For patient safety, make SOPs simpler and more intuitive

The hepatitis C outbreak at Singapore General Hospital's (SGH) renal ward has shone a spotlight on the seldom-discussed issue of patient safety in hospitals.

The Independent Review Committee (IRC) identified gaps in infection prevention and control practices as the most likely cause of the outbreak. It urged SGH to review standard operating procedures (SOPs) and practices in infection control, to ensure adherence to standard precautions for infection control and adopt best practices, and to strengthen the monitoring and supervision of staff to ensure compliance with SOPs.

While these measures are clearly necessary, hospital administrators and leaders should also pay attention to the cognitive limitations of medical professionals.


One of the biggest advances in healthcare in recent decades has been the introduction of standard protocols and checklists, especially in hospitals, to reduce the risks of infection and mistakes by medical professionals.

In the case of the hepatitis C outbreak, the IRC pointed out that the infections were partly the result of "deviations from standard procedures" and "inefficient workflow". Gaps in infection control practices in an environment where patients were at higher risk of exposure and were more susceptible to infection created the ideal conditions for an outbreak.

Reducing the risks of infection at a hospital is a complicated, rather than complex, problem. Unlike a complex problem, which is defined by the ambiguous and uncertain relationship between cause and effect, the risks of hepatitis C infection are well understood. Experts know in advance what can be done to minimise the risks of problems occurring. Medical professionals are also not in any doubt about what constitutes best practices in infection prevention and control.

As American surgeon and writer Atul Gawande illustrates in The Checklist Manifesto: How To Get Things Right, complicated problems like infections in hospitals can be significantly reduced by having checklists and good SOPs. For instance, the implementation of a five-point checklist in the intensive care unit at Johns Hopkins Hospital in 2001 virtually eliminated central line infections, preventing an estimated 43 infections and eight deaths over a period of 27 months. The same checklist was tested in ICUs in Michigan, and reduced infections by 66 per cent in three months, saving more than 1,500 lives in a year and a half.

Failure in hospitals, Dr Gawande concludes, is less the result of ignorance (not knowing what works), and more the result of ineptitude (not applying what we know works).

The IRC's emphasis on adherence to standard precautions for infection control and compliance with SOPs reflects this approach to infection prevention and control in hospitals.


But while establishing checklists and SOPs is a necessary first step, they are probably insufficient. Just because professionals are dealing with problems for which best practices or SOPs exist does not mean they will always comply with them. Compliance with checklists or established SOPs may not be as effortless as we assume. This is particularly so when medical professionals are tired, distracted, or both.

That well-trained professionals sometimes fail to stick strictly to established protocols, or default into less-than-optimal behaviours, when they are tired is quite well established.

A study in 2011 of eight Israeli judges considering more than 1,100 parole applications found that the judges were more likely to grant parole at the start of day, and after breaks for a morning snack and lunch. Mr Shai Danziger, one of the co-authors of the study, argued that the combination of "choice overload" and repetitive decision-making led to the judges choosing the "lazy" or default option of denying the parole application.

In the healthcare context, a 2014 study by researchers from the University of Pennsylvania and the University of North Carolina at Chapel Hill found that while healthcare workers washed their hands on 42.6 per cent of the occasions that they were supposed to over the course of a 12-hour shift, this figure was only 34.8 per cent in the last hour of the shift. The study also found that workers were more likely to wash their hands after a longer time off between shifts.

If fatigue is an important factor in non-compliance with established SOPs, the solution does not just lie in exhortations to hospital staff to "pay attention!", or in increasing monitoring and supervision. Rather, it is to think creatively about how SOPs can be designed in a way that requires less cognitive effort from professionals.

Making SOPs simpler, more intuitive and more compatible with people's cognitive limitations over a long working day is likely to be more effective in the long run than diktats from above. Having medical professionals themselves develop the SOPs they will follow is also a good practice.

A second factor that has been found to reduce the ability of medical professionals to comply with established procedures is distraction. Take medication errors, a common cause of harm to patients, as an example. In wards, nurses are frequently distracted and interrupted by requests from patients, instructions from doctors, phone calls to the ward, handling queries by visitors, looking for equipment, and so on.

While such interruptions and disruptions are common, they can be extremely dangerous when nurses are doing their drug rounds. Interruptions then may cause drugs to be administered wrongly. One solution, which has been tried out and is relatively easy to implement, is to require nurses on drug rounds to put on a sign that says "Drug round in progress - do not disturb!"


Beyond a medical professional's cognitive limitations, it is also crucial to understand the organisational context in which he works. An analysis of the hospital environment suggests more reasons why a singular emphasis on monitoring and supervision for compliance with SOPs may not work as well as in, say, a military setting.

Hospitals are not just large organisations; they are also sprawling ones. Within a hospital, one finds many specialisations, each with its sub-specialisations and, sometimes, its own norms and culture. Medical professionals in one specialisation are also usually reluctant to comment on or to review the decisions or practices of their peers in another.

In addition, while there is a formal hierarchy in hospitals (as there is in an army brigade), this often matters less than the authority and respect that individual physicians command among their peers and juniors. The nature of a hospital's work - 24/7 operations, numerous "transactions" that are usually not visible to managers - also makes it difficult for hospital managers to exercise close monitoring and supervision, or to ensure strict compliance with SOPs that have been agreed upon.

That hospitals are often highly decentralised, even fragmented, organisations also makes it difficult for governments to legislate a certain level of performance.

Legislation assumes that it is possible to pinpoint the specific mistake and the party that committed it. This is probably not possible in most instances of infection control lapses in a hospital. Legislation may also have the unintended effect of "hard-wiring" existing standards based on current knowledge, reducing the flexibility (and creativity) needed for continual process improvements.

In recent years, the proliferation of well-designed and user-centred personal devices has made consumers appreciate the importance of a good interface between humans and machines for optimal performance. Consider the latest smartphones. Even though they contain highly complicated technology, users do not have to undergo special training or read manuals to make good use of them. They are mostly intuitive and easy to operate, based on what most users already know.

But the importance of a well-designed interface between humans and procedures is much less appreciated. Think about how the Singapore Government, in the past, used fines to get people to flush in public toilets. What solved the problem eventually was neither the fines nor more conscientious or considerate Singaporeans. Instead, it was automated toilet flushes.

The lesson here is that it is usually more useful to try to improve processes than to improve human decision-making. This approach may produce useful insights into how we should address complicated problems in high-risk environments such as hospitals.

• Donald Low is Associate Dean of Executive Education and Research at the Lee Kuan Yew School of Public Policy, National University of Singapore. Lam Chuan Leong is a Professor of Practice at the School.

A version of this article appeared in the print edition of The Straits Times on December 19, 2015, with the headline 'For patient safety, make SOPs simpler and more intuitive'. Print Edition | Subscribe