Course attendee comment

This short 2 minute video testimonial is from a Doctor of Emergency Medicine reflecting on how she has seen the significant benefits of Atrainability Human Factors training

 

 

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 familiar tale of high staff turnover



I've been chatting to various clients and a regular subject that we return to is high staff turnover. 

Many organisations do not perform exit surveys and so understanding why people leave is a problem to start with. Perhaps they don't really want to know. It's easier to blame the NHS and pressure of work, targets etc.



For example, Atrainability worked closely with a world famous specialist hospital a little while ago which was suffering high turnover of junior nurses in a particular department.


The view from the top was: 

"The nurses come here to get our good name on their CV's and then move on."


However, anecdotally people were leaving because it was not a great place to work.

Team-working was verbally espoused but reality was somewhat different. Work as imagined was quite different to work as done depending on your level in the hierarchy. 

One nurse told us she had worked her entire shift without any offers of help, breaks or support while the band 6 and 7 nurses had a nice relaxing time. You can imagine the atmosphere when we presented our findings. 


This is by no means unique as many of you will know. 

This very week I've listened to my best friend's wife explaining that she is burned out and leaving the profession the she loves. The reasons? She is a specialist sister in intensive care who is often told to work in other departments. She has been sent to A & E, theatres, wards and even the other sites in her trust which is 20 miles away. 

She has simply had enough. 

What a tragedy which is personal, institutional and cultural for her and us all. 


In London there are 8000 nursing vacancies and huge doctor numbers too, so making your job one that people want to come to must be worth working on? 

Staff retention rather than repeated training costs is a very worthwhile investment, and turning from a Blame Culture to a Just Culture is a crucial start. 

A worthwhile part of team-working is delving in to emotional intelligence and a fundamental concept within that is of course self-awareness. 


Get in touch and discuss with us how we could help your teams, including the senior level of course. 


Trevor Dale, Human Factors Specialist

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Human Factors & Patient Safety Updates (Oct18)

In this edition:
  • Civility Saves Lives
  • Group GP appointments - a breeding ground for error?
  • Waverley BIG Awards Finalist
  • Human Factors in Practice
  • Free conference this November

Civility Saves Lives

Civility when dealing with colleagues and patients may seem like stating the obvious, but sometimes what should happen in theory isn't what happens in practice. 

Civility Saves Lives is the self-funded, collaborative project led by Dr Chris Turner, a Consultant in Emergency Medicine. 

Why does civility matter? Uncivil behaviour not only greatly impacts the reciepent, but it is also proven to have an extended impact beyond the recipent. At Atrainability, we refer to this as 'Mood Contagion'. 

Many professionals have been on the receiving end of rudeness, belittling and bullying. Most are told or feel like 'that's just the way it is'; but if the NHS truly wants a Culture Change behaviours and attitudes at all levels need to adjust. The project aims to raise awareness of what can be done, whilst sharing stories from other professionals as well as relevant, evidence based academic papers.

Atrainability's Trevor Dale has recently been speaking about the importance of civility at Patient Safety Collaborative for Kent, Surrey & Sussex. If you'd like to find out more about how Human Factors training and Civility fit hand in hand, request more information by emailing team@atrainability.co.uk. 

We also highly reccomend taking some time to look at Christine Porath's work. Her book 'Mastering Civility - A Manifesto for the Workplace' has recieved excellent reviews in The New York Times as well as from high profile authors and leaders.



​Group GP appointments - a breeding ground for error?

There has been a recent report about the NHS considering group GP appointments as an option to help alleviate the waiting time for patients and in an attempt to manage the growing shortage of GPs.

 Although further details on this are needed, we at Atrainability believe that this could very well be a potential breeding ground for Human Factors error, our main concerns from a Human Factors perspective include:


 • BEHAVIOUR & COMMUNICATION: The patient relationship with their GP, being confident to raise real concerns. How does the GP manage a room with some extraverted (verbose) people and some introverted (more private & more inwardly driven)?


 • SITUATION AWARENESS: Potential error when adding correct patient notes to correct individual files - how will this be managed from a group sessions?


 • CONFIRMATION BIAS: A group may have similar symptoms, but will this lead to the same path of care? The correct diagnosis? Could things be missed? 


Are you a GP? 

We'd appreciate your thoughts on the subject. Email us in confidence: team@atrainability.co.uk.



​Waverley BIG Awards Finalist


You may know that we've been training health and social care teams across the UK for the last 16 years, however you may not realise that we're classified as a small business. Which is why we are delighted to have been selected as a finalist for Waverley's B.I.G Awards 2018 in the category of 'Customer Delight'. We'll keep you updated on the results which will be announced on 19 October.


​Human Factors in Practice


We were recently copied in on communications from a client to another organisation who were enquirying about our services. We have been granted permission to share this with you: 

Sent 19 September 2018 
Subject: Human Factors in practice 

Hi __________ I'm sorry to have taken so long to reply. We are six weeks in to our annual CQC inspection activity – what is perverse is I am responding to you on today of all days as today is the first day of the actual well-led inspection! 

I have to say, embracing Human Factors was the start of our journey and absolutely the right place to start. There is no other way to, in NHS terms, make the shift from compliance to continuous improvement, or it is likely you would regress back to a compliance focus. Embracing Human Factors tackles capability, by that we mean confidence, competence and capacity. Most other approaches cannot do this and that means you lose staff engagement from the outset. 

I am glad to hear that you are looking to improve the safety culture in your organisation. That shows a lot of insight on your part – a lot of organisations tackle just "culture", which then takes things down an OD direction. Also, culture is a funny term, we do need to break it down into its component parts and Human Factors tackles component parts that other approaches cannot. 

As a direct consequence of our Human Factors work, we have now moved away from audit to improvement and now each team is worked with, as an MDT, to look at their safety performance and we also undertake a patient safety culture survey. This has revealed things to us that our typical assurance mechanisms have not, e.g. we would assume our incident reporting profile equals a safety positive culture, but perception of staff shows that there is still work to do. 

We have used The Health Foundation Model to help us improve how we measure and monitor safety, however having been on the journey, you can't just implement that, Human Factors needs to be grounded in all you do first. I have seen many organisations where Human Factors becomes something that is led by OD and becomes associated with "communication" – Human Factors is much more than that. 

Taking a look at your organisation, it looks like not only do you have a similar profile to us but your CQC ratings are almost identical. We are rated Outstanding for Caring which we put down to, in part, our work in relation to Human Factors. The Safe domain is always a difficult one to shift – let's hope this inspection changes that! Feel free to come and see us or we will come and see you, if you have any questions. We are also open to partnering on things. However I would revisit offers from Human Factors providers first as that really is the foundation. 

Of course my experience is of using Atrainability and there are many reasons for that, aforementioned, in-house approaches risk this being seen as a communication thing, whilst other companies do not tap into the SME that experts in the airline industry have. We have used Atrainability to train what we call "culture carriers" or then have spread and sustained this approach in what has then developed into our patient safety improvement (safety management system) work. 

Atrainability also did two bespoke sessions with our Board, as that demonstrated to our staff the commitment of the Board. So I would suggest you need a programme of works that tackles all levels of the organisation for this to work – we didn't know it at the time, but we used the dosing model which you are probably familiar with. That will help you present any proposals to your Board as this is an evidence based way of building capability in a sustainable way. 

Good luck on your Human Factors journey! 

David Wood, 
Associate Director of Safe Services Cheshire & Wirral Partnership NHS FT


​Reminder! Free Future of Healthcare Conference this November


​Atrainability are proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at The Future of Healthcare Conference, which is free to attend event on 6 November in Exeter. 

The conference brings you speakers from a wide spectrum of specialties. The aim is to inspire & teach NHS staff from all departments, as well as patients, on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance. Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter.

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The Tragic Cost of Avoidable Harm

As I'm writing this, it's only Wednesday, but we have already been made aware of four unrelated never-events at seperate healthcare providers. The unfortunate truth about committing to a Human Factors training programme is that many organisations put it off, until they receive a wake-up call in the form of a never-event, a near miss, bad press or from the CQC. Someone gets told this needs to be addressed, and that's when our phone starts ringing.



The first tragedy of so many harm related incidents is that on reflection they could have been avoided. 

That's one of the reasons this headline in the National Health Executive: "NHS pays out record £20m compensation for brain-injured teenager" caught our attention, but also because it's potentially the largest compensation pay-out in NHS history. 


The second tragedy of avoidable harm is that the suffering of all those involved doesn't end with the error.

The judgement suggests the error was avoidable. Hence Human Factors behaviours will likely have been suboptimal. In this particular case, not only did this nameless young lady have her full enjoyment of life tragically taken from her, but also her parents and entire family. 

We can only imagine the emotional toll that they have endured for the last eighteen years to have this life changing error acknowledged and receive some form of compensation towards her ongoing care. 

Let's also recognise the effect on the healthcare team involved. It's likely that disciplinary action would have been taken, but they have almost certainly been haunted by the knowledge that they could have avoided or trapped the error. 


The third tragedy of avoidable harm, is that it sadly continues to occur. 

There will always be mistakes in healthcare, but embracing a Human Factors mindset can enable your team to be confident in modifying the actions and behaviours that affect safety. 

Atrainability have over 16 years' experience in training and supporting healthcare teams on their individual journeys to truly learn, become more effective and begin to change behaviours for the better. If your teams are performing highly now, consider helping them to stay 'consciously competent' and avoid the trap of complacency.


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


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Human Factors Courses for Foundation Doctors

The General Medical Council has reflected the importance of recognising Human Factors in the development of generic professional capabilities for post graduate medical curricula. 

The context for this is the GMC's core guidance for all doctors, good medical practice, which sets out what is expected of doctors including communication, partnership and working with patients. (National Quality Board Human Factors Concordat 2013) 

Many Deaneries have incorporated Atrainability's Human Factors modules in their curriculum, since 2012. The list is growing year by year and the repeat bookings speak for themselves. 


Atrainability are now taking bookings for Foundation Doctors Human Factors Training for the next academic year

Human Factors is strongly recommended to become a mandatory part of Medical Education and our courses match the Medical Leadership Competency Framework.

Focus points include: 

• how and why errors are made and practical tools to avoid and trap them 

• safe decision making during a stressful day 

• situation awareness - recognising the signs that things are going wrong and dealing with that situation 

• effective escalation - overcoming the barriers to open communication and shared understanding in a high workload environment 

• dealing with difficult people including, sadly, colleagues 


We have over 6 years' experience in delivering training aimed at the next generation of healthcare professionals in a manner that is tailored to their educational needs. 

The Human Factors behaviours related to safety are crucial both for the patient and also the professional confidence within the Doctor while they are in the most high risk part of their education. 

If you have already finalised training for 2018/2019, we'd be happy to discuss your training programme for the next academic year.

Some sample feedback from recent participants: 


"Outstanding course, incredibly useful" 


"This should be mandatory! Very interesting to learn how other industries such as aviation can apply to medicine" 


"Leadership & management is crucial but often overlooked in medical training. Clear, practical advice that I can start putting into practice now." 


"Useful to receive formal teaching in things that it seems we are expected to already be aware of e.g. challenging authority. Good presentation, kept engaged throughout." 


"Important concepts to reflect on, extremely useful to be exposed to this early on in our career" 


We would be happy to discuss your individual needs at your convenience. Please contact us here.

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Unprofessional behaviour in the workplace

The recent press reports of a 'toxic' atmosphere at St George's hospital in South London are distressing to say the least but unfortunately by no means isolated. 

Relations between colleagues in any profession can break down or face difficulties at times. However, healthcare professionals are often a keen focus for criticism in the media and so it's important not only to understand how to prevent unprofessional behaviour in the first place but also how to manage high-performing professionals into cooperative team-working when under pressure. 

In over 16 years of working with health and social care professionals across a wide spectrum of disciplines we have encountered far too many instances of uncivil behaviour sometimes directed at us and certainly at fellow team members. 

It is worthwhile mentioning that this applies at all levels and specialties and not as some apparently think, doctors alone. Currently we are working with organisations where problems exist within nursing bands. When trying to help teams understand the effects of uncivil behaviour we ask the following:


WHAT DOES IT MEAN TO HUMAN?      VS       WHAT DOES IT MEAN TO BE PROFESSIONAL?


Here are sample answers, by no means exclusive:

Maintaining high standards of professional behaviour is a major challenge in any high-pressure working environment. We will sometimes fail to get it right because we can not avoid being human.


MAKING EXCUSES...

One clinician sought to excuse his colleagues inappropriate behaviour by saying the surgery (neuro) he performed was very complex, high risk and stressful and that stress had to be vented somewhere; and so in this way he justified the bullying his colleague dished out to theatre teams! 

Thankfully, this clinician always behaved impeccably with patients and relatives but there is no excuse for undue criticism or abuse of colleagues.

Why does he think it is an appropriate way to behave?

Does he realise the impact he has on staff feeling that they can speak up in the unlikely (we hope) event of some avoidable error?

How will the added stress of working with someone difficult effect the performance and focus of the rest of the team?

If you look again at the 'What makes a professional' image; what makes him believe that he is practicing in a 'professional' manner?

More importantly, how can he be helped to gain self awareness? Certainly not by people making excuses for his behaviour and certainly not by team members keeping their heads down.

MANAGING HUMANS

Everyone has what we refer to as their personal 'stress bucket'. 

So in dealing with 'difficult' people, especially as a manager or team leader it can be helpful to consider why they behave this way. 

Could they be ill or facing huge personal stress, having a personal crisis? Could they lack insight or skill? Could they believe it to be acceptable because that's what they experienced? Could it be my fault? Winding them up? Could they just be plain awkward? 

The first step is to recognise the 'human' elements, treat everyone as an equal with dignity and compassion and by that try to encourage the 'difficult' people into the same behaviour.​

// View our Walking the Tightrope Course here. //


This can be easier said than done, especially if you're not in a management position but one of those perhaps at the blunt end of the behaviour.

In those circumstances the simplest advice would be to reframe your response to this behaviour. For inappropriate behaviour such as bullying or intimidation, it is common for individuals to be singled out as the 'victim'. 

Therefore sticking together as a team is crucial. It is certain that you are not the only one who has noticed or feel uncomfortable with the behaviour. As a collective it's important to not allow yourselves to become victims but to stand together and respond professionally, politely but firmly. 

As a common example if someone refuses to follow a procedure (such a safety checklist, briefing etc) declaring it a waste of time or they know better etc. Together the team needs to take the stance "I'm afraid we will not be going forward with this until this is done." 

Regardless of your faith in reporting systems there should be one that enables you to get support from your management, but any reporting with regards to inappropriate behaviour must be evidence based.


REPEATED UNCIVIL BEHAVIOUR

The NHS is notorious for having a culture where professionals are treated effectively like children. If you treat people in such a manner don't be surprised if you get a child-like response.

However if you treat people in an adult manner, as equals, with respect and understanding it is more difficult for them to maintain an unprofessional behaviour pattern.

At the same time it should be made clear that continued unprofessional behaviour and bullying cannot and will not be tolerated. This comes under the heading of duty of care to the rest of the staff. A fundamental management responsibility.


However, we know of a current situation where after evidence of repeated uncivil behaviour, a formal interview was undertaken with an official warning on file.

The staff member has returned to work, but the manager suspects no behaviour change has taken place and is not getting any further evidence from other staff because presumably they feel that nothing has been done and therefore why waste time making reports?

A conundrum indeed because managers cannot publish confidential personal reports for obvious reasons. Here we believe having a cadre of Human Factors Champions in the workplace could help.

They could be the interface in the workplace and offer advice and support to both staff and management.

So we return to a Just Culture - one where genuine human error is treated with understanding but equally failure to follow standard procedure habitually and inappropriate behaviour towards others is simply not on.


Make an enquiry about creating Human Factor Champions in your team here.

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Human Factors & Patient Safety Updates (Aug 2018)

Free conference for NHS staff this November

We're proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at this free to attend event on 6 November in Exeter. 

The future is uncertain. With the dawn of technology, will healthcare staff be usurped by advanced apps & artificial intelligence? What leadership strategies are in place to help NHS staff cope with the Salisbury Novichok incidents? How will joint working & mergers affect staff? 

This event explores Collaborative Networking - The Future Of Healthcare. This free conference brings you speakers from a wide spectrum of specialties. We aim to inspire & teach NHS staff from all departments as well as patients on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance.

Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter

Fixing a System Under Pressure

Everyone seems to say now that they have a 'Learning Culture' - but what is your SOURCE of Learning? 

The British Medical Association has recently shared some of the footage from The Future Vision for the NHS workshop ran last month. On the day around 50 members from across different parts of the medical profession came together to contribute ideas, experiences and examples to help inform the BMA's work to press for change in the NHS.

Watch a selection of videos from the event here, including 'Fixing a System Under Pressure' a short presentation from Atrainability.


Excellent Feedback from Serious Hazards of Transfusion Conference


​We were recently sent the official feedback from the SHOT blood service conference we spoke at in July. 

This year saw record numbers of delegates, which could be partly attributable to having more international delegates from the IHN meeting. 

There were 270 online submissions for the evaluation survey, which was a response rate of 85.7% (the evaluation survey was sent to 315 individuals, excluding exhibitors). 

Trevor Dale spoke at the conference about Walking the Tightrope.

The feedback on the conference was exceptionally positive, and we were very happy to receive top scores on most informative and best performance of the speakers.


Who's tweeting Human Factors...

One to follow: #learnnotblame is the fantastic campaign lead by Dr Cicely Cunningham launched by The Doctors Association UK, we'll definitely be following and supporting her progress as she raises important issues that's relevant to Human Factors values.

That's our round up of the updates from us for now, please get in touch and let's see how we can help your teams.

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Human Factors and Patient Safety Updates





PATIENT SAFETY TEAM OF THE YEAR

The winners of the HSJ 2018 Patient Safety Awards have been revealed. Well done to everyone who was nominated, commended or won! In particular, we'd like to congratulate the University Hospitals Coventry and Warwickshire Trust Patient safety and risk team. Their team have been awarded the Patient Safety Team of the Year. 


"Integrating Human Factors principles into our safety investigations has been a key part of the changes we have made. An understanding of these concepts is key to learning and improving as an organisation when things go wrong. We started our Human Factors journey two years ago with Atrainability and their Train the Trainers course, and this gave us the knowledge and confidence to develop a systems based investigation process that moves away from blame, towards learning and ensures that the patient is at the heart of what we do." 

- Stephen Tipper, Human Factors Programme Manager

Since instituting a raft of measures over the last year the incident reporting rate at the organisation has increased from 31 to 44 incidents per thousand bed days – in the top 25 per cent nationally. There have also been improvements in staff survey responses on feeling secure when raising concerns.

We of course can not take credit for their achievement but we are proud to have played a small part of their wider plan to make sustainable changes to patient safety with the 5 day Train the Trainer sessions we ran with them two years ago.

Read more about their changes and award here.


TRAINING WITH THE TEAM AT UHNM

Last week we ran 2x two-day Human Factors Awareness workshops for adult and children intensive care teams at UHNM. The courses were presented by our Founder, Trevor Dale and one of our new team members, Rick Craft.

During one of the two-day sessions, our trainers had the pleasure of talking with Emma Biddulph, a Play Specialist who is featured in an article in The Guardian on 70 years of the NHS. Emma told us:

"I came not knowing what to expect, but I found this course really interesting and useful. I plan to start implementing human factors learning asap in my daily practice."

Emma Biddulph, a Play Specialist
We're happy to report that 100% of the staff said they would 'Reccomend this training to a Colleague' and 100% also told us that as a result of the training it was likely or very likely that they would be able to apply the learning to their practice. Enquire about Human Factors Awareness Course

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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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