Human-Centered Systems Engineering: Managing Stakeholder Dissonance in Healthcare Delivery

Introduction

I spend a considerable amount of my time haranguing my clients (the majority of whom are medical device manufacturers) that absent rigorous Design Controls (Samaras, 2010a) their products will have problems, will dissatisfy customers, and be potential sources of adverse events. What I conveniently forget to tell them is that, even though they may do everything perfectly, the way their products are deployed has a profound impact on meaningful use, patient safety, and profitability in the user organization. Why the concern with profitability? Because organizations that are not, by some measure, profitable will wither and die. Meaningful use, patient safety, and profitability in the user organization are three core issues for effective healthcare delivery.

Figure 1 shows two connected Venn diagrams. The upper Venn diagram depicts the interactions of hardware, software, and human factors issues in the design of tools resulting in tool-level problems; the locus of control is the manufacturer of medical devices, information technology systems, etc. The lower Venn diagram depicts the interactions of business, technical and regulatory issues in the user organization resulting in organizational-level problems; the locus of control is the hospital system, the nursing home, the physician’s office, etc. In recent years, especially with increased emphasis on human factors engineering, manufacturers have become quite good at identifying and mitigating tool-level problems. Businesses that deliver healthcare are quite facile at dealing with traditional organizational-level issues common to non-healthcare businesses.

Figure 1.

Source of errors from two levels of interaction

The purpose of Figure 1 is to highlight the multi-level problem of the interaction of tool-use and organizational deployment of these tools in healthcare delivery. This class of problems leads to a phenomenon termed stakeholder dissonance (SD) – a lack of agreement, consistency, or harmony among the stakeholders (Samaras & Samaras, 2010). SD in the healthcare delivery system, results in decreased patient safety and decreased organizational profitability. In the jargon of human factors engineering, the two levels in Figure 1 are called microergonomics and macroergonomics. They are subdisciplines of human factors science and are practiced by different specialists, not unlike industrial versus electrical engineering.

SD is a management concept. It is not the concept of “cognitive dissonance” related to an inconsistency between beliefs and actions. SD is not related to negative drives; it refers to the conflicting needs, wants, and desires (NWDs) among different stakeholders. NWDs are not static; they devolve over time, so that what today may be a Desire tomorrow often devolves to a Want or a Need and is replaced by new Desires. Conflicts between the NWDs of various stakeholders, in the context of healthcare delivery, is evidenced by errors, workarounds, decreased motivation, decreased satisfaction, and even outright rejection of new products, processes, or services. SD is diagnostic for quality deficits.

So, how do we deal with SD in the delivery of healthcare? It is important to realize that SD never can be eliminated totally in any system, including healthcare delivery systems. SD arises from the intentional or unrecognized conflicts between the NWDs of the various system stakeholders. The Venn diagram of Figure 2 depicts the needs of four different stakeholder groups, how they align pair-wise, and how they align for all four stakeholders. It should be self-evident that complete alignment of the NWDs of patients, clinicians, support staff, and management will be very rare, if not impossible.

Figure 2.

Alignment of stakeholder needs