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
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.
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.”