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Here we share some thoughts, insights and ideas related to Human Factors Training

Reacting to tragedy - the aviation experience

It is, of course, inappropriate to speculate on the possible cause of the tragic Ethiopian Airlines crash. However, the reaction offers lessons I believe.

The authorities in Ethiopia and China have grounded the same model virtually instantly until root causes are understood and appropriate measures have been taken.

It may be significant that the aircraft is the same new model as crashed in Indonesia in late 2018, or it may not. Risk management is the name of the game.

One of the contributing factors in Indonesia was the new safety feature built into the aircraft software. The concept was to improve the way the aircraft responds to an unwanted state and is supposed to be an aid.

It is called the Manoeuvring Characteristics Augmentation System (MCAS). It is designed to prevent the aircraft from falling out of the sky in an aerodynamic stall.

However, it appears that the manufacturer, Boeing, did not incorporate the knowledge of the system in its training to crews. Many qualified crews around the world have stated that they nothing about the system's existence.

To compound the problem, it appears that the Indonesian aircraft may have been despatched with a known technical problem which the ground engineers may not have been able to reproduce on the ground.

In other words, the safety system responded correctly, but the suspicion is that it was being fed erroneous data from a faulty sensor. In this case the AoA (angle of attack) sensor – which detects the airflow over the wings.

Some of you may be aware that a cost saving feature is that this latest model of Boeing 737 is deemed to require only 'differences' training if a crew is qualified on the earlier model. They do not do a full technical knowledge course just learn and are assessed on the differences.

It seems the new safety feature was not included. Human error by the manufacturer? The result in a non-technical sense is a loss of situation awareness – how and why the aircraft is reacting.

Those of you who remember the tragic Kegworth crash in January 1989 which started with the crew identifying the wrong engine in an unclear flight situation and ultimately crashing across the M1 motorway in England's East Midlands.

Of the 126 people aboard, 47 died, and 74 sustained serious injuries.

Implicated was the pilots not being aware that the right engine supplied the air conditioning to the flight deck as opposed to the left engine in previous models.

The smell of burning was a small misleading clue. They had only completed a very brief 'differences' course.

Airbus have also suffered accidents in the past because the aircraft was so advanced and complicated that crew struggled to understand how the plane was reacting.

History can repeat, but we learn the lessons the hard way.

I flew six different airliners from four different manufacturers in my career. Comprehending what was going on was sometimes tricky and fundamentally down to how well the crew knew the aircraft. In other words, training.

In other professions such as healthcare, we all involve people trying to comprehend what is going on.

Healthcare professionals face a much more difficult job because no two patients are the same even more so than with aircraft. Knowledge and understanding are crucial, especially in how any one of us can get it wrong and right.

Human factors has been mandatory training in aviation since 1995, and even that can't prevent everything. But it sure helps.

I've presented training packages to several NHS Boards and senior management teams. Not surprisingly cost is a feature. Some get it; some seem to struggle.

After all, finding a direct correlation between safety and training is not easy.

But precisely who initially said, "If you think training is expensive, try having an accident"? I'm not sure, but it has been attributed to many wise people over the years.

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What’s in a name?

In our everyday lives, people are typically polite to each other. At social events, we carry out personal introductions a matter of course.

So why is this behaviour not the norm in healthcare?

When working with healthcare teams that are sometimes experiencing challenges with safe team workings, we often observe a reluctance to introduce ourselves by name - especially our given first name.

When I joined my first airline employer in 1971 that was indeed the case.

The Captain was always addressed as Captain or Sir, on and off the aircraft.

I still vividly remember my first BOAC flight as a very lowly second officer under training. The Captain was a very senior manager and trainer, and he exacerbated the situation by referring to me to his chums in the bar in Manhattan as 'one of those bloody cadets still wet behind the ears'. What an excellent example to set.

It was an example I chose as a model of what not to do when I finally achieved Command 18 years later.

Furthermore, I made a point of never introducing colleagues as 'my First Officer' or 'My Cabin Crew'. These are professional people in their own right and deserve all the respect associated with it.

This is an important issue because failure to use given names in the workplace can create a significant barrier to people speaking up when they have doubts about safety.

Why would any professional want to place an additional block to open communication, especially if someone's' life could be at stake?

I met one senior clinician in the last few months who looked with abject horror when I suggested they make a point of introducing themselves by first name at a pre-surgery huddle! "I really don't think I could do that", she said! Why on earth not?!

The unit in question has an appalling staff attitude survey result, a string of 'Never-Events' and 'near-misses', a high sickness rate and high staff turnover. Go figure!

The excellent Rob Hackett in Australia had the astonishingly simple idea a while back of putting name and job title on his theatre hat. This has become known as 'the theatre cap challenge'. Odd isn't it that it should even be regarded as a 'challenge'!

It's quite amusing to hear all the excuses why people can't adopt this simple practice of the theatre cap challenge in their own unit.

Infection risk? Well, there is a chap out there making them integral in theatre caps. You could invest in a few to get you through the week if you like your own personalised hat.

Power is granted, respect is earned.

We must not forget either that using titles can help in difficult situations.

As an airline captain, there were many occasions where a colleague referring to me as Captain Dale was useful to re-establish appropriate hierarchy in front of passengers or an engineer.

The other week I was delivering a talk in Bath, to a room of around 100 healthcare professionals, ranging from medical students to retired senior consultants.

When I reached the end of my talk, I asked how people in the room felt about using first names? I explained that when you have to think about titles and ranks, you are creating an additional barrier to someone helping you out when you need them the most.

I don't mind if you introduce yourself as Professor John Smith, but I prefer if you call me Professor Smith. This might not be as beneficial as working on a first names basis, but it sure beats the all too common introduction, "We all know each other don't we?" which equates to "You all know me, don't you? .. and you don't matter".

Do get in touch to discuss how our human factors training for critical teams can help you maintain and enhance safety.

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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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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 & 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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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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HFE in Healthcare, Investigation and Education


We at Atrainability are proud to have been invited to sponsor the

Clinical Human Factors Group's upcoming Aberdeen Open Seminar on 23 May.


"We are honored to be supporting this event and pleased to be able to contribute towards the ongoing mission of the Clinical Human Factors Group" - Trevor Dale, Managing Director, Trevor is also planning to attend the event and he hopes to see you there.


Please find further details below:

- - - - - - - - - - - - - - - - - - - - - - - - - -

CHFG's next Open Seminar will take place in Aberdeen on the 23rd May 2018.


The Keynote speakers are:


• Keith Conradi, who will provide an update on the developing work of the Healthcare Safety Investigation Branch (HSIB)

• Dr Paul Bowie from NHS Education for Scotland and Craig McIlhenny at NHS Forth Valley Scotland, talking about the new national multi-agency initiative on Human Factors in NHS Scotland.

Breakout session topics include:


Dr Karthryn Mearns - Safety culture - we can measure it, but can we manage it?

• Manoj Kumar - Safety reviews: bridging the gap between work as imagined and work as done

• Professor George Youngson - The impact of bullying and discrimination

• Dr Helen Vosper - Human Factors as a strategy for improving Medication Safety

• Dr Alastair Ross - The Functional Resource Analysis Method and how to develop a model of everyday work

• Professor Ron Mcleod - Bowtie analysis as an approach to the assessment of the risk in healthcare

• Dr John Rutherford and Dr David Macnair - Good practice in running Human Factors training in a district general hospital

• Dr Shelly Jeffcott - Pushing back on "the way we do things around here": What holds us back from integrating HF/E


This one day event will focus on Human Factors in healthcare and applications in investigation, clinical practice and education.


Register for the event here & View full programme here.


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A ZERO fatality year...

Once again we've heard comments that aviation and healthcare are radically different, the point being of course, that healthcare can't possibly transfer learning from an industry such as aviation. Well of course our industries are different, but it's not as simple as some people think.

We've heard this so many times. 

"Pilots would not get airborne with a plane that wasn't working properly, where as Doctors and Nurses are dealing with people who've had something go wrong" 

This misses the point. 

Most people don't realise that if something goes wrong in an airplane, rarely do you see it coming and the chances are we're already airborne. 

Aviation in the 21st century is incredibly safe, so much so that there is talk of a zero fatality year worldwide due to accidents, leaving aside deliberate acts. 

Extrapolating this it suggests that aviation is, as is often claimed, 99% boredom 1% sheer terror. Not strictly accurate, but mostly things do not go wrong, but what flight crew have to maintain is a wary eye for potential problems.If they occur…

The enemy here is complacency. 

Flight crew, like healthcare teams, have to be like the proverbial coiled spring, ready to react, safely and sensibly in times of extreme stress and with limited options. 

In a nutshell, where learning from aviation can be beneficial and transferrable to healthcare is via our techniques and methods for understanding human behaviour. Being able to be proactive rather reactive, be situationally aware as well as self-aware, understand how to communicate effectively to avoid misunderstanding. 

These skills when mastered, can create leaders and teams who can make better judgement calls, minimise risk and maximise safety. Knowing what we do about the effects of the amygdala and fight, flight and freeze, it is the ability to control your actions under extreme stress that we have to practice. 

Preparedness is crucial. 

Flight crew are trained to consider what could realistically ruin their, and you the passengers, day. One of the aviation techniques is to use periods of low activity, not to simply chat and pass the time of day, but to discuss with your colleagues and your team what they might consider to be a potential problem. When flying how would we handle a depressurisation or a hydraulic system failure. In healthcare something akin to a cardiac arrest or pranging a major blood vessel, or an unanticipated allergic reaction for instance. 

Alternatively a challenging aspect could be when you know you're going to be working with a difficult colleague, so you could discuss in advance how you will try to change the trajectory of incivility into a harmonious team outcome. 

Atrainability are able to provide tailored Human Factors support for teams that are in need of advice, support or development.

Further reading...

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Improvement Science for Better Outcomes

Atrainability have teamed up with The Quality Improvement Clinic and QIC Learn to create a one-day masterclass which will show you how Human Factors and Improvement Science can help you deliver better outcomes.

Small changes can effect big changes and we can equip you with the knowledge and confidence to take new ideas back to your setting.

What will I gain?

After taking part in this masterclass delegates will be able to:

• Be inspired to use human factors and improvement science to deliver better outcomes for their patient e.g. during transitions of care

• Understand Threat and Error Management - an essential concept in learning from error and success

• Understand and accept the causes of mistakes -how to maintain confidence in the high pressure workplace

• Know the early warning signs that things are not as they should be and what to do about them

• Understand and adopt effective communication -ensuring mutual understanding

This 1 day masterclass has been designed to give you an appreciation of Human Factors in the workplace and how it can help you deliver better care.

Through attending this course, you are becoming a change agent, leading the way to help make your patients and your ward safer with Human Factors.

We look forward to you joining us on Friday 23 March 2018.

​BOOKING NOW:

Human Factors Principles + Improvement Science = Better Outcomes


When: Friday 23 March 2018
Where: De Vere West One Conference Centre, London

JOIN US:
Click to find out more OR
Click to book online

. **Special Offers** 15% Group booking Discount or 10% Card Payment Discount
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A renewed focus on NatSSIPs

NatSSIPs - National Safety Standards for Invasive Procedures 


Many of our prospective clients often tell us that they are working successfully towards a safer culture, and yet never-events and avoidable harm do not appear to be diminishing on a National basis.* 

Let's look at NatSSIPs and LocSSIPs on which there is a renewed focus at this time. Otherwise known as the Five Steps to Safer Surgery. 

LocSSIPs is a topic that we have masses of experience in, helping Trusts develop their own best practice in briefing, checklist and debriefing . We are privileged to witness many excellent demonstrations using Natsipps techniques but sadly, we occasionally meet individuals who think they don't need such aids to safety. 

Very recently I was disappointed to witness a Clinician quite deliberately reading news reports on his Smartphone while a Safer Surgery Checklist was being read. Sadly his clinical colleague said nothing. Rest assured that the situation was rectified at the time. However this is still not unique, though happily rare. 

We have a responsibility to ensure the importance of NatSSIPs and the reasons behind its introduction are understood. In our view (and others) the use of checklists and safety techniques is not a personal option, but a mandate and a necessary core function of professional surgical performance. 

NatSSIPs is built around the aviation based concept of threat and error management. This came out of the original NASA funded research at the University of Texas under the late professor Bob Helmreich. 


Threat and Error Management is three steps: 

•AVOID – in an ideal world you would avoid everything that could possibly go wrong

TRAP - But of course you can't avoid everything in the real World. What you haven't been able to avoid you would wish to trap, in order to minimise any errors resulting in potential harm. 

•MITIGATE (read definition)- Finally, one needs to reduce the effects if harmful but to stretch the meaning of 'Mitigate' – to learn from failure and of course success. 


How does this work in practice? 

In healthcare, as in aviation, the 'AVOID' phase is accomplished by having a briefing (Handover or Safety Huddle) normally performed at the start of a working shift or day. This is where the team get together, share plans for what should happen, build situation awareness (Plan A) across the whole team and prepare themselves for what they hope won't happen (Plan B, plan C etc). 

'TRAP' - The 3 steps of the WHO Safer Surgery Checklist fulfil this role.The checklist serves as a memory aid to ensure all necessary safety issues have in fact been completed. Note – it is a Checklist - not a TICK LIST. It is completion of the actual CHECK that is crucial and not the ticking of a box! 

Finally, 'MITIGATION'. Debriefing sits here as a tool for learning not blame. In the case of a successful outcome debriefing is the opportunity to discuss what went well, why it went well and how we will try to ensure it goes well tomorrow and thereafter. 

In the event that it has not gone well, rather than resorting to blame and finger pointing; this step serves to investigate why and how something went awry. How and why well-intentioned, well-trained people have perhaps made an error, with a view to genuinely learning lessons and moving forward effectively for the whole team and ultimately the organisation and the profession. 

Duty of Candour sits here too and is of course a legal, professional and a compassionate necessity. 

After all, quite apart from the safety aspect, who gains the most respect? Someone who accepts and owns up to their own fallibility or someone who seeks to hide it? 

Atrainability would be delighted to assist you in implementing LocSSIPs for your teams, please get in touch to arrange an informal phone chat at your convenience. 


*Source: Never events data, click here

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Walking the Tightrope...

Self-Confidence is vital but Self-Awareness is Key to Learning Success.

Confidence is a vital commodity when it comes to delivering safe, effective performance in any job, sport or profession. One must have a degree of self-belief in order to fly a plane full of people, compete in sports or indeed perform medical treatment. However, a simple, basic facet of being human is that we are all fallible.


Are we aware of our response to our own errors?

Firstly, we have to realise that we have indeed made an error, because initially whatever action was taken was likely done with the expectation that it was correct. The dawning realisation that we have indeed committed an erroneous act can trigger a response, which could be fight, flight or freeze. Once confidence is damaged, it can manifest in a variety of ways. If we have a critical voice in our head, telling ourselves off; compounded by friends, family or colleagues also berating us, we can spiral downwards into depression. Often if we are unable to accept that we're responsible for a mistake we can respond defensively by directing our responses outwards;


                                                          "Why didn't YOU tell me!"

                                                         "Why didn't YOU stop me?"

                                                         "YOU didn't tell me…"


…in other words, if I can't accept my own fallibility it must be yours. This in some cases leads to arrogant behaviour, and does not make for safe, effective teams.

We as individuals need to work on our self-awareness, take responsibility and manage our responses, but we also need a team around us who don't continue the cycle of berating and instead supports and learns when mistakes are made.

How has aviation dealt with this? By embedding Human Factors principles at all levels from Board to the frontline.

The Board must walk the talk or any transformation program will fail, because it is perception at the individual level of the safety culture that is crucial to success.

Pre-1980's aviation training focussed purely on the technical skills of flying a plane. Effective communication, team-work, situation awareness – these were not considered important. However, with the improved use of black box recordings and analysis of significant aircraft accidents it became apparent that it was the human element that was mostly at fault. What is now known as – Human Factors.

How was it dealt with? By educating flight crew and then embedding effective human factors practice in ALL technical training. Although it took time, it is now completely accepted as part of the culture. Furthermore regular refresher training, feedback and assessment is given to flight crew on their flying skills and their interpersonal and cognitive skills to keep best practice at the forefront of their daily practice. In terms of appraisals these are taken very seriously.

If a pilot fails to meet the standards in either category of technical or non-technical skills he/she will be given further training and ultimately he/she can be removed from service. Just imagine if this took place to the same extent in healthcare and some other professions.

The fundamental point though is to understand error and the causes of error, and to accept them and to work with them. Humility is an essential part of professionalism. One of our clients (a large critical care unit in a major trauma centre) has recently contacted us to say how our training has had an impact on their team.

Furthermore we've been told that staff turnover has been reduced to a very low level indeed. These changes have been visible after in-depth Human Factors training and coaching, although they cannot be directly attributed of course.

Atrainability would be delighted to help any team or organisation delve further into their own short-comings and help to highlight their areas of success. Contact us for an informal, confidential discussion or alternatively enrol for our upcoming Open Courses listed here.
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ITV Tonight - Medical Blunders & other updates

ITV Tonight - Medical Blunders & other updates

Here at Atrainability, we're pleased to say it's been an eventful few weeks.

ITV Tonight: How Health & Social care can learn from Aviation.

I recorded an interview with ITV Tonight, Click here for Catch Up.or alternatively watch here. The programme is focused on Patient Safety and my suggestions were aimed at helping explain some of the elements that increase the chances of human error in health and social care. Part of the interview was filmed in-flight to demonstrate why checklists are a vital and completely accepted aspect of safety in aviation.

Fallibility is of course an inevitable, though sad facet of the Human Condition. Accepting that and helping to avoid, trap and/or mitigate error is fundamentally what we at Atrainability are concerned with. Although the programme focussed on the NHS, we would like to be clear that we know and understand that private providers make mistakes to. We'd be interested in hearing your thoughts on the subject. Tweet #ITVTonight @atrainability or get in touch.

The Glasgow Emergency Surgery and Trauma Symposium

It was a great pleasure to be invited to take part actively in the 2017 Glasgow Emergency Surgery and Trauma Symposium where I gained so much valuable insight into complex post trauma care from some truly World-leading experts in both clinical and non-clinical skills. The latter involved Professor Rhona Flin from Aberdeen University. All the faculty were honoured, in my case by the award of Membership of the Royal College of Physicians and Surgeons of Glasgow.

Coaching and Mentoring in the Operating Theatre

Now we are helping an NHS Trust further develop their non-technical teamworking in association with their LocSSIPS, by coaching and mentoring in operating theatres.

One aspect of this has been debriefing a successful emergency C-section. On first asking "why did it go well?" the answer from one of the senior nurses was that it has "just worked well". However, so much more learning is available with careful encouragement.

In brief, the team had been widely scattered across a large area of the hospital when they received the 'Crash Call'. They clearly moved rapidly and had no time to lose. They didn't do a formal briefing but had in fact accomplished one which they set to work. They shared plans, updated Situation Awareness and allocated tasks to the appropriate team member. A good job achieved and a healthy baby delivered safely.

The work is continuing with debriefing and feedback on specific areas such as checklist design, development and implementation with guidance on how to maximise safety. Much effective work is being pointed out and reinforced as well as some corrective advice.

The Society of Radiographers - 'Putting Patient Safety First'

"When it comes to developing and changing a culture...simple changes can make things better." - Naomi Burden, Quality & Governance Radiographer at Royal Cornwall Hospitals. Atrainability are very proud to have helped progress Human Factors awareness in Radiography. Read the full article.

New Masterclass

We're now offering An Introduction to Coaching and Mentoring workshop which has been developed by Atrainability's Ben Tipney. More information will be available shortly on our website but if you'd like to find out more please contact us.

As always, we're happy to discuss any challenges you are currently facing or answer any questions you might have about our Human Factors training.

Trevor and the Atrainability Team.

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Compassion Costs Nothing?

Compassion Costs Nothing?

Compassion; to empathise for others, to show you care; what does this cost in psychological and emotional terms? 

At my great age I just fell into a trap at a conference of agreeing that compassion costs nothing. How could I do that? The emotional cost of true empathy (as opposed to simple 'passive' listening) can be huge. It can be draining for those in caring professions - constantly feeling compassion and empathy for service users, patients and relatives - it takes its toll. This may explain why front line teams sometimes seem so dispassionate. Would they really have entered into such professions if that was what they truly felt?

What could have happened?

Well when we say "physician heal thyself" we tend to think of the physiological; food, water, putting ones feet up – if you like, the most obvious, visible signs of wellness. But when we consider the emotional and psychological toll that caring for others exerts it is in fact, blindingly obvious. What are we doing to provide our front line workers with the awareness and tools to handle the inevitable stress that comes with caring for unwell people? Do we even encourage ourselves or others to 'tune in' to our own emotional state, let alone put strategies in place for our own well-being?

We neglect our psychological and emotional wellness at our peril.

Atrainability have developed training to help deal with all aspects of wellness and stress. We're always available for an informal, empathetic chat to discuss your specific needs. Click here to contact us today.


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You don't have to put up with it.

You don't have to put up with it.

We recently ran a successful Open Course in Birmingham and the mix of participants that attended all shared their Human Factors challenges; which included typical problems such as not cross-checking adequately and some good situation awareness stories.

The best part about our Open Courses is that we get a good combination of people attending; recently we've had a room of blood bank teams, Ophthalmic surgery teams, Junior Doctors and Occupational Therapists - to name a few! All from different healthcare providers; travelling to our classes, openly sharing their experiences without fear of judgement and leaving with new found confidence and solutions that they can implement as individuals and within their teams.

For us as trainers, it's always interesting to have open discussions about the difficulties different individuals and teams are facing, but the reason we keep doing this is because we can see the changes in people after our training. 

For some, it's in the class; we call this 'the light-bulb moment' (more on this here) and for others it's a few days later, when they get in touch to tell us they just avoided an error because of our training techniques or they've found their confidence in speaking up to the staff member they were having communication issues with.


You may find it comforting to know that there are always similarities in each story, which is how we know we can help you.

Typical problems include: communication issues, dealing with difficult behaviours, poor attitude, situational awareness, briefing and debriefing effectively, stress and time management, poor leadership, hierarchy barriers, lack of feedback and confidence. All amount to how to learn from inevitable errors and successes without unnecessary blame.


So whatever challenge you are facing, know that there is a solution. Don't keep putting up with it, talk to us today about our next Open Course.

There's still time to book a last minute space on our London Open Courses next week and we're also taking bookings for London in February 2016. You can book a space for either of these through our website here or alternatively email us or call Trevor on 01483 272987 and we can discuss how we can help you further.


We look forward to hearing from you.

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I could have told you that

Many high-performing professionals make their job look easy. Well maybe not micro-surgery but aviation is a good example that it seems is widely misunderstood. I hear many people say "you pilots don't understand – we deal with sick people who aren't OK when we start treating them. You wouldn't get airborne in a plane that wasn't OK" 

Well pretty much of course not. But if only life were that simple! Pilots and for that matter cabin crew, are there for emergencies, generally unanticipated, often at periods of low arousal. Look at Kegworth – 1989 - routine flight Heathrow- Belfast - relaxed take-off and climb and suddenly an engine breaks apart. The crew, who must have been terrified, misidentify the problem and shut down the wrong engine. 47 people die.

Lessons learned? Well it is an imperfect World and the same essential error happened in Taiwan in January 2015. You will probably remember the horrific images of the plane with wings vertical crossing a bridge before plunging into the river killing 43. The error was the wrong engine shut down again.

However we all now accept that flying is significantly safer than any other form of transport taking into account the number of flights per annum. Things do go wrong but what helps prevent tragic potentially fatal accidents is training and preparation. Especially thinking ahead and discussing what could go wrong and having a plan in place for how it would be handled if it did. Think Captain Sullenberger and crew and the Hudson River successful outcome.

How often have you said with hindsight "I could have seen that coming" or "I could have told you that would happen"? Experience is a great learning tool but trial and error is simply not acceptable.

That seems to be what healthcare is doing though. There is still a general reluctance to learn day to day success, failure and near-misses.

This is what Human Factors training can aid such as how to share plans across the team and encourage input from everyone who might spot the impending threat and intervene for safety. Even more so when it comes to post-hoc debriefing discussions about what worked well and what could be improved.

When you get down to it aviation and health and social care is about risk management. Risk management is about Human Factors. Mental preparedness and appropriate hierarchy and open communication.

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Human Factors Training – Published evidence that it works!

We all know how challenging it can be to find good quality hard evidence that training teams and leaders in Human Factors awareness and skills enhances Patient Safety. Health Education England are seeking such evidence now for all forms of training. Quite right too. We have worked with various teams over the years notably at the University of Oxford with varying degrees of success. There are a plethora of published papers out there with our names on them. One of the arguments has been what to measure and I believe firmly that the only real measure is patient outcome. We have taken part in other recent research and I am led to believe that some further positive results will shortly be published. 

Some of you who have been with us a while will know that we were invited in to Newcastle Neurosurgery unit by Patrick Mitchell, the clinical lead, in 2006 where after some in-house training they had reduced the wrong-side error rate for cranial and spinal procedures dramatically (from 1 in 300) but then had a recurrence. 
The training consisted of putting all the direct theatre team and their immediate leaders through a one day interactive training course in understanding the problems around human behaviour and fallibility and practical solutions. This was supported by coaching to help embed the skills in practice. I think it is fair to add that two senior team members found it difficult to attend.
The result is now over 5 ½ years without a side error from a pre-intervention rate of 1 in 300! That is over 21,500 sided procedures in the unit with essentially the same entire team, although one of the senior clinicians did leave a couple of years ago – to concentrate on private practice.
 
The results have been published and is available to download freely - Click here to view full report in PDF format
 
I don’t believe it is unfair to say that the fundamental issues were around behaviour, especially team briefings and checklist discipline. Incidentally this was before the WHO checklist was published. Patrick Mitchell is a private pilot himself and has a clear understanding of the importance of checklists in safe performance. 
I would like to emphasise that the Atrainability team didn't achieve this –we simply helped the front-line team to build and maintain the confidence and skills to deal with the problems successfully. 
We encourage all our clients, colleagues and prospective clients to continue to seek and share evidence and best practice to improve Patient Safety for everyone. 
The Atrainability team are of course, very happy to explore further opportunities to develop solutions to human error, poor behaviour and help teams avoid avoidable harm.
 
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Human Factors are not just for Christmas

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.

 

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We promote what we tolerate.

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!

 

 

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