by presenting a coherent conceptual framework, process tools, design tools and procedural advice that can be adapted for a target organisation.

Ergonomics action research I: shifting from hypothesis testing to experiential learning.

This paper presents the case for the need for 'Action Research' (AR) approaches to gain understanding of how ergonomics considerations can best be integrated into the design of new work systems. The AR researchers work collaboratively with other stakeholders to solve a real-world problem: gaining insight into the problem and factors influencing solution building from an embedded position in the development process. This experience is interpreted in terms of available theory and can support further theory development. This non-experimental approach can help provide practical new approaches for integrating ergonomics considerations into real work system design processes. The AR approach suffers from a lack of acceptance by conventionally trained scientists. This paper aims to help overcome this weakness by developing the underlying theory and rationale for using AR approaches in ergonomics research. We propose further development of hybrid approaches which incorporate other evaluation techniques to extend the knowledge gains from AR projects. PRACTITIONER SUMMARY: Researchers should engage directly with organisations in ergonomics projects so that they can better understand the challenges and needs of practitioners who are trying to apply available scientific knowledge in their own unique context. Such 'Action Research' could help develop theory and approaches useful to improve mobilisation and application of ergonomics knowledge in organisations.

Doing 'organizational work': expanding the conception of professional practice in ergonomics.

Literature on ergonomic practice contains many discussions of how ergonomists should work but far less attention has been paid to how they do work and the factors that influence their practice. In an effort to improve our understanding of ergonomic practice as it occurs and how it is conditioned by broader contexts, we conducted an interview study with 21 ergonomists in Canada. We were particularly interested to understand the different kinds of activities study participants engaged in during the course of their work, the challenges they faced and the strategies they employed for facing these challenges. Findings indicate that in the course of their professional practice ergonomists engage in a variety of types of activities. This includes consulting on risk factors as well as a proactive role of fostering the application of ergonomics in organizations. The process of advocating for ergonomics brought study participants into a variety of interactions and collaborations with workplace parties in a type of activity we have called "organizational work". In the course of doing organizational work, ergonomists utilize different strategies, including "political manoeuvring", tailoring data collection and report presentations to clients' concerns and 'goal hooking' in order to make the case for implementing ergonomics in workplaces. The article concludes with a list of "tips" for practicing ergonomists that are suggested by the analysis.

Effect assessment in work environment interventions: a methodological reflection.

This paper addresses a number of issues for work environment intervention (WEI) researchers in light of the mixed results reported in the literature. If researchers emphasise study quality over intervention quality, reviews that exclude case studies with high quality and multifactorial interventions may be vulnerable to 'quality criteria selection bias'. Learning from 'failed' interventions is inhibited by both publication bias and reporting lengths that limit information on relevant contextual and implementation factors. The authors argue for the need to develop evaluation approaches consistent with the complexity of multifactorial WEIs that: a) are owned by and aimed at the whole organisation; and b) include intervention in early design stages where potential impact is highest. Context variety, complexity and instability in and around organisations suggest that attention might usefully shift from generalisable 'proof of effectiveness' to a more nuanced identification of intervention elements and the situations in which they are more likely to work as intended. STATEMENT OF RELEVANCE: This paper considers ergonomics interventions from perspectives of what constitutes quality and 'proof". It points to limitations of traditional experimental intervention designs and argues that the complexity of organisational change, and the need for multifactorial interventions that reach deep into work processes for greater impact, should be recognised.

Biomechanical and psychosocial risk factors for low back pain at work.

OBJECTIVES: This study determined whether the physical and psychosocial demands of work are associated with low back pain. METHODS: A case-control approach was used. Case subjects (n = 137) reported a new episode of low back pain to their employer, a large automobile manufacturing complex. Control subjects were randomly selected from the study base as cases accrued (n = 179) or were matched to cases by exact job (n = 65). Individual, clinical, and psychosocial variables were assessed by interview. Physical demands were assessed with direct workplace measurements of subjects at their usual jobs. The analysis used multiple logistic regression adjusted for individual characteristics. RESULTS: Self-reported risk factors included a physically demanding job, a poor workplace social environment, inconsistency between job and education level, better job satisfaction, and better coworker support. Low job control showed a borderline association. Physical-measure risk factors included peak lumbar shear force, peak load handled, and cumulative lumbar disc compression. Low body mass index and prior low back pain compensation claims were the only significant individual characteristics. CONCLUSIONS: This study identified specific physical and psychosocial demands of work as independent risk factors for low back pain.

Comparison of four peak spinal loading exposure measurement methods and their association with low-back pain.

OBJECTIVES: This paper examines the performance of 4 different methods of estimating peak spinal loading and their relationship with the reporting of low-back pain. METHODS: The data used for this comparison was a subset of subjects from a case-referent study of low-back-pain reporting in the automotive industry, in which 130 random referents and 105 cases (or job-matched proxies) were studied. The peak load on the lumbar spine was determined using a biomechanical model with model inputs coming from a detailed self-report questionnaire, a task-based check list, a video digitization method, and a posture and load sampling technique. RESULTS: The methods were directly comparable through a common metric of newtons or newton meters of spinal loading in compression, shear, or moment modes. All the methods showed significant and substantial associations with low-back pain in all modes (odds ratios 1.6-2.3). The intraclass correlation coefficients (ICC) showed strong similarities between the checklist and video digitized techniques (ICC 0.84-0.91), moderate similarities between these techniques and the work sampling method (ICC 0.49-0.52), and poor correlations (ICC 0.16-0.40) between the self-report questionnaire and the observer recorded measures. CONCLUSIONS: While all the methods detected significant odds ratios, they cannot all be used interchangeably for risk assessment at the individual level. Peak spinal compression, moment, and shear are important risk factors for low-back pain reporting, no matter which measurement method is used. Questionnaires can be used for large-scale studies. At the individual level a task-based checklist provides biomechanical model inputs at lower cost and equal performance compared with the criterion video digitization system.