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.”
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.