Improving SI investigations with HFACS


What happens when healthcare organisations adopt the Human Factors Analysis and Classification System (HFACS) as a means of improving investigations and helping to reduce harm in healthcare? The Winston Churchill Memorial Trust has kindly funded me to visit leading US healthcare providers this year to find out. This is a summary of some key lessons learned during the first half of my Fellowship.

Finding out about HFACS

You can read my account here of what HFACS is and how it works. I have been using it for the past twelve months or so with innovators in the UK who wanted to explore whether and how it could help them improve the quality of their investigations, and develop more effective systemic responses to harm. But some US healthcare providers have been using HFACS for a while, and I wanted to learn as much as I could from their experience. Huge thanks are due to  Juliane Bingener-Casey and her colleagues at the Mayo Clinic, Linda Scott and Dan Reed and colleagues at Christus Health, and LaTasha Burns and Cindy Segal at University of Texas MD Anderson Cancer Centre. They have very graciously shared their insights. Much gratitude too, to the Winston Churchill Memorial Trust, for funding my visit.


  • HFACS is an analytical tool (part 1). It helps to identify and record sources of human error across organisations. This is particularly valuable for an organisation like Christus Health, which provides services in over forty locations. HFACS is helping them implement a strategic response to eliminating common errors. The same aim was driving MD Anderson’s use of HFACS for investigating ‘sentinel events’ in surgery (roughly the same as NHS England’s surgical ‘never events’). All healthcare providers are vulnerable to the pressure to focus on quickly fixing whatever went wrong last. This is partly a result of a genuine desire to prevent further harm. It is also a consequence of accountability structures that demand every investigation be accompanied by an action plan. But the need to find quick fixes results in a resource-consuming game of ‘whac a mole’. Each time an event is fixed a similar event pops up somewhere else. Christus Health and MD Anderson are using HFACS to understand the underlying issues. They’ve set out to tackle the mole runs, rather than whack the moles.

Whac a mole

  • HFACS is an analytical tool (part 2). HFACS doesn’t give you easy fixes.  HFACS can definitely help make your investigations better. It can help you be sure you’ve looked at an event in the context of your organisational systems, and considered how those affect what front line staff are doing. It can help you identify trends, and tackle the most prevalent human errors. It can help you check that solutions you are coming up with are truly systemic, and measure the effect of your interventions. So, HFACS can help you find the mole runs, but it can’t tell you how to fill them in or how to manage the moles. That needs creative thinking, improvement science, and organisational commitment.
  • HFACS provides a ‘balanced scorecard’ of error (1) But is that what leaders want? Committing to HFACS is a bold leadership move. HFACS provides a ‘board to ward’ view of the issues affecting safety in organisations. This is why it is potentially very powerful. It is also potentially very unsettling. Organisational leaders who feel comfortable blaming the front line for safety lapses will feel far less comfortable reading reports that call attention to board room failures. The awkward truth is that unbalanced RCA investigations are serving a useful purpose for some leaders. They deflect attention away from the difficult problems very senior managers have not yet managed to resolve.
  • HFACS provides a balanced scorecard (2) Is this what clinical staff want? Generally, the answer is ‘yes’. Because HFACS provides a ‘board to ward’ view of error, and because it supports a consistent approach to investigations, both clinical staff and investigators are inclined to see it as fairer than less structured approaches to RCA. This doesn’t mean that everyone loves all aspects of it. Staff don’t always feel comfortable talking about some of the ‘preconditions’ HFACS prompts investigators to consider (for example fatigue, stress, self-medication and so on). And more experienced RCA investigators can be resistant to the introduction of HFACS.
  • HFACS adds great value when you investigate near-misses. US colleagues recounted how useful it was to fully investigate near misses with HFACS. Staff were proud they’d halted the course of an adverse event. So they were keen to talk about how it might have happened, how they stopped it, and how it might be prevented in future. Near misses presented a great opportunity to look at all of the organisational influences and supervisory issues that are included in the HFACS framework and which affect the course of daily clinical work.
  • HFACS serves a specific purpose. The problem with investigations into healthcare harm is that they have many purposes. They help patients and staff make meaning out of what is oCluedo_1956_Small_Red_Box_Editionften a devastating event. They may underpin legal action. They may underpin internal disciplinary action. They may provide an account to be given to the public, through the media. They may provide accountability to a regulator or other interested body. They are supposed to be a source of ‘lessons learned’. All of these varied purposes have their own requirements. It may be that HFACS can serve some better than others.
  • HFACS means a culture change, not just a change in the way events are investigated. Embedding HFACS as ‘the way we do things’ has powerful effects. One is that it can promote and sustain human factors conversations across an organisation. But to embed HFACS requires a strategic approach, good training, and commitment from leaders.

If you think your organisation is up for really improving how it learns from healthcare harm – get in touch