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.
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!
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!
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 Dealing with difficult people
Ø Leadership & team-working
Ø Briefing & Checklists
Ø Debriefing for LearningIt 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.
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.
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.
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