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Healthcare is a multifaceted environment and the human is the common factor across all areas. Guests Drs. Sarah Parker and Laurie Wolf discuss improving personal protective equipment (PPE) for healthcare workers on the frontlines in order to improve human performance in complex and sometimes uncomfortable settings. This episode also discusses redesigning six-foot distancing processes in dental offices. To achieve an environment where patients and staff can be as safe as possible, our guests share the importance of understanding what the human capabilities and limitations are and taking into consideration the processes and environment when designing equipment.

This is episode 24 of Beyond the Mouth, a podcast series in which ADA’s Dr. Betsy Shapiro chats with a diverse group of people who can help with the non-clinical challenges dentists experience every day.

This episode was released on December 9, 2020.

Dr. Laurie Wolf is the Director of Human Factors Implementation at Carilion Clinic. Dr. Wolf is a Certified Professional Ergonomist with a PhD in Human Factors and Ergonomics from Loughborough University. She is a Certified Six Sigma Black Belt from the American Society of Quality. Dr. Wolf has over 20 years of experience in the healthcare environment and has published over 20 peer-reviewed articles and three book chapters. Her interests include improving safety for both patients and staff and her recent healthcare work involves quality improvement projects to achieve efficient processes and error proofing that result in a safe environment for staff and patients.

Dr. Sarah Parker is the Director of Human Factors Research at Carilion Clinic and Senior Director of the Center for Simulation, Research and Patient Safety. Dr. Parker is an assistant professor in the Virginia Tech Carilion Research Institute and the Department of Biomedical Science in the Virginia Tech Carilion School of Medicine. She has over 10 years of experience applying human factors and industrial/organizational psychology principles to healthcare. Dr. Parker received her BA in psychology from Wittenberg University in Springfield, Ohio; her MA in human factors and applied cognition from George Mason University in Fairfax, Va.; and her PhD at University of Aberdeen in Scotland. 

This transcript was edited for clarity.

Betsy Shapiro: Welcome to the American Dental Association's Practice Podcast, Beyond the Mouth, where we won't discuss clinical dentistry, but everything else is fair game. I'm Dr. Betsy Shapiro, a director with the Practice Institute of the ADA. In this episode, we're talking about personal protective equipment, health care research in this area, and how that research gets implemented, and ultimately may land in the practice of dentistry.

Betsy Shapiro: Joining me today are doctors Laurie Wolf and Sarah Parker. Dr. Wolf is the director of human factors implementation at Carilion Clinic. She's a certified ergonomics professional, with a PhD in human factors and ergonomics, and a certified Six Sigma Black Belt from the American society of quality. Dr. Wolf has over 20 years experience in the healthcare environment, and her recent work involves quality improvement projects to achieve efficient processes in error proofing that result in a safe environment for staff and patients. Something that is very important in any dental office. Hello, Laurie, and welcome to our show.

Laurie Wolf: Hi, thanks for having us today.

Betsy Shapiro: Also joining us today is Dr. Sarah Parker. Dr. Parker is the director of human factors research, and an associate professor at Virginia Tech's Carilion School of Medicine. She is also the senior director of the Center for Simulation Research and Patient Safety. Dr. Parker has over 10 years of experience applying human factors, and industrial, and organizational psychology principles to healthcare. Her research interests include team performance, and communication in healthcare settings, which of course, very aptly applies to any dental office already. Sarah, welcome to our show as well.

Sarah Parker: Thank you so much for having us.

Betsy Shapiro: You both have very, very impressive resumes and it shouldn't be surprising that we're turning to you to help us better understand some complex issues here. Of course, with COVID we're wearing additional PPE in dental offices, it's happened overnight, it's our new norm. I don't think it's going away. It does impact every aspect of providing oral health care, from before the patient enters the practice, to actually a little bit beyond when they exit. And we need to start thinking about how our environment impacts our performance, and our work duties, and how it all rolls up into one big ball.

Betsy Shapiro: Laurie, I'd like to start with you. You have an interesting background in a variety of fields, all kind of feeding right into what we do as dentists, I think. Part of it includes the Six Sigma Black Belt from the American society of quality. Can you just tell us what that certification is? And then a little bit about how you came to be doing the work you're doing now?

Laurie Wolf: Yeah. So Lean and Six Sigma have entered the healthcare world about 10 years ago or so. And I believe that each different specialty provides us tools to help us achieve a most efficient, least variation, process way of doing things in healthcare. So coming from the manufacturing environment early in my career, I've been in healthcare now for over 25 years. And I am constantly impressed with how our staff is so dedicated and achieves heroic measures, no matter what their task is.

Laurie Wolf: Healthcare can be a very complex and constantly changing environment. So it's critical that the expertise that we can bring from performance improvement work with Six Sigma and Lean, combining that with the science of human factors, brings in our science of understanding what human capabilities and limitations are, matching them to the data that we have in designing the appropriate equipment and processes, to achieve an environment where our patients and our staff can be as safe as possible

Betsy Shapiro: Human limitations do impact. We can do all the research in the world, but it's how the humans factor in. Correct?

Laurie Wolf: Exactly. What we try to do is make it easy as possible to do the right thing, and impossible, or certainly very difficult to do the wrong thing.

Betsy Shapiro: I need that kind of help in my life, in every aspect. So we might have to have another episode where you fix me. I know you've had a pretty wide ranging background of areas you've helped. I think there was some mention in a previous conversation about the military, and General Motors, and healthcare, all of those factoring in, have you found commonalities amongst all of those or common challenges in all these areas?

Laurie Wolf: The human is really the common factor across everything. So whether I'm designing car interior tanks, helicopter cockpits, or how a provider uses an IV pump, they all require the human interacting with something in their environment to achieve a task that they want. And oftentimes it's done in high stress, very complicated environments, maybe they're a little fatigued, or hot, or not optimal human performance behaviors. And what we try to do is achieve the easiest method for them to achieve whatever goals they want, but humans are involved in all of these tasks, and have to be because they are complex, and they need the human component when it's necessary.

Betsy Shapiro: Yeah. I think your points about high stress, and perhaps a little fatigued, and perhaps a little overheated, certainly not to the degree that someone would be in a tank in a warfare type situation, but many of those adjectives can explain how our dentists are feeling these days. You've done some recent work on designing waiting rooms, and patient flow, and social distancing, and all of those things within healthcare. Can you tell us a little bit more about that?

Laurie Wolf: So what we did as we started to come back to full capacity after the initial COVID-19 rollbacks, we wanted to come back as safe as we could. And so we applied social distancing to all of our work environments. And whether that is the waiting rooms, or break rooms, or patient care areas, we needed to be sure our patients and our staff were as safe as we could make them. So what we started with was, initially, we thought we could come up with a quick equation, and just come up with what a capacity would be, but we found that it wasn't as simple as an equation might be. Because some of the complexities might be the configuration of the room, maybe it wasn't perfectly square, or the doorway was in the side, or you had a pillar in the middle of the area. So you have to work around that in your six foot distancing.

Laurie Wolf: A second one might be, what activities are required in that space? If it's a classroom style, or someplace where you need to see a monitor, you have to look at the line of sight of the people sitting in the area, or we need some flexibility with seating, because if a patient brings family in, and that family is in a pod that's safely at home together, they don't have to sit six foot apart, and they may even need a caregiver to sit closely with them. So you need a little bit of flexibility in your seating area. The time they spend in the waiting room also matters on the configuration.

Laurie Wolf: If it's something where it's a short wait period, and they get up and move throughout the area without a lot of acuity of the patient, that's one consideration. But if it's a area where the patient may be sitting for several hours at a time, and very concerned about their patient, the doctor might not have to come out and have a private conversation, that way you might want to configuration more of a pod area, where it has a little bit of privacy, as opposed to line of chairs every six foot apart. Little more like a DMV type thing, where you can just crank patients through.

Laurie Wolf: So they're two very different approaches. So the technique you use for separating the patients is important. Also, we found not only just separating them in social distancing, but to do visual cues, to let patients know how to move through the area safely. And that takes a lot of pressure off the staff of trying to be the PPE police, and trying to make sure everybody's doing what they should do. If the environment tells them what they need to do to stand here and move throughout the space, that is a lot more simple for everybody involved.

Betsy Shapiro: We have yet to figure out how to actually perform dentistry from a safe six foot distance. Your remarks are hitting mark here. Aside from the clinical aspects. Of course we are closer than six feet. We have had to rethink how the flow goes through our office. And in fact, your point about directional signs, we've talked to dentists about having patients move one way, loop around, come back, so people are registering and exiting on different pathways, and the pod concept, when you just have to have a discussion about perhaps a treatment plan when you're not actually providing care. How that might flow better, and how to do that, and achieve what you need, but be observant of our new norms, that certainly is an ever-changing, ever interesting world.

Laurie Wolf: So that brings up a good point. So it's not only getting social distancing in the environment itself, but then it's just as critical to identify all the work tasks that cannot be achieved in that area. And if it's physically impossible, say to work on someone's teeth at six foot distancing, you must come in closer, and then you must have the correct personal protective equipment to achieve those tasks. We also think a third thing is important, is to have a way for the staff to report problems that they're seeing, and to escalate that problem up as efficiently as we can, so that it's taken care of as quickly as possible.

Laurie Wolf: Whether that's patients not behaving in the way we think, or even our workers or colleagues, maybe someone's not wearing a mask, and we think they should, or it could be an indication that it's not just the human and not acting right, but we need to ask why is the human behaving that way? Maybe there's some limitations about the environment, or something we can change to help achieve the behavior we're trying to get them to do.

Betsy Shapiro: Boy, that's an excellent practical point. So I think what I'm hearing is, we need to empower everyone on the staff to be able to bring those observances forward to the proper person, and then try to work for a solution throughout the group, in the practice, or in any situation.

Laurie Wolf: Exactly. We're all in this together. It won't work unless our patients and everybody from our staff, everyone involved, not just the direct caregivers, we all have to be helping each other out to achieve this difficult concept of social distancing.

Betsy Shapiro: Sarah, I'd like to bring you into our conversation, because you have some experience in the research and design of environmental impacts on each individual's performance. Can you share a little bit more about your professional background, and how you landed where you are right now?

Sarah Parker: Sure. So my background is very much as a human factors and industrial organizational psychologist, but the only environment where I've ever gotten the opportunity to apply those things is within healthcare. So I've been working, trying to understand human performance in these settings for the last 10-15 years. And it's an awesome environment in which to explore human capabilities and limitations. You have wonderful, hardworking, well-meaning people, who just want to do the right thing. And the system often is not designed to achieve those results, as Laurie mentioned.

Sarah Parker: And so when we walk into a clinical environment, we get the opportunity to really say, "Okay, what is it that you want to do? Okay. Now what's holding you back? What are the things that are getting in your way?" Whether it be something about the physical space, or about the cognitive work, or about how the team is communicating, you kind of get to look at it from all these different perspectives. What helps your people do super well, is find a way to get whatever they need to, done for their patients. That's what healthcare people are awesome at. But what our jobs allow us to do is come in and say, "What's making you crazy? What doesn't work the way that you think it should?" And to work with those frontline staff, as Laurie mentioned, to design it better. And so that's where we really get excited.

Betsy Shapiro: So what have you been designing better?

Sarah Parker: It's a great question. So in this time of COVID, obviously, you've already mentioned, PPE is such a huge part of this. Our team was actually asked to be part of a design effort around face shields. Dentistry actually has been one of the industries that we've been really looking toward, because you all have amazing work on face shields. Obviously, you use them every day, and they're really integrated into your practice. And so when the healthcare system had to switch over from face shield just for an acute interaction, to face shields for a 12 hour shift, we really needed to think harder about, how is this design made such that, number one, it can last for a 12 hour shift? It doesn't give you a headache.

Sarah Parker: Number two, it doesn't fog every time you exhale. Number three, it allows the tension to keep your face shield on your head, to not be centralized at your temples, where you can get a headache. Also, how can you actually get the shield away from your face if you're doing computer work? And so really trying to understand, not just, "We need a face shield. End of story. Everybody has to wear it and we're going to mandate face shields. And that's the end of this particular discussion." The difference is, you get to say, "What kind of PPE do you need? And then what are the design criteria that will make it so that you can achieve that goal of wearing your PPE for a full shift?" So some of the work that we're doing with face shields, partly it's usability work, but we're also doing stronger trial design, randomized controlled trials, trying to understand which type of design frontline caregivers prefer to use.

Sarah Parker: And then we get feedback from the frontline staff, as well as from our awesome engineer colleagues at Virginia Tech, and have been able to kind of merge those two things together, to hopefully come up with a face shield that's wearable, that gets the job done, and also provides that imperative protection, especially during COVID.

Betsy Shapiro: Thank you for giving us credit on the face shield issue in dentistry. We certainly have had them around, but I will say that up until COVID, it perhaps wasn't standard to wear them all the time. We would have a mask, and goggles, or safety glasses, but now face shields are added onto there. So we have challenges with all of the layers, and if you're a dentist who wears loops and have a light attached, and it's reflecting back against your face shield, that causes distortion, or in fact just inability to see. So it's a whole multitude of things we're trying to work around and find the best solution for each person.

Sarah Parker: That's exactly right. And then if your solution as a system, so you were talking about, how do we empower frontline folks to speak up? If your solution is, "Wear your PPE or else." That actually doesn't solve the problem. The problem is, "I want to wear my PPE, but it's giving me a headache, or my loops bonk into it. So I literally can't do my job, or I can't see this person's mouth because of the glare." So that's a design opportunity, not an accountability opportunity. That's how we really try to think about these things. Like Laurie said, you come to work to do the right thing. So how do we facilitate that by the design?

Sarah Parker: And the face shield is a perfect example. People want to wear them, but there's a point at which if your headache gets so bad that you have to take it off, you've chosen that risk. It's the risk of taking this off is better than how I'm feeling right now. And I think that's a really important point to bring up, because we're working with such highly motivated people, that for it to get so bad that they can't do what we're asking them to do, that's where you need to be thinking differently. That's where it should be kind of an indicator or a trigger, as a leader, or as a designer, that this is inadequate, and we got to do something different.

Betsy Shapiro: So, Laurie, I'll bring you back in here a little bit, you're the implementation woman. If we're looking at Sarah doing research, and you doing the implementation, what did you observe as this was all kind of going on in Sarah's arena, as you were trying to implement, what were you seeing?

Laurie Wolf: So we are so lucky at Carilion Clinic, first off, to be able to have the honor to work with Sarah and her Virginia Tech colleagues, but our human factors team has been very integral in conducting usability studies, where we take the designs that Sarah and her team comes up with, and get to use our frontline people that are actually on the frontline using her designs and coming up with feedback. How do they like it? How does it make them feel? We ask them to give us rating scales on different aspects of the performance. And these will lead into data-driven design suggestions. They're fed back to Sarah and her team. They come up with the next innovations and another model. So it is very easy to translate Sarah's designs into the real world because it's so integral as part of the design process.

Sarah Parker: I want to say just really quickly, it's not my design. There're always a million people who contribute and who make these kinds of things happen. So we have colleagues in mechanical engineering, experts in 3d printing, experts in surface tension, and stuff like that at Virginia tech, as well as our colleagues in emergency medicine, and infection prevention saying, "Hey," giving us that feedback, "This hits my glasses. I can't see." As well as our experts in human factors that are just critical to actually coming up with an iterative design process.

Sarah Parker: I think this is one of those perfect stories of how you really couldn't go into a room by yourself and just have a genius idea. It takes so many different people with different perspectives to pull something like this together. And it takes a really compelling problem. And this is a really compelling problem. So this has really been an opportunity to try things, to fail fast, fail often, you know that old adage, and to then collect data on what works well.

Laurie Wolf: Sarah, that's such a good point. It has to be multi-disciplinary, or we could not come up with all the facets and components that have to be involved in coming up with a good solution like this

Sarah Parker: You're exactly right. It can't just be one discipline or one person.

Laurie Wolf: Everybody was involved in this collaboration, because you have to think of so many facets, because healthcare is complex and very diverse. So it takes a whole team to make it work.

Sarah Parker: And I don't think we want it to sound scary. You can only do this if you have a massive team of people. That's not, it's just those perspectives, the more perspectives that you can get and bring together, in our small experience, and actually the research supports this, that the diversity of perspectives really does create a better and more implementable solution.

Laurie Wolf: Thinking of it from a whole systems perspective. So organizationally, what are the tasks involved, the technology we have to do?

Betsy Shapiro: And to your point, Sarah, I think it can sound scary sometimes. And I think certainly for many of us, especially at the onset of all this, everything sounded scary about how we were going to be able to return providing care safely, keeping our office staff, and patients, and ourselves healthy, but we've learned one step at a time. And that feedback loop, Laurie, everyone being able to contribute to a solution. And of course, each individual dental office has its own little challenges, just as I'm sure you see in each and every office to which you're sharing out your knowledge and getting feedback.

Sarah Parker: The tailored solution, listening to those people who know the work the best. Whether that be a two person dental office or a 90 person dental office, really hearing those people who do the work and tailoring the solution to their experiences, and being willing to not be married to your solution, are really the thing. I mean, those are kind of the grounding principles of any sort of implementation, especially a successful implementation.

Sarah Parker: Sometimes in an ideal world, we talk about, "You need to limit variability, you need to do it standardized." And those things are good, but at the same time, allowing for that customization that works for you and your organization at a given point in time, I think particularly during COVID, is even more important. Because it gives people permission to have a little bit of control, rather than just having standardization for standardization. It allows people to take ownership of their own work. And especially, as you mentioned, when so much feels out of control, that's really important and empowering.

Laurie Wolf: It never takes the human error as the final word. If someone's not wearing their face shield, dig deeper and find out why.

Betsy Shapiro: So do you you feel, Sarah, that now you are at a point where your face shield design is more or less perfected?

Sarah Parker: We're proud of where we've gotten, I wouldn't say it's perfect by any means. And I would also say there's tons of opportunity, but I am a 1000% happy with our minimal viable product. We're quite pleased because we've actually taken it to frontline staff, and they've said, "Heck yeah, I'll wear this for a 12 hour shifts." Which is bonkers to me. I couldn't ask for more. So basically what we've really tried to come up with is a lightweight visor that allows you to flip up without contaminating the visor or yourself. So we have little handles on the sides near the temples that you can actually flip up the top shield if you're doing computer work, and then you can flip it back down, and it has two elements of coverage to meet our IP standards, which are on the visor that's touching your forehead.

Sarah Parker: It has a little tiny hat bill, and then on the visor that slips up, that clear plastic that flips up, it has a little covering at the top as well. So it provides you ventilation, at the same time is providing you appropriate protection. We just had a meeting with our colleagues at Virginia Tech, and they had already come up with two new, probably better, ideas. And so at one point, we need to get our frontline staff was a thing, and that's important. And then on the other point, I'm really excited about continuing to work on making this better.

Betsy Shapiro: Where would our dentists learn more about your design, or its availability, or anything like that?

Sarah Parker: Sure. So the 3d printed version of the design is actually available on NIH's 3d printing website. And that's how we've been doing all of our prototypes. We are in the process actually of finishing off an article to share much more widely about exactly what the design looks like, including our CAD drawings, and our SDL files, and things like that, because this is the kind of stuff that we have to share. So our team has been working on that, and hopefully we'll have that out and available pretty soon. If you Google NIH and 3d printing, it will pop right up. And there's lots of different, great face shield designs on there, and ours is from Virginia Tech. And this one is particularly for healthcare, because it's got that kind of flip up aspect to it.

Betsy Shapiro: Sarah, where else might we find more information?

Sarah Parker: Sure. If you just Google Carilion Clinic, C-A-R-I-L-I-O-N Clinic and Simulation Center, it'll pop our website right up, and we'll post additional information there, as well as on our Twitter feed, which is linked on that website.

Betsy Shapiro: Ooh, that sounds very fun, and we can watch what's really happening right at the moment. And just generally speaking, Laurie, you're talking about your work in patient flow or distancing, all of those, where do we find those kinds of information? How do you share out what all you're doing and learning with the world?

Laurie Wolf: We do the best we can at trying to publish in peer review journals. And actually, we just submitted a publication for ergonomics and design with this six foot distancing project in there. The work process, it has to be so individualized, depending on what it is you're trying to do. So it's a little hard to publish something in a generic way, but in the six foot distancing one, we did come up with something called, "The Quick Start Guide," that just has the generalities of how to measure, and then what to do when the task you are trying to achieve, doesn't fit in this new socially distance environment, and where to reach out for help. And that's where the customization comes in. So I would highly encourage some kind of quick start guide, we're glad to share that stuff too with your audience, if that's helpful, at least of what we did, and then you can tailor it for your own area.

Betsy Shapiro: Before I let you go, is there anything else you'd like to add?

Sarah Parker: I think, particularly during COVID, the enormous capacity of people who work in healthcare, who work in dentistry, who work in caregiving industries, home health, and physical therapy, occupational therapy, folks like that, the enormous heroic effort that people have gone to, to care for their patients, is just extraordinary. And so to me, one of the major lessons has been, first off, when somebody says, "This doesn't work right," really listening, because it's not because they're complaining, usually. It's usually because it really doesn't work right. And then the second thing is finding those... We try to do it through design, but finding those kind of deep ways to connect with folks as they're doing this really work, and really emotionally intense work of caring for others.

Sarah Parker: I mean, I believe that goes across caregiving professions. This is a new level of exhaustion. And I think acknowledging that when we're thinking about human capabilities and limitations, is something that has been really important for us, really thinking about how we're maintaining our own teams, but as we design solutions for frontline caregivers, thinking about it in a different way, thinking about the emotional toll, as well as the work toll in a different way, I think, is really important now.

Betsy Shapiro: And, Laurie, any parting words from your end?

Laurie Wolf: Oh, I just think that the more we spend on trying to optimize, whether it's personal protective equipment or the environment we're working in, all of that will help us achieve a safer environment and process, for both our staff and our patients.

Betsy Shapiro: Well, thank you both so much for joining us today. We truly appreciate you being with us. And we especially appreciate all the work you're doing, because it does translate to our world in more ways than you've probably even imagined. So thank you for that.

Sarah Parker: Thank you for the opportunity. Yeah.

Betsy Shapiro: If you'd like more information about the Parker lab at Virginia Tech, you can visit their website at labs.btc.vt.edu/parker. Now we're at the member question of the day. This is where we answer a question we've received from a member. And for this part of the show, I'd like to welcome back Katie Call, a manager in the Practice Institute. Hi, Katie, welcome back to the show.

Katie Call: Hi Betsy, thanks.

Betsy Shapiro: In the Practice Institute here at the ADA, we answer member questions every day, and we wanted to share one we've received with our listeners. Katie is going to turn the tables on me today because she is going to ask a question, and I am going to get to answer this time around. So here we go, Katie. Fire away.

Katie Call: Thanks so much, Betsy. So here's a question that we've received in the past. And I know this is something that you have prior experience with, here's their question, "I've noticed that wearing additional PPE has caused me to change my posture and positioning by the patient. I'm starting to also notice increasing stiffness and tension. What can I do to still maintain a good posture while wearing PPE, and also what can I do to prevent future injuries?"

Betsy Shapiro: Thank you for that question, Katie. As you alluded, it's something I have a little bit of experience with, not so much through COVID and wearing extra PPE, but having had some ergonomic injuries when I was back in practice, I recognize fully how important it is to try to prevent future injuries. Staying healthy is much easier than getting healthy. Thinking about how to stay healthy, how to prevent any long-term problems. First of all, as our speakers just alluded to, it's a very personal thing. It depends entirely on the setup of your office, on how thick or thin your operatory chairs are when you're tipping a patient back, but go back to your days of dental school and reflect on proper posture, how to best be seated, engage your staff in this exercise, ask them to let you know when they notice that you're not sitting quite right, when you don't have your loops or your chair vision adjusted quite perfectly.

Betsy Shapiro: And then also follow through by doing the same thing for your staff, because you want to keep them healthy as well. In addition to all these minute changes that you might make patient by patient, you want to think about the overall picture, and you want to be sure that you're doing exercises to keep your flexibility or to increase your flexibility, to pay attention to your range of motion. If you visit ada.org/ergo, you will see short videos that can help you with the number of stretches or positioning issues that are very easy to incorporate into your day, and to incorporate into your staff's day as well. And if you start with those now, and keep including them as part of your daily regimen, I think you'll find that you can really be helpful to yourself, to your staff, and to your productivity.

Katie Call: Thank you so much, Betsy, for sharing all of that information.