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Atrainability Blog

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

A systems thinking approach to error

Attending the Clinical Human Factors Group Open Seminar this year was a great pleasure in many respects, interacting with old friends and new. Learning about updates and gaps in my knowledge in all aspects of Human Factors, was so very valuable.

It was evident from the conference that systems thinking is the way forward and the overriding theme of the day was about looking at the bigger picture whilst ensuring we don't lose sight of the individual in the process, especially the patient. We lose sight of the individual at our peril, but more than that, the patient's peril.

When organisations want to identify specific areas to improve or show evidence that they have indeed achieved improvements, data is crucial. But data so often can mask the fact that we are of course dealing with real people.

Whilst 'live tweeting' at the conference about this very subject, a fellow tweeter commented:

And how very true that is; you need both the data combined with the human story to understand why change is needed, why something has gone wrong or particularly well and also to convince others to become advocates, sharing the learning and helping to implement what is required. 


We completely support the idea of systems thinking. One of the talks that I listened to with interest was focussed on Root Cause Analysis. They talked about one particular study and what they found was the Root Cause often came back as: 


                                                                                   "Process Not Followed". 


Now, that sounds like an easy answer, but firstly, that doesn't give much to work with. That's almost as bad as pointing your finger at someone and saying, "That person didn't do it right." More details are needed to understand what is going on.

Taking a systems approach to the 'Root Cause' would take into account the bigger picture and begin to investigate WHY it wasn't followed. 


Is it a training issue for the individual? 

Is there something wrong with the process which means it's very difficult for front line teams to do their job and adhere to the process?

Or, could it be the person is in the wrong job? 

Perhaps it's 'the process' and not the person that is the real Root Cause and it needs revisiting. 

It certainly seems to be the case with a number of Surgical Safety Checklists, where it looks like the checklist itself is not fit for purpose. 

We are currently working with an NHS Trust where the checklist is not fit for purpose. Investigating, observing and promoting open conversations with front line individuals is a good start for any organisation that wants to understand what they can do to make improvements. 

Overall there was a strong feeling of optimism at the Clinical Human Factors Group Seminar. There are, without a doubt, more people taking an interest in Human Factors in healthcare and there is also some truly excellent and insightful work on developing solutions to changing the Culture on this…even if, at the same time, it's apparent there are still some pockets of resistance.

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CQC - From 'Requires Improvement' to 'Outstanding'

Claire Hughes, Critical Care Matron

If you've been following us for a while you'll often see us mentioning in our blog that one of the many ways you can recognise a good team is the fact that team members will take the time to tell their colleagues when they've done something well.

On this subject then, we feel it's important to walk the talk and congratulate one of the Trusts we've been working with for a while, The Critical Care team at Royal Stoke University Hospital.

Following their previous Care Quality Commission inspection, the leadership team, with the support of the trust made the decision to embark on a transformation programme to address the issues that had been highlighted.

As a result the CQC rating of their Intensive/Critical Care unit has been changed from 'Requires Improvement' to 'Outstanding'. Read their report here


Implementing Human Factors training combined with support for a full transformation programme has helped make this possible.


Claire Hughes, Critical Care Matron at Royal Stoke writes:


"The Critical Care Team at University Hospital of North Midlands has invested greatly in Human Factors training with the aim to have 50% of all staff trained in this topic.

Our unit has undergone a Transformation Program to bridge identified gaps between the General Provision for Intensive Care (GPIC's) guidance against a former baseline position. Specific work was required to address incidents both local and intra hospital.

Trevor Dale was able to provide an excellent foundation training schedule to address the issue and instigate 'Human Factors' as a challenge and change culture for our unit.Staff who have attended the training course are fully complimentary of the skills attributes gained from the overall experience and scenario based learning.

It is already evident that Human Factors training is positively changing everyday practices and culture amongst the many staff on our very busy critical care unit.

A recent Major Incident highlighted how significant communication and human factors was, to ensure patient safety in this complex situation. For this, we thank you Trevor and the team"


This Critical Care unit is a great example of how having the support of the leadership team and Trust when it comes to implementing positive changes through training can make a difference.


By approaching learning as an ongoing journey of development and not a tick box exercise you can make improvements that are sustainable. So congratulations to all the hard work the team has put in towards making it happen.

It's been an absolute pleasure to be part of their improvements and we are looking forward to our continuing to work with them.



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A Situational Violation



Picture yourself in this situation; you're an Anaesthetist who has been called to attend to a patient who needs an emergency C-section. There's a small window to act fast and save the baby, but you notice that the patient isn't wearing an identity wristband. Would you anaesthetise?



Before we go any further, consider this similar situation before making a decision on what your course of action would be. Again, a real-life story that we've been made aware of recently. 

A small boy and his mother are rushed into a busy A&E department at an NHS Trust, the boy having been mauled by a dog. The child is quickly referred to the Trauma Team and there is no doubt that they have the right child; he's covered in blood, bite marks, screaming and the mother is upset as you'd expect. They do what needs to be done, they do their jobs, clean wounds and patch him up. Afterwards, they find out he's got the wrong wristband on. 

The hospital decides to deal with this error with disciplinary action against the Clinicians. 

Take a step back and you can see how a small mistake like this can occur. A busy department, a small boy screaming, arms flailing about…he requires urgent medical attention and it's clear what he needs; but why go straight to disciplinary action, and if not a disciplinary then how should it be dealt with? 

Treating individuals of any specialty, nursing or clinician like responsible professionals is almost guaranteed to have a much better outcome. This incident should have been approached as something to learn from, a discussion point. A team conversation in which this error is highlighted and shared. An opportunity for staff to explore all the circumstances which led to the name check being missed, to think about the likelihood that this could happen again, and then if necessary, think about steps that can reasonably be taken to avoid a repetition of this error. 

Using a risk matrix can help differentiate between low frequency events with very serious untoward outcomes and those with much less serious outcomes. And of course, the risk of not taking action must also be assessed to give a balanced perspective.


Let's think again about the mother who needed an emergency C-section. 

On this occasion, the Anaesthetist refused to anaesthetise the patient because of the missing wristband, which lead to a ten minute delay while they got a wristband on her. The result of this, was that the precious opportunity to get the baby out safe was missed. The child is now permanently brain damaged. 

The easy thing to do is blame the Anaesthetist. He or she could have acted differently, taken a risk, broken a rule to act fast and then justified his/her actions later. Or perhaps the finger of blame points at the nurse or doctor who was responsible for making sure the patient had a wristband on? 


Of course, there's other elements to muddy the waters. 

What does this individual normally do? Flout rules or routinely demonstrate good practice? Do they have previous history which led to this particular decision? Were they previously involved in, or even just exposed, to a patient misidentification that resulted in serious harm? 

Patient misidentification is known to contribute to errors and is a cause of patient safety incidents; including operating on the wrong patient, or performing the wrong procedure, or performing surgery / an intervention on the wrong body part (e.g., right vs. left knee replacement operation). 


So what's the answer here? 

It's a tragic story and an upsetting, ongoing experience for all involved. We feel however that it highlights how easy it is for leaders to unintentionally get it wrong and in doing so, stopping professionals from getting it right. 

One major factor in high risk decision making has to be whether your front line team feel safe and supported. Now, what that means to us is that a management system needs to be set up and run in such a way that makes front line staff feel safe. This must be borne out in reality, as opposed to being implied and then not acted on when the time comes;


"Well of course you're safe with us, we operate a no-blame culture"


Saying it doesn't make it true. 


Did the Anaesthesist feel safe? 

If frontline staff feel they have to protect themselves first from disciplinary action or being struck off then that's how hospitals end up with staff who will refuse to do something that in hindsight would have been the "sensible" action. The sense of covering one's own back is a normal human reaction to a perceived threat and it is a clear signal that all is not well with the system. 

If individuals and teams feel safe and supported it will reduce stress and they will feel enabled and empowered to make better decisions. This not only means better care and outcomes for patients, but also builds trust and team morale. 


Join us for the our next Masterclass in London.

Atrainability are now working alongside Quality Improvement Clinic to offer a one-day Masterclass which combines Human Factors and QI Science which will be running on 25 June 2018 in London. Read more about the masterclass here or Register for the event here.

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HFE in Healthcare, Investigation and Education


We at Atrainability are proud to have been invited to sponsor the

Clinical Human Factors Group's upcoming Aberdeen Open Seminar on 23 May.


"We are honored to be supporting this event and pleased to be able to contribute towards the ongoing mission of the Clinical Human Factors Group" - Trevor Dale, Managing Director, Trevor is also planning to attend the event and he hopes to see you there.


Please find further details below:

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CHFG's next Open Seminar will take place in Aberdeen on the 23rd May 2018.


The Keynote speakers are:


• Keith Conradi, who will provide an update on the developing work of the Healthcare Safety Investigation Branch (HSIB)

• Dr Paul Bowie from NHS Education for Scotland and Craig McIlhenny at NHS Forth Valley Scotland, talking about the new national multi-agency initiative on Human Factors in NHS Scotland.

Breakout session topics include:


Dr Karthryn Mearns - Safety culture - we can measure it, but can we manage it?

• Manoj Kumar - Safety reviews: bridging the gap between work as imagined and work as done

• Professor George Youngson - The impact of bullying and discrimination

• Dr Helen Vosper - Human Factors as a strategy for improving Medication Safety

• Dr Alastair Ross - The Functional Resource Analysis Method and how to develop a model of everyday work

• Professor Ron Mcleod - Bowtie analysis as an approach to the assessment of the risk in healthcare

• Dr John Rutherford and Dr David Macnair - Good practice in running Human Factors training in a district general hospital

• Dr Shelly Jeffcott - Pushing back on "the way we do things around here": What holds us back from integrating HF/E


This one day event will focus on Human Factors in healthcare and applications in investigation, clinical practice and education.


Register for the event here & View full programme here.


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Unintended Consequences

(Revised: 15.2.18)

In the wake of the tragic death of Jack Adcock and the conviction and subsequent striking off of Dr Hadiza Bawa-Garba, we need to work together to rebuild the damage done to the safety culture. How? Revenge and blame feel great don't they? But neither of these options offers a solution to stop repeated errors. It is easier to point the finger at an individual, rather than a flawed system.*

Martin Bromiley is a shining example in seeking no retribution in the aftermath of the death of his wife, Elaine. Instead, he has made it his life's mission to educate others. 


It should be highlighted is that the mitigated circumstances which often lead to a tragedy, are sadly not unique.

The abnormal, such as multi-tasking, staff shortages, no handovers, hierarchy barriers etc…eventually becomes normal practice. We want to help professionals in all status's and across all aspects of health and social care feel safe and encouraged to report and aid learning from the most basic of human conditions, fallibility. 

Time and time again you've probably been told that near misses (near hits?) and incidents are the richest source of learning. Yet we still find that these often go unnoticed in all fields, sometimes because they don't get reported. Or, as mentioned by some professionals we've spoken with recently; it's because "human factors" is stated as the cause of the error yet it's not adequately analysed, or learned from and the true underlying causes remain. Perhaps this is a side effect of the abnormal becoming normal? 


I appreciate that too much has been made of aviation as a model. 

But one thing I would argue is indisputable is that the way the culture changed was by embedding human factors ergonomics principles in every single thing, from training through to all processes. My own son, flying now for a major international airline simply says "it's just the way we do it!" – but it took time to get to that stage. 

The term Human Factors is certainly more heard of and understood in healthcare than it was when we started fifteen years ago; but a one-off Human Factors course as part of a knee-jerk reaction or tick box exercise will not make sustainable changes.


It's one thing to say you know about Human Factors – but what actions are you taking? 

We're currently delivering long term training solutions with coaching and ongoing support to a number of NHS and private providers. Train the Champion and Train the Trainer as well as foundation awareness are helping to kick start that embedding process. It is terrific to see how general awareness is growing! 


But it's not all about error. 

It's important that teams understand why things "go right" too and how to repeat that. One organisation we've just tendered for are rated 'Good' across the board by the CQC, but they want to achieve 'Outstanding'. That's the way to go.

Please get in touch and let's see how we can help your teams. 


PS. *The British Medical Association has just launched an online space allowing doctors to report their experiences and examples of how the system is preventing them from providing safe care. https://r1.dotmailer-surveys.com/00jvxef-a92tly1f


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An apology regarding the earlier version of this blog piece sent out via e-mail on 15 Feb 2018:

We at Atrainability regret that we have passed on some mis-information in the earlier version of this blog piece, distrbuted via our e-newsletter on 15 Feb 2018.

Prof Terence Stephenson, Chair of the GMC made a statement on 2 Feb 2018 that in fact the e-portfolio reflective statement was NOT used as evidence against Dr Bawa-Garba. The GMC have clarified that the details reported in this case were not accurate.

Thank you to those of you who took the time to inform us about our error. We have amended the above post and resent out a revised copy of the e-newsletter to reflect this. Despite this unfortunate error, we believe that the potential damage to the reporting culture is still tangible and valid based on our conversations with a number of Clinicians.

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A ZERO fatality year...

Once again we've heard comments that aviation and healthcare are radically different, the point being of course, that healthcare can't possibly transfer learning from an industry such as aviation. Well of course our industries are different, but it's not as simple as some people think.

We've heard this so many times. 

"Pilots would not get airborne with a plane that wasn't working properly, where as Doctors and Nurses are dealing with people who've had something go wrong" 

This misses the point. 

Most people don't realise that if something goes wrong in an airplane, rarely do you see it coming and the chances are we're already airborne. 

Aviation in the 21st century is incredibly safe, so much so that there is talk of a zero fatality year worldwide due to accidents, leaving aside deliberate acts. 

Extrapolating this it suggests that aviation is, as is often claimed, 99% boredom 1% sheer terror. Not strictly accurate, but mostly things do not go wrong, but what flight crew have to maintain is a wary eye for potential problems.If they occur…

The enemy here is complacency. 

Flight crew, like healthcare teams, have to be like the proverbial coiled spring, ready to react, safely and sensibly in times of extreme stress and with limited options. 

In a nutshell, where learning from aviation can be beneficial and transferrable to healthcare is via our techniques and methods for understanding human behaviour. Being able to be proactive rather reactive, be situationally aware as well as self-aware, understand how to communicate effectively to avoid misunderstanding. 

These skills when mastered, can create leaders and teams who can make better judgement calls, minimise risk and maximise safety. Knowing what we do about the effects of the amygdala and fight, flight and freeze, it is the ability to control your actions under extreme stress that we have to practice. 

Preparedness is crucial. 

Flight crew are trained to consider what could realistically ruin their, and you the passengers, day. One of the aviation techniques is to use periods of low activity, not to simply chat and pass the time of day, but to discuss with your colleagues and your team what they might consider to be a potential problem. When flying how would we handle a depressurisation or a hydraulic system failure. In healthcare something akin to a cardiac arrest or pranging a major blood vessel, or an unanticipated allergic reaction for instance. 

Alternatively a challenging aspect could be when you know you're going to be working with a difficult colleague, so you could discuss in advance how you will try to change the trajectory of incivility into a harmonious team outcome. 

Atrainability are able to provide tailored Human Factors support for teams that are in need of advice, support or development.

Further reading...

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Improvement Science for Better Outcomes

Atrainability have teamed up with The Quality Improvement Clinic and QIC Learn to create a one-day masterclass which will show you how Human Factors and Improvement Science can help you deliver better outcomes.

Small changes can effect big changes and we can equip you with the knowledge and confidence to take new ideas back to your setting.

What will I gain?

After taking part in this masterclass delegates will be able to:

• Be inspired to use human factors and improvement science to deliver better outcomes for their patient e.g. during transitions of care

• Understand Threat and Error Management - an essential concept in learning from error and success

• Understand and accept the causes of mistakes -how to maintain confidence in the high pressure workplace

• Know the early warning signs that things are not as they should be and what to do about them

• Understand and adopt effective communication -ensuring mutual understanding

This 1 day masterclass has been designed to give you an appreciation of Human Factors in the workplace and how it can help you deliver better care.

Through attending this course, you are becoming a change agent, leading the way to help make your patients and your ward safer with Human Factors.

We look forward to you joining us on Friday 23 March 2018.

​BOOKING NOW:

Human Factors Principles + Improvement Science = Better Outcomes


When: Friday 23 March 2018
Where: De Vere West One Conference Centre, London

JOIN US:
Click to find out more OR
Click to book online

. **Special Offers** 15% Group booking Discount or 10% Card Payment Discount
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Debriefing - The Holy Grail

Debriefing or feedback is a vital part of ensuring teams communicate effectively and learn from experiences. How good are we at giving and accepting praise and positive feedback?

An insight I've gained from working with and observing teams is how surprised individuals can be when given positive feedback. Also sometimes they have real difficulty accepting it and view it as patronising. But feedback is a gift and let's be honest we don't do it well. Most of us are swift to blame and slow to praise.

Perhaps it's that quintessential Britishness which hinders us thanking or complimenting a colleague's contribution or skill? We are a very multicultural society now and what richness that brings, so perhaps we can move forward.

Being praised for good performance not only raises morale but improves trust and performance within the team and beyond. It can benefit sickness rates and staff retention as it has in some of our clients.

I recently had the privilege of watching a series of Maternity deliveries by C-section. After introductions during one of the safety huddle at 8am, I explained I was hoping to observe and help them recognise what they've done well – and so it proved to be.

The team were not anticipating any particular problems, and although the first mother had a history of previous C-section deliveries, a scan had been conducted to check the position of the placenta.

Unfortunately, when accessing the uterus they encountered Placenta Previa, and along with the accompanying significant blood loss it was discovered that the baby had inhaled some of the fluid. Rather than a healthy cry, the baby omitted a half-choking squawk and instantly the body language of the team changed and the call was made for the paediatricians to attend urgently.

To cut a long story short, I can report that all was handled extremely well and the baby was quickly whisked off and the outcome was a healthy mother and child.

Afterwards I was asked by the team for feedback. After going into some non-clinical detail on how they'd handled a tricky situation really well I then encouraged them to provide some positive feedback to each other. It did not come naturally, but eventually the Registrar agreed that yes it did go very well. When asked if she could tell me why, she looked stunned and after some thought replied;

"The Scrub Nurse did a great job and I had everything in my hand before I barely asked for it."

With some gentle reassurance, The Registrar relayed her positive feedback to the Scrub Nurse directly.

After being told what a great job she'd done she beamed and said,

"Firstly I'm a midwife, not a scrub nurse. I am only doing this because the scrub nurse called in sick today, it's not my normal job."

I said "Well you've just had some great feedback!" She then added "When they pranged the placenta my heart sank and I thought we were going to have real problems but what held me together was how calm the two surgeons remained as they handled the situation successfully."

Soon, the rest of the team started opening up about their own worries and self-criticisms during the procedure, all which were met with empathy as well as positive and constructive feedback from their colleagues.

The senior midwife had been acting as team leader and in a circulating capacity. She thought she had left it too long before comforting the mother and father. I commented that it did seem like a long time, but the parents had looked relaxed and unconcerned. However the only people who could comment were the parents themselves. How about go and ask them? They were in fact fine.

Everyone now professed that they felt so much happier and confident. They all had a much better team understanding. Everyone was smiling and the atmosphere was positively buoyant.

So what's the moral of this story? You don't really need a trainer to tell you what you've done well, but you might need some help to get your team to a place where positive and constructive feedback become the norm.

We'd be delighted to help you.

Atrainability offer both in-house and Open Course training and coaching solutions. We'd be happy to have an informal chat (in confidence of course) to discuss your current challenges. Please get in touch and one of our team will get back to you

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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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Where is the evidence that 'blame' works?

If so many medical people profess to be evidence based and blame is so rampant within health and social care where is the evidence that blame works?

Atrainability have just been asked to help a major NHS trust to sort out their blame culture which is proving very damaging to an already over-stressed, over-worked, under-resourced Emergency Department.

The atmosphere is apparently poisonous and learning from error consists of pointing the finger at a colleague who didn't do something appropriate. Learning from success isn't an option it seems simply because no one even considers it.

We believe strongly that explaining human fallibility is a crucial aspect of building an understanding and an awareness that most error is not caused by bad people but by genuine, hard-working, caring people, working under difficult conditions.

We ask the question – if we provide training for you, what would success look like?

One answer would be that team members started looking after themselves and each other. Although working conditions are typical of an over stressed department, the benefits of taking even short breaks to refresh, clear the mind and to replenish fluids and blood sugar levels cannot be overestimated. Furthermore, appreciating how knowledge-based, skill-based, rule-based errors originate is the route to an open reporting culture, where people feel safe both personally and collectively.

Other signs of success could be:

  • A team that shows compassion, not just to its patients but to each other.
  • A change in the flavour of incident reporting from finger-pointing to understanding, learning and providing solutions.

What would success look like for you?

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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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Who is the best person to train you – a colleague or an external ‘expert’?

Who is the best person to train you – a colleague or an external ‘expert’?

This is an interesting question and is of course quite complex with a multitude of variables to consider. If it is a purely technical or clinical matter then I believe another similarly qualified expert with knowledge of the issues and techniques is generally preferable. However I believe that when it comes to Human Factors (non-technical, non-clinical, non-medical) concepts there is an argument that says an outside 'fresh pair of eyes' can have a significant advantage.

I can understand why you may disagree with this statement. How can someone who hasn't done the job themselves possibly have any in depth understanding of the pressures, stresses and nuances of your decision making? How could they, an outsider, achieve that essential experience gained through days/weeks/ years of hard graft?

Let me confess that in my 'old' life as a pilot in a major airline, we chose to go down the 'peer' training route. However it must be said that I now believe this meant we had to learn the lessons from scratch and went down a few unhelpful blind alleys. One was failing to grasp, for some years, that describing technical and non-technical skills as being separate was erroneous and unhelpful. What woke me up was when one of our senior managers said "it was such a high-workload that we didn't have time for any of that 'Human Factors stuff'! This demonstrated a complete misunderstanding that human cognitive and social skills are present at all times and are an integral part of all performance as an individual and team member. It wasn't his fault, it was ours.

Fast forward 25 years later and Human Factors is completely embedded in aviation – ask my son who is 6 years into his commercial aviation career.

As peer instructors we also had to blend training and debriefing of Human Factors non-technical skills into our colleagues 'technical' training. This proved a hard obstacle. It is acknowledged that the optimum method of encouraging behaviour change is by facilitation – helping students and peers to find their own solutions. This style of facilitative training and coaching was alien to aviation 'instructors' who were used to telling people what to do and how to do it.With behaviour change this rarely works, consider interaction with teenagers!

People have got to want to make changes and have to truly understand how and why. Many instructors focus on the technical problem and/or focus on blame and this can mean they often struggle to see the underlying Human Factors issue beneath, such as communication, hierarchy, or overload.

Now we come all the way back to the advantages of an outsider expert. There is no in-house hierarchy barrier. The outsider expert doesn't know the technical, clinical, medical issues in depth and hence don't get confused, or distracted by them. Another advantage is that they also bring with them a wide diversity of experience from other health and social care provider sites and teams. Finally, an outsider expert can also easily observe and debrief on the human factors issues and ask those awkward but telling questions about team interaction which can help facilitate learning and positive change quicker.

Understanding the concepts, the routes to normal error making and the ways in which human factors training can and does genuinely improve all human behaviours is what we can help you achieve.

We'd like to hear your thoughts and experiences. Please let us know.

Trevor Dale

Tweet @atrainability

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Why we need to be more serious about acknowledging human limitations. (Guest blogger)

Hello, I'm David Wood – Associate Director of Safe Services at Cheshire and Wirral Partnership NHS Foundation Trust (CWP).

As a provider of Mental Health and Physical Health Community Services, healthcare of the types we deliver are essentially based on face-to-face human encounters; which are relatively low technology.This means that the people who deliver our services regularly manage risk autonomously and in environments which are anything but controlled.Now that's a challenge!

My working environment, on the other hand, is much more controlled (even if my day-to-day work is less so).Recently I found myself making a number of ill judgements which, whilst they did not cause any harm, troubled me greatly as I could not rationalise why; in effect, I had "lost control".Only days later, after attending an NHS Leadership Academy event, did I realise I needed to apply a degree of self compassion and accept that it was the pressured situation I was in; which included being distracted by factors at home, that compromised my decision making and my performance (having exacting standards and expectations of myself does not help, as anyone who works with me will tell you!).None of us has an internal switch; we bring our whole selves to work.

So, Human Factors are exacerbated by high pressure situations and mental workload, where we are all fallible.My learning was that to mitigate potential adverse impacts of this, you need to be self-aware. If you have distractions, in your work or home life (or both) even if you think you have "parked them", consider yourself at a greater risk of making a mistake. There are some tactical steps you can take; why not read Implementing human factors in healthcare for some tips.

The important thing to acknowledge here, as in my situation, is that the vast majority of people do not act with the intention to make a mistake, to cause harm, or not wanting to do the right thing – quite the contrary.The hazards that apply in working in either controlled environments or not, are making decisions in dynamic and intense situations.In a complex working environment like health, this problem is not going away!

There needs to be a coherent plan (to embed Human Factors training) underpinned by, as we'd argue in CWP, a long-term patient safety cultural campaign; in order to develop a positive patient safety culture.Both these things require high level leadership.We invested in our very own campaign called #CWPZeroHarm, to tackle unwarranted variation and improve reliability; supported by cultural change to empower us to put patient safety, clinical excellence and patient-centred care at the heart of all we do.The campaign promotes the idea that everyone, before they act, should "Stop, Think, Listen".These same principles of "stopping", "thinking" and "listening" happen to be one way of looking at mitigating the potential adverse impacts of Human Factors.

Part of our investment was in Human Factors training from the Board to those providing direct care.We have also recently invested in our own simulation suite, which will include mock-ups of care settings like people's own homes, to predict "what could go wrong". We have done this as we know simulation is highly effective in creating learned responses to situations, where pressure may affect a person's ability to think as clearly as they normally would. Key to this is training as teams wherever possible - Human Factors based team working is essential to promote safer care.

We have achieved many other things by applying Human Factors principles and practices.In the main these have come from the pledges made by what we call our Human Factors "culture carriers" – people who attended Human Factors awareness sessions and pledged to implement changes in their workplace.Examples include simple changes such as implementation of briefing, debriefing and safety case reviews; through to more ambitious changes such as enhancing clinical audits and reflective review processes, to capture the impact of Human Factors practices and therefore demonstrably improve safety in a number of critical areas - for example reducing the incidence of physical restraint by well over 50% and on a sustained basis.

Why do we need to be more serious about acknowledging human limitations? Well, when decision making is compromised this can significantly impact on the quality of care, clinical outcomes and potentially cause harm to both people who access and deliver healthcare.This all increases costs.This is where Human Factors offers ways to minimise and mitigate human limitations, and so reducing error and its consequences.

Healthcare has a lot to learn from systems which promote safety in high reliability industries like the aviation and nuclear industries.I'd like to see a system-wide adoption of Human Factors concepts to empower the whole care system. I was therefore pleased to be a consultee of Health Education England in exploring how Human Factors practices and principles can be included in the curricula and training frameworks for health professionals.This resulted in what I think is a milestone publication Improving Patient Safety Through Education and Training.

I will be working again with HEE's "Learning to be safer" programme on 14 July (2016) to develop plans to implement the Commission on Education and Training, for Patient Safety's twelve far-reaching recommendations, on improving patient safety through education and training.I hope that the key output will be tactical steps to ensure that Human Factors is not something that's standalone, rather it's something "we all do around here", as part of the design of processes, jobs and training.

The HEE cannot do this alone; all of us, no matter what level we are in the system need to commit to embedding an understanding of Human Factors.

We're in this together.Human Factors awareness has improved, but more needs to be done to make it our everyday business in delivering reliably safe healthcare.Good luck on your Human Factors journey!


Tweet @DavidWood_CWP #CWPZeroHarm #ATRblog


About our guest blogger:

David Wood is currently Associate Director of Safe Services at Cheshire and Wirral Partnership NHS Foundation Trust.His role is to lead the Trust strategically in relation to a portfolio of clinical and corporate governance, compliance, assurance and regulation which effectively contributes to the Trust's delivery of safe services.

He graduated from Keele University with a first degree in Biomedical Sciences and his career since has spanned 15 years during which time he has been employed in many diverse areas within the NHS, substantially in senior clinical governance lead roles (including North Staffordshire, Cambridgeshire, Cheshire/ Wirral) within mental health and learning disability services, primary care and community physical health services.

David has professional interests in strategic approaches to healthcare quality, and more recently professional practice including leadership, development and change as part of his Master of Science degree in Professional Studies.His dissertation was on early warning and pre-emptive systems to improve the safety of patients and reduce avoidable harm, graduating from the University of Chester in 2013 with a distinction.

David has a demonstrable track record in clinical quality and governance with extensive experience of quality improvement and change through strategy development and implementation.He was a former longstanding member of the Department of Health hosted National Audit Governance Group, is a professional reviewer of the standards of inpatient mental healthcare through the Royal College of Psychiatrists' Accreditation for Inpatient Mental Health Services initiative, and a regular Healthcare Quality Improvement Partnership consultee. David has recently become a director of assurance representative on the NHS Providers Quality Reference Group.



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How compassionate care can reduce mistakes.

One of the questions we ask on many of our courses is "who is in your team?"

It is always fascinating to see how long it is before someone mentions the patient or service user in amongst all the doctors, nurses, porters, ODP's, managers, HCA's, therapists, allied healthcare professionals etc.

On one memorable occasion with a roomful of a particular group of specialist surgeons (no clues) the mere suggestion that the patient could be part of the 'team' was like a grenade going off. "They are the task, how can they be part of the team?"

My next question was "Could the patient save you making a mistake?"

"Yes of course" came the reply.

It is obvious. If you treat people like a task, you might inhibit them speaking up and potentially stopping calamity happening – wrong leg etc (there's a clue!). Compassion, empathy and demonstrating a genuine interest of the patients main concerns will reduce stress and empower your patients to have their voices heard.

During our time working with the Medical Protection Society we learned that there is compelling evidence that the initial interaction between medical professional and patient affects the willingness to complain and sue if things subsequently go wrong. If they feel valued and listened to, they are more likely too forgive, and vice versa.

"Empowered patients can communicate changes and observations that can make a real difference in their medical care…many times patients are intimidated, or sometimes bewildered, by the medical world around them. Also, it can be hard to speak up if the doctor or nurse is perceived to be rushed and ready to move on to the next patient." - Elizabeth Cohen, CNN senior medical correspondent and author of The Empowered Patient

The book 'If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently' by Fred Lee also makes interesting reading. Describing staff at Disney theme parks as 'actors' is in fact exactly what we would expect a 'professional' healthcare worker to do. We all adopt a cloak of professionalism at work don't we? Well, clearly some do better than others, judging by the evidence about abusive and inappropriate behaviour we hear about."Patients judge their experience by the way they are treated as a person, not by the way they are treated for their disease."

It's also well acknowledged that patients recover quicker if they feel cared about. If bed blocking is as much of a problem as it is reported; then anything that can be done which helps patients to recover, have a positive experience and get home again fast, has got to be worked on.

Treating patients like numbers – "go check the BP on bed 5" is entirely different to "pop along to Mrs Smith in bed 5 and check her BP".

It's clear that many providers are becoming more aware of compassionate care, and implementing training to help staff achieve this. Many staff may feel that this is something they do every day naturally; caring for people after all, was perhaps one of the main reasons for choosing their profession, but it is easy to become complacent.

I was recently admitted to a private provider where everyone who came into my room started with "Hello my name is .." However it was quite clear that because every single person used exactly the same form of words it had all the sincerity of concrete. Why couldn't one of them at least say something like "Hi Mr Dale, I'm Bill .."

You can reduce error by treating your patients as part of the team. However it is important that compassion, empathy and a genuine interest come across as sincere.

We have developed "The Keys from Courtesy to Compassion" course which covers the aspects of helping staff deliver compassionate care on a regular basis and it is clear that some places would benefit from it.

Here is a testimonial from one of our recent clients:

"Atrainability was wonderful to work with. They took our needs for instilling 'Disney' values into healthcare, and they worked closely with us to develop and deliver an enjoyable training session for our senior midwifery leadership team. The team enjoyed the fresh concepts and attuning these to their daily practice." - Amy Maclean, Head of Patient Experience at Birmingham Women's NHS Foundation Trust

"Thank you for helping us…and giving us some really useful strategies to complete our journey and make our business all about people." – Helen Young, Director of Nursing & Midwifery at Birmingham Women's NHS Foundation Trust.

To enquire about this course, click here to contact us for further information.

Trevor

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Sharing the Learning

I had never really thought about situational awareness in the past. I'm a pharmacist myself. I know that I've made mistakes. None of my mistakes have been life threatening; in fact, they've probably been near-misses, but this (course) made me think about how situational awareness affects the way we do things- Julie Jones, Birmingham Healthcare NHS Trust

Atrainability has provided Human Factors training for over 14 years and during that time our team has spoken to lots of people at various stages in their career, and across a range of different disciplines.

We've always been grateful when participants are open about sharing their learning experiences with us. One thing that seems to occur often is that during or shortly after the training sessions there is a moment of clarity when dots are joined and suddenly that person understands how and why those near-misses happened and more importantly what they can do to avoid future errors. There are many stories we could share, but here are a couple :

I was talking about having compassion for patients as well as colleagues on a course recently, and a Dental Surgeon who was attending said: "Quite a lot of patients are just awkward with unrealistic expectations" he went on to say that he'd received a significant number of complaints and some claims. I asked him if this was just something which he encountered or did his colleagues also find the same? After the course, he thanked me and said that moment had made him realise he was perhaps playing a part in the problems he was experiencing, and he would be more aware of his communications with both patients and colleagues when he returned to work. – Trevor Dale

During the coffee break of a course I was running an F2 Doctor approached to thank me, and explained the Situational Awareness module was a light bulb moment for her. During a night shift, she had a difficult hand-over at a time of high workload. The nurse had handed over a patient with a verbal description of a dosage of a respiratory drug, there was a mistake made but the Doctor was clear of the dosage in her mind. The Doctor was working very hard and so did not acknowledge the dosage handover to the nurse. She told me she now understands why she did not read back the instruction. She was stressed and her speech had been degraded due to an overload of information. Although she was cleared of any wrongdoing, she was troubled why she made the mistake. The Doctor was delighted to understand that her mistake was just an indication of her human fallibility; not incompetence, and that now she felt she had the tools to help her avoid repeating that error. – Matt Lindley


As you may be aware, Atrainability has been running Human Factors Open Courses this year at key locations in England. We can't promise Light bulb moments for all, but we can promise a course which will help you find solutions and gain a greater awareness of how you and your teams' behaviour, communication, leadership and briefing and debriefing skills can improve outcomes for everyone. 

If you can't make the dates listed on our Open Course page, or if we haven't announced new dates yet, do get in touch to discuss how our bespoke in-house courses can help your team. 


Trevor

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The Remarkable Truth about 'People Stuff'

​If you ask the question "What makes a difference to your every working day?" and other than the weather, your IT systems and somewhere to park your car, you begin to realise that everything else is about PEOPLE.

So if 'people stuff' has the most impact on your performance, how can we ignore it? Human Factors may be considered a 'buzz word' for some, but the fact is; it's an unavoidable part of everyday life. If you gain an understanding of why colleagues and patients behave the way they do and understand why some communications turn out to be 'Chinese whispers' you can also gain insight into why some of your processes are failing and what you can do to avoid repeating mistakes. This is why Human Factors is so important.

I recently had a morning session with the board of an NHS Mental Health Trust, where they have been fortunate to apply for and gain funding for a coherent training programme to embed Human Factors principles in their organisation.

Virtually all of the Board were completely unaware of the term 'Human Factors', what it meant and of course how important it is to ensure the safe, effective, efficient performance of their Trust.

There are still many organisations that are seemly unaware of the crucial importance of factors that affect their Front Line staff and in fact everyone in the organisation. Notwithstanding the publication of the HF Concordat ( link -  https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-hum-fact-concord.pdf ) in 2013.

We have helped a number of NHS and private healthcare providers improve their performance and the CQC positively encourages Human Factors initiatives. We are very keen to come and help your organisation be it already successful or indeed in need of some improvement or help. All of our work is bespoke and our experience stretches all the way across the entire health and social care spectrum from acute through to community and primary care.

Don't ignore your 'People Stuff'. People are the lifeblood of your organisation.

Trevor

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More of the same? Don’t limit yourself

​The New Year: a time of self-analysis; looking back and looking ahead. 'New Year, New You' is an overused line that you will probably see almost everywhere.

So here's our piece of advice. Let's look beyond ourselves and reflect on your teams work environment too.

If we concentrate on our model of Whirlwind Debriefing – what is one thing we do well? What is one thing we could do more of or indeed less of ?

In general it is accepted that few of us emphasise our successes and share what we do well. Let's try and change to doing that.

That doesn't work for us

In aviation it is mandatory to have an in depth initial course with each new company that a crew member joins and by international law it must be refresher trained and assessed 2 or 3 times a year. Even then our human frailty and fallibility is still susceptible to error.

Human Factors training is about transforming behaviour to create safer more efficient staff. You cannot completely error-proof the human but you can provide the right training and support to give them the best chance to get it right and be safe under quite trying and stressful conditions.

This can't always be achieved in one brief intervention. In order to see noticeable effects your team should be allowed the time to fully digest the learning points from the training sessions and attend refresher sessions so that they can begin to embrace a new way of thinking.

Make achievable targets

Do you want your team to be part of the solution? We don't need to tell you that motivation is one of the first steps to making positive changes.

If you're struggling to make a New Year's resolution that's achievable for you and your team, here are a few suggestions:

This year we will:

  • Gain the confidence to raise issues
  • Be more motivated and effective
  • Find long term solutions to recurring issues and everyday challenges

Once you've decided on your resolution, we can help you stick to it.

Start your team on the journey to a successful New Year...

We offer help for individuals and small teams in the form of Open Courses click here to visit the page on our website. We can also provide training and support for departments and larger teams click here.

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