Atrainability Blog

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

Trevor is a specialist in human factors teamwork training since its introduction in commercial aviation in 1990. Since 2002 when he formed Atrainability he has been working extensively in healthcare, with extensive experience in training and coaching clinical teams in a multitude of operating theatres across the UK in NHS and private hospitals.

Trevor enjoyed a full career as a pilot with British Airways, retiring as a senior Training Captain flying Boeing 747 aircraft in 2005. By then he had been a trainer in classroom, simulator and aircraft for over 12 years. In this time he had extensive experience in facilitating learning and with a small team developed a range of innovative train the trainer courses that have gone on the become mandated internationally in commercial aviation. It is these skills which have been widely recognised in healthcare and have been utilised in courses for such as the Royal College of Surgeons and a variety of research programmes conducted with teams at the RCS and the University of Oxford.

As a result of these he was approached to tender successfully for the development and design of the Productive Operating Theatre teamworking modules for the NHS Institute. His experience across healthcare is wide and far-reaching, including a specialty in Surgery, Radiology as well as Primary Care, Emergency Care, Critical Care, Mental Health and Secondary Care.

He is widely sought as a conference speaker internationally on the subject of human factors training in healthcare. Trevor is an active member of Lions Clubs for over 30 years and has been President of his local club twice.

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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