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.

The Chandelier Principle

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

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

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

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

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

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

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

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

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

Atrainability can help to spread that light.

Recent Comments
Guest — Mike Fealey
Great blog Trevor, I the chandelier analogy.
Friday, 06 December 2013 09:31
Guest — flip seal
like it.....I guess that the training and embedded human-factors in an organisation's culture would equate to the long-life bulbs ... Read More
Tuesday, 10 December 2013 08:16
Guest — Brian Davison
Excellent Trevor - this the antithesis to the apochryphal " Toc-H lamp" perhaps ?! The best teaching uses clear and bright analogi... Read More
Thursday, 12 December 2013 15:58
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Embedding Human Factors knowledge and understanding to combat avoidable harm

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

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

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

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

Here are some of the course comments:

· “fantastic course”

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

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

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

 


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Guest — sue
congratulations once again - raising the standards in the NHS - people understanding how to be better themselves, as team members... Read More
Sunday, 22 September 2013 10:22
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The importance of Self Awareness

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

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Junior Doctors training

This morning (1st July 2013) on BBC Breakfast TV (0722 for those with BBC iPlayer) there is an extensive report on training junior doctors at Newcastle University. The focus they mentioned was Care, Compassion and Dignity - excellent, just as it should be. Dr Matthias Schmidt understands the need and the issues as do many of his colleagues. "If I don't set a good example we won't be looked after properly in the future. Of course.
 
There is also associated research at Cardiff and Dundee Universities. Lynn Monrouxe from Cardiff was interviewed as well as an anonymous junior doctor- too concerned for his own future to be named. He spoke of the dangers of "not showing due deference to seniors"!
What was a pleasure was to hear one of the co-authors, junior doctor Stephanie Wells speak of learning from the poor experiences as well as the good ones. There are indeed silver linings.
 
However as they went deeper more troubling comments were made about regular observations of poor behaviour by senior doctors, some of it potentially dangerous to patients and certainly demonstrating lack of concern about patient dignity. One comment was about poor hand washing - did Semmelweis teach us nothing? Another was about being requested to perform an unconsented procedure while the patient was anaesthetised. Aren't these simple basics? Hippocratic Oath anyone?
 
Abusive behaviour was a significant facet of their training. Then they mentioned the 'H' word - Hierarchy and the potential career-limiting move of reporting such unsafe and inappropriate behaviour. Let's face it, that isn't limited to juniors! sadly.
 
What on Earth is going on? Why do some senior clinicians think this is an OK way to behave? Is it repeating the behaviour they experienced as juniors? Is there any excuse? 
 
We regularly run Human Factors courses for FY2 doctors across the country and always ask - "could you challenge every one of the senior doctors that you work with?" We have never had a positive answer to that. Indeed there was a major research programme a couple of years ago in the US where 100% of junior doctors stated exactly that - they could not challenge every senior.
 
We now ask the following question - "do you want to be one of the people that others hesitate to challenge when you qualify as a Consultant? If not now is the time to think about adopting safe open behaviour."

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Guest — Sue Dale
Let's hope that where the BBC go others will follow - Ministries, Royal Colleges, Training Universities.
Tuesday, 02 July 2013 17:41
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Workshop feedback 01

This is the reaction to one of our training days for the NHS Wales National Leadership Programme last week.

“I also attended the Human Factors Training on Thursday afternoon.(which incidentally was a brilliant afternoon and must be fed back effectively to staff who weren't lucky enough to be there) This is the area i work in and already the practice of the WHO checklist has been introduced and has seen great benefits in the Operating Theatre. 
However there are still improvements to be made and all grades to realise they have a duty to be involved, and as Denis Campbell stresses it is a tool that may need changing if the professionals who are using it feel it is not working, as in the Aviation business it has been transformed many times over the last 40 years. It has the ability to be brilliant if everyone comes aboard. 
The advantage that the aviation profession have over us is the Black Box, where every bit of what went wrong is recorded, so they know exactly where things went wrong and precisely at what point. We do have documentation and some equipment that holds data, but a lot of our errors are gathered like pieces of a jigsaw and not always 100% accurate. Communication and Reflection are our biggest tools and Horizon mirrored this with the scenario of a failed airway.(This again is a brilliant piece of work). Through all our roles we can find examples of things that went well, could have gone better, went wrong and must always reflect and learn from these and use this experience to pass on. 
An honest and open approach is one we must adopt unlike the Politicians!! I again ask the Managers to come out from their offices and look at the Work force i.e the Human Factors that are contributing to the patient care that is being delivered, all levels within the Health Board need to examine their behaviour towards patients and staff, as Denis Campbell said you don`t want to change someone`s personality but they may need to change their behaviour towards a patient or Team members. 
If staff are happy in their work, patients may have a better experience, if checks are done it should be a safer one too!!Its not rocket science, its so achievable if staff felt cared for this would definitely have a good effect on the morale and to the working day and in turn be really good news for our patients!! Sometimes we become so bogged down with all the politics we forget the basics and that is Care and this goes for patients and staff!! 
One of the exercises that we did as a group on the Human Factors presentation was "What makes a good day" and "what makes a bad day" Have a think with your Team members you may be surprised!! We can`t get out of this mess but we can hopefully make the best of it!!
We in Theatres are working on it!!!!!!!!”

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Blame or learning?

Blame or learning?
On a recent course a consultant clinician told me of a colleague who had made a genuine error and patient harm had resulted.
The clinician went to their own management and told the tale against themself with the intention of sharing learning and stopping the identical thing happening again.
The treatment they received can be described in a couple of words - blame and humiliation. 
 
Result - never again will that sensible honest professional ever confess. 
 
The more tragic result is the loss of such a powerful educational lesson.
 
The real lesson from high reliability professions is to seek to learn from every possible opportunity.
 
We get told these tales all the time on courses, where we have explained how errors occur and what the barriers are everyday to open communication and defeating inappropriate hierarchy.
 
Healthcare professionals all seem to have horror stories of their own. Some where they have committed the error, some when they have failed to intervene. There is so much learning out there. The vast majority appear to be human factors related. What a wasted resource. 
 
With training, management and teams can learn to shift focus towards a learning culture rather than blame. The result? An open reporting culture, with better communication and less repeated mistakes.
 
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How to avoid mistakes in surgery Horizon 22 March BBC 2

How to avoid mistakes in surgery Horizon 22 March BBC 2
 
The programme itself was very well presented but left the biggest question unanswered: If the evidence for using WHO Safer Surgery checklists is so compelling and use has been mandated, why do so many clinicians still refuse to use it? We are currently engaged by three Trusts that have problems with compliance with use of the checklist. They are not alone.
 
I ran three courses for doctors of various specialties this week gone with about 50 doctors in total. Each of those courses had at least one who expressed reluctance to use the WHO checklist, at least at first. In a way you cannot blame them. If their Trust introduced the checklist by email, as so many did, can you wonder at it? 
Treat people like children and they may just act like them. 
 
We find that treating healthcare professionals appropriately, listening to their concerns and worries gets buy-in. Also explaining what checklists are for, how to use them and particularly what can happen if they are used but not correctly can produce greater willingness to comply. 
In aviation the Spanair MD-80 crash at Madrid in August 2008 resulted ultimately from the crew not performing the pre-take-off checks correctly. The flaps were not set and the result was a disaster that killed 154 passengers and crew. http://www.fomento.gob.es/NR/rdonlyres/EC47A855-B098-409E-B4C8-9A6DD0D0969F/107087/2008_032_A_ENG.pdf
 
Similarly the Air Florida crash into the Potomac river in Washington DC in January 1982 was caused by incorrect checklist usage – the engine anti-ice was not selected on in severe winter weather. The engine intake probes were iced resulting in an incorrect (overreading) power indication. The aircraft accelerated too slowly, failed to get airborne and crashed into the bridge and the river.
http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR82-08.pdf
 
That’s the issue for aircrew, if they screw up there is a good chance they will die. That tends to get their attention.

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Guest — Jonathan Downham
Devils advocate....is it right that the refusal to use a vital tool is down to petulance?? Lives at risk here.
Sunday, 24 March 2013 10:02
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Course comments March 19

Course comments March 19
It is a delight to read the comments of the course I have just presented to just 6 middle grade doctors. The big question is where were their colleagues? 
Comments from today - “The things I learned in the course are all very practical and make sense. I now realize that in addition to technical competence, how important a part human and social factors play in the outcome of various situations. Proper understanding of human factors situation awareness, decision making process and team working can make a huge difference in the outcome of difficult incidents.”
Another “a very memorable and enjoyable course, very important for NHS employees to attend – to improve safety and relationships with colleagues. I plan to perform briefing, checklist and debriefing for my bronchoscopy list”.
My favourite is “Fantastic! Let’s get the Managers and Chief Exec on this course too”. That is a comment we often hear. However when one of our SHA clients invited Board members to a special day about a year ago – how many do you think turned up? Just 2 non-execs. How many apologised for the no-show – none.

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Hey very nice blog!! Man .. Excellent .. Amazing .. I will bookmark your site and take the feeds alsoI'm satisfied to find a lot o... Read More
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Guest — Sue
Human Factors training obviously makes people review themselves, their colleagues and their situation - and work more effectivley... Read More
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Zero Tolerance on Error

Zero tolerance on error

Jeremy Hunt was quoted over the weekend saying that there should be zero tolerance of error and comparison with the aviation professions was the starting point.

Let us be clear, in aviation error is expected throughout the system. But thorough training is put in place – initial and recurrent – and assessment of non-technical skills performance. All technical training has the non-technical aspects blended in. But also there is constant vigilance for system problems which damage the Safety Culture. All incidents and near hits must be reported and all reporters of error are encouraged and responded to.

How could healthcare teams and individuals be expected to maintain zero error rate if they have no idea what ‘right’ looks like? The vast majority of Trusts and Hospitals have not trained their teams at all in a meaningful way. This is abundantly clear when we go into operating theatres and wards.

Only last week I heard of a theatre sister who proudly announced that she ticked all the boxes and signed the WHO Safer Surgery Checklist so that “all the paperwork was correct at the start”!  It simply cannot be her fault – she clearly has no idea what the checklist is for and how to use it. I bet the local internal audit shows 100% compliance though, so that’s all right then.

A year ago we worked in a small DGH that had 100% compliance with theatre checklist. Not a single anaesthetic preparation room had a ‘Sign In’ sheet in it; the ‘Time Out’ was laminated and on the wall of every theatre – but never used; not one of the Consultant Surgeons had heard of ‘Time Out’ because they always left early for ‘The Boy’ to close up and nobody else ever bothered to use it.

How prevalent is this? Probably highly so. If you work in a department which does perform checks properly be pleased and spread the word.

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Guest — Sue Dale
excellently put - shout it from the rooftops!
Monday, 18 March 2013 08:42
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Mental Health 2013 Conference

Atrainability is the Main sponsor for Mental Health 2013 Manchester March 14 http://www.publicserviceevents.co.uk/241/mental-health. 
We get 15 minutes in the plenary session and a MasterClass in Human Factors to boot. With our current work to bring HF practical tools to all aspects of healthcare this is crucial to spread the word. 
Today I had a great reception from 70 odd psychiatrists in South Yorkshire. I find it amusing to talk practical HF tools like the sterile workspace concept - not allowing interruptions and distractions to increase error opportunities - with a group of psychiatrists. But it seems we do have a different way of looking at things. The same goes for the basketball video demonstrating our attention weaknesses.
Yesterday with another Mental Health Trust team we discussed using checklists and aide-memoires for such as checking the risk for removing service-users from seclusion. It seems there can be a distinct aversion on the part of the staff to get service users back into the normal part of the unit and the perception of risk is what weighs heavily on their minds. I heard one tale of a patient who was threatening to shoot staff so they wouldn't let him out. But someone pointed out that they were under obs in a seclusion room and couldn't possibly have a weapon!
But under observation for prolonged periods is itself a non-human-friendly task. We teach that the attention span is limited, possibly as little as 20 minutes for concentration. So is it any wonder that lengthy obs are not carried out well? Would it be better to rotate staff around jobs to break up the monotony and keep eyes sharp?
Another issue is being prepared for what could go wrong. I heard of a staff member getting thumped because he was observing a patient taking the air after a violent episode. But the staff member was standing with hands in pockets leaning against a doorway with no room to duck when the patient walked past him and just simply hit him. The two staff had been chatting to each other and had taken eyes off the task. Probably won't do that again, but somebody else might. That is why debriefing to learn is so important.
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