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Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

A renewed focus on NatSSIPs

NatSSIPs - National Safety Standards for Invasive Procedures 


Many of our prospective clients often tell us that they are working successfully towards a safer culture, and yet never-events and avoidable harm do not appear to be diminishing on a National basis.* 

Let's look at NatSSIPs and LocSSIPs on which there is a renewed focus at this time. Otherwise known as the Five Steps to Safer Surgery. 

LocSSIPs is a topic that we have masses of experience in, helping Trusts develop their own best practice in briefing, checklist and debriefing . We are privileged to witness many excellent demonstrations using Natsipps techniques but sadly, we occasionally meet individuals who think they don't need such aids to safety. 

Very recently I was disappointed to witness a Clinician quite deliberately reading news reports on his Smartphone while a Safer Surgery Checklist was being read. Sadly his clinical colleague said nothing. Rest assured that the situation was rectified at the time. However this is still not unique, though happily rare. 

We have a responsibility to ensure the importance of NatSSIPs and the reasons behind its introduction are understood. In our view (and others) the use of checklists and safety techniques is not a personal option, but a mandate and a necessary core function of professional surgical performance. 

NatSSIPs is built around the aviation based concept of threat and error management. This came out of the original NASA funded research at the University of Texas under the late professor Bob Helmreich. 


Threat and Error Management is three steps: 

•AVOID – in an ideal world you would avoid everything that could possibly go wrong

TRAP - But of course you can't avoid everything in the real World. What you haven't been able to avoid you would wish to trap, in order to minimise any errors resulting in potential harm. 

•MITIGATE (read definition)- Finally, one needs to reduce the effects if harmful but to stretch the meaning of 'Mitigate' – to learn from failure and of course success. 


How does this work in practice? 

In healthcare, as in aviation, the 'AVOID' phase is accomplished by having a briefing (Handover or Safety Huddle) normally performed at the start of a working shift or day. This is where the team get together, share plans for what should happen, build situation awareness (Plan A) across the whole team and prepare themselves for what they hope won't happen (Plan B, plan C etc). 

'TRAP' - The 3 steps of the WHO Safer Surgery Checklist fulfil this role.The checklist serves as a memory aid to ensure all necessary safety issues have in fact been completed. Note – it is a Checklist - not a TICK LIST. It is completion of the actual CHECK that is crucial and not the ticking of a box! 

Finally, 'MITIGATION'. Debriefing sits here as a tool for learning not blame. In the case of a successful outcome debriefing is the opportunity to discuss what went well, why it went well and how we will try to ensure it goes well tomorrow and thereafter. 

In the event that it has not gone well, rather than resorting to blame and finger pointing; this step serves to investigate why and how something went awry. How and why well-intentioned, well-trained people have perhaps made an error, with a view to genuinely learning lessons and moving forward effectively for the whole team and ultimately the organisation and the profession. 

Duty of Candour sits here too and is of course a legal, professional and a compassionate necessity. 

After all, quite apart from the safety aspect, who gains the most respect? Someone who accepts and owns up to their own fallibility or someone who seeks to hide it? 

Atrainability would be delighted to assist you in implementing LocSSIPs for your teams, please get in touch to arrange an informal phone chat at your convenience. 


*Source: Never events data, click here

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Walking the Tightrope...

Self-Confidence is vital but Self-Awareness is Key to Learning Success.

Confidence is a vital commodity when it comes to delivering safe, effective performance in any job, sport or profession. One must have a degree of self-belief in order to fly a plane full of people, compete in sports or indeed perform medical treatment. However, a simple, basic facet of being human is that we are all fallible.


Are we aware of our response to our own errors?

Firstly, we have to realise that we have indeed made an error, because initially whatever action was taken was likely done with the expectation that it was correct. The dawning realisation that we have indeed committed an erroneous act can trigger a response, which could be fight, flight or freeze. Once confidence is damaged, it can manifest in a variety of ways. If we have a critical voice in our head, telling ourselves off; compounded by friends, family or colleagues also berating us, we can spiral downwards into depression. Often if we are unable to accept that we're responsible for a mistake we can respond defensively by directing our responses outwards;


                                                          "Why didn't YOU tell me!"

                                                         "Why didn't YOU stop me?"

                                                         "YOU didn't tell me…"


…in other words, if I can't accept my own fallibility it must be yours. This in some cases leads to arrogant behaviour, and does not make for safe, effective teams.

We as individuals need to work on our self-awareness, take responsibility and manage our responses, but we also need a team around us who don't continue the cycle of berating and instead supports and learns when mistakes are made.

How has aviation dealt with this? By embedding Human Factors principles at all levels from Board to the frontline.

The Board must walk the talk or any transformation program will fail, because it is perception at the individual level of the safety culture that is crucial to success.

Pre-1980's aviation training focussed purely on the technical skills of flying a plane. Effective communication, team-work, situation awareness – these were not considered important. However, with the improved use of black box recordings and analysis of significant aircraft accidents it became apparent that it was the human element that was mostly at fault. What is now known as – Human Factors.

How was it dealt with? By educating flight crew and then embedding effective human factors practice in ALL technical training. Although it took time, it is now completely accepted as part of the culture. Furthermore regular refresher training, feedback and assessment is given to flight crew on their flying skills and their interpersonal and cognitive skills to keep best practice at the forefront of their daily practice. In terms of appraisals these are taken very seriously.

If a pilot fails to meet the standards in either category of technical or non-technical skills he/she will be given further training and ultimately he/she can be removed from service. Just imagine if this took place to the same extent in healthcare and some other professions.

The fundamental point though is to understand error and the causes of error, and to accept them and to work with them. Humility is an essential part of professionalism. One of our clients (a large critical care unit in a major trauma centre) has recently contacted us to say how our training has had an impact on their team.

Furthermore we've been told that staff turnover has been reduced to a very low level indeed. These changes have been visible after in-depth Human Factors training and coaching, although they cannot be directly attributed of course.

Atrainability would be delighted to help any team or organisation delve further into their own short-comings and help to highlight their areas of success. Contact us for an informal, confidential discussion or alternatively enrol for our upcoming Open Courses listed here.
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ITV Tonight - Medical Blunders & other updates

ITV Tonight - Medical Blunders & other updates

Here at Atrainability, we're pleased to say it's been an eventful few weeks.

ITV Tonight: How Health & Social care can learn from Aviation.

I recorded an interview with ITV Tonight, Click here for Catch Up.or alternatively watch here. The programme is focused on Patient Safety and my suggestions were aimed at helping explain some of the elements that increase the chances of human error in health and social care. Part of the interview was filmed in-flight to demonstrate why checklists are a vital and completely accepted aspect of safety in aviation.

Fallibility is of course an inevitable, though sad facet of the Human Condition. Accepting that and helping to avoid, trap and/or mitigate error is fundamentally what we at Atrainability are concerned with. Although the programme focussed on the NHS, we would like to be clear that we know and understand that private providers make mistakes to. We'd be interested in hearing your thoughts on the subject. Tweet #ITVTonight @atrainability or get in touch.

The Glasgow Emergency Surgery and Trauma Symposium

It was a great pleasure to be invited to take part actively in the 2017 Glasgow Emergency Surgery and Trauma Symposium where I gained so much valuable insight into complex post trauma care from some truly World-leading experts in both clinical and non-clinical skills. The latter involved Professor Rhona Flin from Aberdeen University. All the faculty were honoured, in my case by the award of Membership of the Royal College of Physicians and Surgeons of Glasgow.

Coaching and Mentoring in the Operating Theatre

Now we are helping an NHS Trust further develop their non-technical teamworking in association with their LocSSIPS, by coaching and mentoring in operating theatres.

One aspect of this has been debriefing a successful emergency C-section. On first asking "why did it go well?" the answer from one of the senior nurses was that it has "just worked well". However, so much more learning is available with careful encouragement.

In brief, the team had been widely scattered across a large area of the hospital when they received the 'Crash Call'. They clearly moved rapidly and had no time to lose. They didn't do a formal briefing but had in fact accomplished one which they set to work. They shared plans, updated Situation Awareness and allocated tasks to the appropriate team member. A good job achieved and a healthy baby delivered safely.

The work is continuing with debriefing and feedback on specific areas such as checklist design, development and implementation with guidance on how to maximise safety. Much effective work is being pointed out and reinforced as well as some corrective advice.

The Society of Radiographers - 'Putting Patient Safety First'

"When it comes to developing and changing a culture...simple changes can make things better." - Naomi Burden, Quality & Governance Radiographer at Royal Cornwall Hospitals. Atrainability are very proud to have helped progress Human Factors awareness in Radiography. Read the full article.

New Masterclass

We're now offering An Introduction to Coaching and Mentoring workshop which has been developed by Atrainability's Ben Tipney. More information will be available shortly on our website but if you'd like to find out more please contact us.

As always, we're happy to discuss any challenges you are currently facing or answer any questions you might have about our Human Factors training.

Trevor and the Atrainability Team.

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Compassion Costs Nothing?

Compassion Costs Nothing?

Compassion; to empathise for others, to show you care; what does this cost in psychological and emotional terms? 

At my great age I just fell into a trap at a conference of agreeing that compassion costs nothing. How could I do that? The emotional cost of true empathy (as opposed to simple 'passive' listening) can be huge. It can be draining for those in caring professions - constantly feeling compassion and empathy for service users, patients and relatives - it takes its toll. This may explain why front line teams sometimes seem so dispassionate. Would they really have entered into such professions if that was what they truly felt?

What could have happened?

Well when we say "physician heal thyself" we tend to think of the physiological; food, water, putting ones feet up – if you like, the most obvious, visible signs of wellness. But when we consider the emotional and psychological toll that caring for others exerts it is in fact, blindingly obvious. What are we doing to provide our front line workers with the awareness and tools to handle the inevitable stress that comes with caring for unwell people? Do we even encourage ourselves or others to 'tune in' to our own emotional state, let alone put strategies in place for our own well-being?

We neglect our psychological and emotional wellness at our peril.

Atrainability have developed training to help deal with all aspects of wellness and stress. We're always available for an informal, empathetic chat to discuss your specific needs. Click here to contact us today.


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You don't have to put up with it.

You don't have to put up with it.

We recently ran a successful Open Course in Birmingham and the mix of participants that attended all shared their Human Factors challenges; which included typical problems such as not cross-checking adequately and some good situation awareness stories.

The best part about our Open Courses is that we get a good combination of people attending; recently we've had a room of blood bank teams, Ophthalmic surgery teams, Junior Doctors and Occupational Therapists - to name a few! All from different healthcare providers; travelling to our classes, openly sharing their experiences without fear of judgement and leaving with new found confidence and solutions that they can implement as individuals and within their teams.

For us as trainers, it's always interesting to have open discussions about the difficulties different individuals and teams are facing, but the reason we keep doing this is because we can see the changes in people after our training. 

For some, it's in the class; we call this 'the light-bulb moment' (more on this here) and for others it's a few days later, when they get in touch to tell us they just avoided an error because of our training techniques or they've found their confidence in speaking up to the staff member they were having communication issues with.


You may find it comforting to know that there are always similarities in each story, which is how we know we can help you.

Typical problems include: communication issues, dealing with difficult behaviours, poor attitude, situational awareness, briefing and debriefing effectively, stress and time management, poor leadership, hierarchy barriers, lack of feedback and confidence. All amount to how to learn from inevitable errors and successes without unnecessary blame.


So whatever challenge you are facing, know that there is a solution. Don't keep putting up with it, talk to us today about our next Open Course.

There's still time to book a last minute space on our London Open Courses next week and we're also taking bookings for London in February 2016. You can book a space for either of these through our website here or alternatively email us or call Trevor on 01483 272987 and we can discuss how we can help you further.


We look forward to hearing from you.

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I could have told you that

Many high-performing professionals make their job look easy. Well maybe not micro-surgery but aviation is a good example that it seems is widely misunderstood. I hear many people say "you pilots don't understand – we deal with sick people who aren't OK when we start treating them. You wouldn't get airborne in a plane that wasn't OK" 

Well pretty much of course not. But if only life were that simple! Pilots and for that matter cabin crew, are there for emergencies, generally unanticipated, often at periods of low arousal. Look at Kegworth – 1989 - routine flight Heathrow- Belfast - relaxed take-off and climb and suddenly an engine breaks apart. The crew, who must have been terrified, misidentify the problem and shut down the wrong engine. 47 people die.

Lessons learned? Well it is an imperfect World and the same essential error happened in Taiwan in January 2015. You will probably remember the horrific images of the plane with wings vertical crossing a bridge before plunging into the river killing 43. The error was the wrong engine shut down again.

However we all now accept that flying is significantly safer than any other form of transport taking into account the number of flights per annum. Things do go wrong but what helps prevent tragic potentially fatal accidents is training and preparation. Especially thinking ahead and discussing what could go wrong and having a plan in place for how it would be handled if it did. Think Captain Sullenberger and crew and the Hudson River successful outcome.

How often have you said with hindsight "I could have seen that coming" or "I could have told you that would happen"? Experience is a great learning tool but trial and error is simply not acceptable.

That seems to be what healthcare is doing though. There is still a general reluctance to learn day to day success, failure and near-misses.

This is what Human Factors training can aid such as how to share plans across the team and encourage input from everyone who might spot the impending threat and intervene for safety. Even more so when it comes to post-hoc debriefing discussions about what worked well and what could be improved.

When you get down to it aviation and health and social care is about risk management. Risk management is about Human Factors. Mental preparedness and appropriate hierarchy and open communication.

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Human Factors Training – Published evidence that it works!

We all know how challenging it can be to find good quality hard evidence that training teams and leaders in Human Factors awareness and skills enhances Patient Safety. Health Education England are seeking such evidence now for all forms of training. Quite right too. We have worked with various teams over the years notably at the University of Oxford with varying degrees of success. There are a plethora of published papers out there with our names on them. One of the arguments has been what to measure and I believe firmly that the only real measure is patient outcome. We have taken part in other recent research and I am led to believe that some further positive results will shortly be published. 

Some of you who have been with us a while will know that we were invited in to Newcastle Neurosurgery unit by Patrick Mitchell, the clinical lead, in 2006 where after some in-house training they had reduced the wrong-side error rate for cranial and spinal procedures dramatically (from 1 in 300) but then had a recurrence. 
The training consisted of putting all the direct theatre team and their immediate leaders through a one day interactive training course in understanding the problems around human behaviour and fallibility and practical solutions. This was supported by coaching to help embed the skills in practice. I think it is fair to add that two senior team members found it difficult to attend.
The result is now over 5 ½ years without a side error from a pre-intervention rate of 1 in 300! That is over 21,500 sided procedures in the unit with essentially the same entire team, although one of the senior clinicians did leave a couple of years ago – to concentrate on private practice.
 
The results have been published and is available to download freely - Click here to view full report in PDF format
 
I don’t believe it is unfair to say that the fundamental issues were around behaviour, especially team briefings and checklist discipline. Incidentally this was before the WHO checklist was published. Patrick Mitchell is a private pilot himself and has a clear understanding of the importance of checklists in safe performance. 
I would like to emphasise that the Atrainability team didn't achieve this –we simply helped the front-line team to build and maintain the confidence and skills to deal with the problems successfully. 
We encourage all our clients, colleagues and prospective clients to continue to seek and share evidence and best practice to improve Patient Safety for everyone. 
The Atrainability team are of course, very happy to explore further opportunities to develop solutions to human error, poor behaviour and help teams avoid avoidable harm.
 
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Human Factors are not just for Christmas

The Festive Season is upon us again and thoughts turn to gifts. What finer gift than support for a Human Factors Training programme?

 

It is apparent that the importance of Human Factors training across all workplaces is being recognised after all this time. How pleased Martin Bromiley must be.

One of the most pleasing changes this year has been the growth in organisations that realise that short interventions are a waste of effort and money.

You don’t change the culture (whatever that means) with a few hours of classroom chat about how to avoid errors.

This year has seen a number of NHS Trusts and private healthcare providers come to us and ask for programmes that address deep-rooted issues. We have started programmes of in-depth training of managers and team leaders to help enable them to understand the flaws in the processes and procedures that their staff have to deal with - the error-provoking conditions under which the front-line staff work. These are the holes in the Swiss Cheese models!

One of the delightful comments we received was from a middle manager in a mental health Trust who had performed a disciplinary procedure quite differently after an Atrainability course. She said that beforehand the staff member would probably have been sacked for violating procedures. But she then realised that it had been done with the best interests of the service user in mind. There was no desire to harm, no malice. So they have kept their job, albeit with a comment on their personal file, but the lessons are shared with others. A palpable shift to a ‘Learning Organisation’.

I know the aviation comparisons are sometimes overplayed but please bear in mind that Human Factors are taken seriously enough that by law they must be refresher-trained each year. Once a foundation knowledge and understanding is embedded within the organisation, refreshing and updating is comparatively easy.

So like the proverbial puppy, Human Factors is not just for Christmas it is for life – literally!

May we at Atrainability wish you all a very Happy Christmas season and a safe, effective New Year.

 

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We promote what we tolerate.

It was very good to see so many old friends at NAMEM (National Association of Medical Education Managers conference) recently and particularly put faces to those names!

What will probably stick in all our minds was the talk by Dr Victoria Bradley on her culture-changing experiences and her successful challenge of an unsafe clinical department situation. It was a pleasure to hear that her bold actions brought real front-line improvements in staffing levels and patient care.

She had to overcome her concerns about ‘whistle-blowing’ and potential repercussions and having done so was rewarded and thanked by very senior management in her Trust. Quite right too. But sadly this is not a frequent occurrence regarding the happy ending.

Frequently we hear course delegates stating that they don’t feel confident in raising concerns and in some situations don’t feel anyone is listening and nothing will change.

However how does this fit with duty of candour? We promote what we accept and tolerate. Turning a blind eye is simply not professional.

However the multiple reasons why so many of us don’t challenge unsafe or unprofessional situations are understandable and often a facet of our very essence of being human, such as the Fight, Flight, Freeze response. We have recently run several courses when admissions of passive behaviour have been manifest. But we at Atrainability have found we can help rebuild that confidence and re-motivate team members to speak up with appropriate persistence.

Courses combined with individual and team coaching helps build more-effective safer team-working. We are constantly developing new material, with a focus on advanced Human Factors looking at Stress Solutions and dealing with difficult people – including colleagues!

 

 

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Human Factors - common sense made conscious

We have begun a major training programme at a large private healthcare provider in London where all staff are attending an initial very short introductory module on Human Factors. 
The content is limited to why the subject is relevant to them all, some explanations of why we are all fallible and a few practical takeaway tools on how to try and avoid things going wrong. The long term plan is to continue to work together and build a sustainable high reliability organisation with safety at its core. 
Later in the Autumn it will include training trainers and champions to embed safe policies and procedures and seek to support staff.
The Director of Nursing had been actively seeking such training and has been a fantastic advocate, but the clincher was getting to present to the Board. 
The Chief Executive is a smart no-nonsense lady. I asked her and her senior colleagues if they knew what Human Factors is. Her instant response "well it's just common sense". Of course it is, but the trick is how to bring that to the conscious brain when faced with all the pressures and hazards of everyday work life.
That is where we seem to be helping judging by the feedback from the attendees. They love the simple messages and that we are talking their language.
Mind you it's quite a challenge with each class containing up to 30 from every area in the Hospital from finance through reception to ITU and theatre teams.
It is fun, engaging and at first sight seems to be making a tangible difference. 
Here is an example of unsolicited feedback from an ODP in paediatric theatres:
 
"I just wanted to say how much I enjoyed the training session. I think Ben delivered a really good session and I personally learned a great deal. It has given me some good ideas of ways we can improve our day to day practice within our department and has inspired me to look further into the human factors training principals and background.
If you could pass my thanks on to him that would be appreciated."

The icing on the cake, though, is that the Executive Board are all attending alongside all the 600 staff. 
Now that shows what leadership should be and will undoubtedly have a profound positive effect.

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Reporting Near Misses - Untoward Incident or Known Complication?

The benefits of reporting near misses are surely beyond dispute. Each close shave is a learning opportunity which should be shared with others. Does every doctor need to experience problems first hand and patients endure possible harm in order to gain a high level? 

I have recently heard of an incident in maxilla-facial surgery which has disquieted me. A senior consultant decided to perform two lengthy operations in one day and incur a significant overrun to the detriment of the theatre teams. It had been possible to ask a fellow senior surgeon to take on one case and indeed such an offer had been made. The offer was impolitely refused.
The second procedure was commenced at 4 pm and involved a neck dissection. Unfortunately a small tear was made in the lower end of the jugular vein where it joined the subclavian vein. The anatomy was non-normal in that the vein was above the clavicle rather than under.
 
There was considerable haemorrhage which was not controllable. Vascular surgeons were called and the vessel was approached from the anterior chest wall, but were unable to control the bleeding. Eventually orthopaedic surgeons were called to divide the clavicle and the tear was over-sewed. The patient lost 18 units of blood and the cell-saver was used successfully to replace lost blood. The anaesthetist performed very well in difficult circumstances.
 
What could be learned?

The surgeon did not consider this a reportable incident and indeed was most vociferous in wishing it not to be reported. One must ask why? Does it indicate fear of the local culture? Or is it something more ego-driven?
 
What would you consider the professional response?
 
Surely if this is a recognised non-normal anatomical situation it should be shared to help junior doctors learn to avoid it happening to them?
 
How can we make it ‘safe’ to report near-misses and move the whole culture closer to the aviation model where incident reporting is actively encouraged? 

We specialise in training for debriefing to learn. Blame serves little useful purpose unless people are wilfully ignoring rules and due process.
 
Training utilises the greatest resource – a team member who may have made a mistake despite trying their best not to. What a resource to help the whole organisation learn! Shame to waste it.

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Lighting the Blue Touchpaper

Lighting the blue touch paper

The trainers are excellent, engaging, knowledgeable and enthusiastic. The Training was brilliant and it has really set fire to my personal blue touch paper. It has made me think about how to look at things differently, and as a result I revisited a policy I am working on; so that lessons learned can be applied in a more meaningful, informative way, rather than staff feel they are being blamed and penalised.

Project Lead, Safe Services, Cheshire and Wirral Partnership Foundation Trust

This was feedback from this week when we presented a train the trainer course for Cheshire and Wirral Partnership Mental Health Trust. This is the second in a series aiming to bring about sustainable improvements in a Zero Harm campaign. Other selected comments from the evaluation sheets:

 

·         Very eye-opening course which used common-sense ideas & delivered them in a structured constructive manner

·         Thoroughly enjoyable & thought-provoking. Ought to be part of mandatory training

·         Need more staff from clinical area to attend this training to enhance knowledge, practice, empower them.

·         Hope the Trust fully embeds this learning into the culture

·         Excellent course – pragmatic, common sense & gives words to describe how I feel about potential change culture

The initial response has been fantastic.

 

At the end of Day 1 one of the delegates from the first course spoke passionately of the changes she now felt able to make. She really enthused her colleagues.

Most startling and pleasing was to hear from her how what had begun as a disciplinary inquiry became a lesson in learning and understanding the good reasons why a staff member had deviated from procedures in efforts to do the best for the patient or service user.

We offer a flow chart based on that of Professor James Reason that clarifies when training is the correct treatment for rule violations and those rare occasions when disciplinary action is necessary.

In simple terms if you are not employing psychopaths or sociopaths in your teams, then most errors are unintentional or made with good outcomes in mind.

Understanding why and how errors are made at the Human level is so beneficial to creating a resilient high performing sustainable system.

It could even mean a redesign of some procedures. Many of our clients are doing that now.

If it results in a reduction in avoidable harm it must make sense!

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Real positive change at the frontline

The Patient Safety Congress is in Liverpool this week, and the subject of Human factors is to the fore. Back at the front-line we are delighted to report that feedback from nursing staff at one department we have recently trained has reported real improvements in team practice and hence morale -

"Since we attended the Human Factors course, we now, as a department have daily meetings to discuss ‘job’ allocation, so that everybody is aware of what is expected of them during the day. This is working particularly well, everybody is now focussed on what they need to do, rather than overlapping, and tripping over each other,

We also have a  debrief at some point in the day, to ensure everything is  still running smoothly, and talk about any problems or situations that may have arisen through the day. All the nursing staff are very happy implementing this, and wish as a group to say thanks again."

This was a result of a whole department enjoying a full day of class-based training consisting of:

Ø  Introduction to Human Factors

Ø  How & why we make errors

Ø  Situation Awareness

Ø  Decision Making

Ø  Communication

Ø  Dealing with difficult people

Ø  Leadership & team-working

Ø  Briefing & Checklists

Ø  Debriefing for Learning

It was a full day but enjoyable all round. Not bad when you consider it included the whole range of staff from clerks, reception staff through nurses and ophthalmologists! Phew.
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Safety in Neurosurgery - a successful Human Factors intervention

 
Five years have now passed since the Atrainability team helped a neurosurgery unit in the North East of England overcome a string of major wrong side errors. 
Prior to our training and coaching intervention their had been a rate of 1 in 300 wrong side errors. The surgical Lead had instituted a 'knife' check - a check that everything was as it should be pre-knife to skin - but then another error occurred.
 
Atrainability trained almost all the team members in how to avoid and trap errors and particularly how to assert the need to brief the team and check all appropriate items, including of course surgical site. One or two senior team members were unable to attend but those who did were trained in dealing with colleagues who were not keen on such non-technical matters, politely but firmly.
This was all before the WHO checklist had been mandated.
The result is now five years without another incident. Time between error is the measure and is statistically valid.
 
It is a sad fact that many organisations contain 'difficult' people who feel their skills are being questioned. Not everyone is open to comments about their behaviour. It is not an accepted part of the culture in many areas of healthcare. But if the team stand united and firm, challenging individuals can be handled without any unpleasantness. 
 
Although not part of an academic randomised control trial, these results are notable and a splendid testament to what can be achieved in the name of patient safety.
 
As the Surgical Lead said - "The error you have to prevent is 2 years from now, out of hours, when you are on holiday and a locum surgeon you will never meet is operating at night with a junior anaesthetist and newly appointed scrub nurse."
 
For those still sceptical, consider the cost of training against the cost of compensation and litigation. It is an investment well worth considering.
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Debriefing? Missed opportunities to learn from near misses.

The accepted theory of Threat and Error Management 1,2  indicates that there is tremendous benefit to safe teamwork  by attempting to avoid all possible problems in advance. From this has come the practice of team briefings before surgical procedures. However not everything can be foreseen and our memories of what has been discussed may be erroneous due to such as the passage of time, fatigue, hunger, personal stresses or just ineffective communication. For this reason the WHO Safer Surgical Checklist has been mandated and its use is accepted across healthcare surgery. However it seems from our experience that compliance is less than 100%. One of our Atrainability team has just had an operation where the WHO paperwork does not appear to have been completed and performance of the checks themselves somewhat suspect. Fortunately no harm has apparently occurred.

However the greatest opportunity for improving safety is a simple debrief. The front-line team are the most under-utilised source of learning from success as well as failure.

A recent investigation of a particularly tragic case highlights the resistance to learning from everyday events. Our team was taking part in a research project in a major hospital in 20083. A scrub nurse taking part in a neurosurgical procedure was asked to hand the surgeon a syringe of saline to wash out the operating site in the cranium of a child. The surgeon did not remove his eyes from the microscope and did not check the syringe. It so happened that the nurse was under training in this specialty and had mistakenly handed a local anaesthetic. Fortunately the error was trapped by the supervising scrub nurse who handed her the correct saline. Both syringes were externally identical – no colour-coding. The Consultant surgeon was completely unaware, but the Anaesthetist was fully aware.

Within 2 years of this a tragic but similar incident occurred in the same hospital. http://www.bbc.co.uk/news/uk-england-london-25916336

At the time of our observation the Consultant Anaesthetist declined to debrief with the team because "nothing happened".

No direct conclusion can of course be drawn but overcoming resistance to learning from near misses (near-hits?) should be a professional response.

Encouraging debriefing and responding appropriately to warnings of unsafe situations, avoiding unnecessary blame, must be the way forward for management and multi-disciplinary teams.

References:

1) On error management: lessons from aviation - Department of Psychology, University of Texas at Austin, Austin, TX 78712, USA Robert L Helmreich professor of psychology helmreich@psy. utexas.edu BMJ 2000;320:781–5

2)     Culture, Error, and Crew Resource Management Robert L. Helmreich, John A. Wilhelm, James R. Klinect, & Ashleigh C. Merritt, Department of Psychology The University of Texas at Austin

3)     Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety 6(3), pp. 180-186.

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The Human Factors Message is spreading

It is great to spread positive news about the growth in adoption of Human factors. Increasingly Healthcare organisations, NHS and private sector are adopting training and process redesign with a view to make care of patients safe by design not by luck.

Atrainability have been engaged to train Trust-wide trainers and Champions in several healthcare providers. Here are some anonymous examples:

·         One of the top-performing Trusts in the NHS in England is offering Atrainability Human Factors Train the Trainer courses to all its trainers – clinical and non-clinical. Almost 50 have attended and we have a waiting list. They are tasked with embedding safe practice and checking procedures for sense and practicality.

·         A major private healthcare hospital has engaged Atrainability to train the entire nursing staff across all wards and units.

·         We have recently worked with a clinical simulation unit and then subsequently with the same Trusts Maternity Unit using advanced simulation debriefing techniques.

·         Training and coaching in a Medical Assessment Unit has revealed solutions to blockages in patient throughput from A & E or GP input to ward or discharge to home.

·         We are working with a Mental Health Trust on smarter procedures and checklist design for such as safe monitoring of in-patients and service users including early recognition of potential slips, trips and falls.

·         A major cardiac centre has engaged Atrainability to help build safer, more resilient teams in the ITU. The same centre has changed Operating Theatre procedures around Briefing, Checklist usage and Debriefing with our training and coaching support.

·         As a sign that the knowledge and skill of safe Human Factors working is spreading we are delighted to be able to streamline the SMART anaesthetics course that we run with the team from the Difficult Airway Society http://www.das.uk.com/course/smart

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Never events and those pesky Human Factors

I’ve recently heard of several recent never events and thought I would share the Human Factors elements as reported to me.
In a Maternity unit a vaginal swab was left in post-delivery and the doctor was  found guilty by the Root Cause Analysis because he had failed to follow standard procedures. But looking at incident in more detail it transpires that he was interrupted by 4 other urgent cases in the unit while trying to deal with this one. The dangers of interruptions and distractions are well recognised and we should all work hard to reduce and ideally eliminate them.
You could argue that this is another side-effect of short-staffing perhaps?
 
The next was about a junior doc who had ignored the Time Out check and had helped himself to local anaesthetic and scalpel behind the scrub nurse. Instead of the trigger finger release planned he went into the wrist as for a carpal tunnel procedure. What was stunning was that this was 18 months ago and I know of an identical error at a high performing Trust 10 miles away – this Summer. It is the responsibility of all the team to ensure correct application of the WHO checklist. Many times we hear of how use of the checks slows down the flow of the day especially in small day case units, but this is what happens if you don’t. No-one would be happy to take off in a plane where the pilots hadn’t checked everything that mattered …..!
 
The latest report into Barrow Maternity unit make unpleasant reading too http://www.bbc.co.uk/news/uk-england-cumbria-25322238. 
‘Insufficient supervision’; ‘inadequate training’; ‘failure to monitor CTG’ etc. Bad people? Maybe but probably a failure of training. Nurses, doctors, midwives are not normally chosen from the ranks of psychopaths, but in order for us all to adopt safe procedures we need to know the rationale. The investment in training pays you back in every way – the human cost – patients, relatives etc; retention of staff due to improved morale and non-acceptance of poor behaviour; reduced cost of case reviews and CNST payments.
 
To find out more about our Human Factors training courses click here.
 
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The Chandelier Principle

I’ve had a great week – 3 days running a train the trainer with Humberside Fire Service and their offshoot HFR Solutions. Our new partnership will help to spread the Human Factors message across Emergency Services and Industry in the Humberside region and beyond. Great team there with imagination and vision, coupled with the energy and intelligence to make a real difference.

Yesterday, December 5 Atrainability exhibited and ran a MasterClass in changing healthcare safety culture.

Today I am off to meet Air France and discuss SportsTec high quality video recording and playback software. British Airways have just bought this for installation in their simulators. It is without question the most fantastic training aid.

In the MasterClass I referred to teams as being the light-bulbs that have to want to change in order to improve safety behaviour.

I just woke early with my own light-bulb moment.

A successful organisation is like a chandelier with long life bulbs. They require less energy, they cost more to begin with, but they last longer. They shine out like a beacon and bring light around them. They work.

A less successful organisation is like a chandelier with many bulbs out. They run old fashioned incandescent bulbs. They fail frequently and the overall effect is dim. They don’t shed much light.

Training is not cheap – up front. But it makes a lasting change. It brings long term excellence that sustains. Successful organisations, be they NHS Trusts or commercial organisations recognise this.

Nothing is so powerful a training aid as watching your own performance and hearing your own words. It helps the light-bulb want to change.

Atrainability can help to spread that light.

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Embedding Human Factors knowledge and understanding to combat avoidable harm

I am fresh back from 3 days of Train the Trainer for Northumbria NHS Foundation Trust, one of the top-performing Trusts in NHS England. I am invigorated and full of the joys because here we have a healthcare provider that knows how to maintain high quality resilient compassionate care.

Atrainability increasingly work in the North East of England. Previously Safer Care North East recognised the crucial importance of human factors in dealing with avoidable harm and engaged Atrainability to educate a multitude of influential team members across what was then the Strategic Health Authority. Happily the enlightened ones have found positions of influence and are carrying on the plan.

Northumbria Trust has realised that having a profound embedded understanding of Human Factors within every department can help to avoid, trap and mitigate potential costly harm within the system.

This week I have had the pleasure of the company of a diverse group of enthusiastic, intelligent, committed professionals and judging by their feedback comments changed their outlook. We are all hoping this will have impact on how staff are trained, how procedures are designed and implemented and how a safe just culture is sustained.

Here are some of the course comments:

· “fantastic course”

· “my outlook on life has changed forever! I am looking at life through Human Factors glasses. I’ve also learned a lot about myself. I would thoroughly recommend this course I have honestly never got so much information and enjoyment from a course before!”

· “Relaxed, informal but very informative, thank you”

· “I will develop a 1 day error-proofing training course and invite colleagues to attend. My aim is to share and spread the message across the North East so that people become aware of their behaviour and act appropriately. This should result in an increase in reporting and a reduction in errors.”

 


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The importance of Self Awareness

I've just been reading Daniel Goleman in his blog about teaching emotional intelligence skills to school kids as a method of reducing bullying and other anti-social behaviour. Self awareness alone is fundamental to effective working with others and seems to be lacking in some cases. I will explore more of the Emotional Intelligence elements in later posts.
 
As Jung said "everything that irritates us about others leads us to a better understanding of ourselves".
 
The issue is complicated by the shortage of skills in management and fellow team members  to adequately deal with those lacking in this insight.
Educating emotional intelligence has been standard practice in many schools here in the UK for some years. Clearly there will be variation in how well the message gets through. Having personally witnessed some  inappropriate behaviour by a minority of clinicians, and nurses in some cases, over the years one does wonder whether there should be more emphasis on EI in the medical school curriculum or indeed perhaps it should be part of the selection process for anyone entering healthcare employment.
 
In my time in aviation the 'person specification' was changed from pure piloting skills alone to people who could work well with others.
OK some outliers always sneak under the wire but generally the culture of the profession has changed for the better. This is in large part down to a focus on the customer but also on the recognition that effective team working makes for safer performance. It has been stated often that over 70% of aviation accidents are due to human error in one form or other and rarely do any airline crew work alone be it in flight deck or cabin or even on an engineering team.
Aircrew get properly appraised 3 times a year on their technical and non-technical skills and must by law be refresher-trained on both every year.
Safe sustainable  effective working doesn't happen by chance it is the product of investment in training and hard work. Plus having a supporting culture that encourages effective emotionally intelligent behaviour and acts to put a stop to the inappropriate behaviour. 
Now that Sir Bruce Keogh has reported in a profoundly sensible manner perhaps we can all benefit. The news that Sir Mike Richards is recruiting an 'army' to inspect and report on sites is copying the age old 'wife and kids test'.
Back to when i was a Training  Captain in the airlines -would I let this pilot fly my family?
Works for me!

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