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

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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Human Factors - common sense made conscious

We have begun a major training programme at a large private healthcare provider in London where all staff are attending an initial very short introductory module on Human Factors. 
The content is limited to why the subject is relevant to them all, some explanations of why we are all fallible and a few practical takeaway tools on how to try and avoid things going wrong. The long term plan is to continue to work together and build a sustainable high reliability organisation with safety at its core. 
Later in the Autumn it will include training trainers and champions to embed safe policies and procedures and seek to support staff.
The Director of Nursing had been actively seeking such training and has been a fantastic advocate, but the clincher was getting to present to the Board. 
The Chief Executive is a smart no-nonsense lady. I asked her and her senior colleagues if they knew what Human Factors is. Her instant response "well it's just common sense". Of course it is, but the trick is how to bring that to the conscious brain when faced with all the pressures and hazards of everyday work life.
That is where we seem to be helping judging by the feedback from the attendees. They love the simple messages and that we are talking their language.
Mind you it's quite a challenge with each class containing up to 30 from every area in the Hospital from finance through reception to ITU and theatre teams.
It is fun, engaging and at first sight seems to be making a tangible difference. 
Here is an example of unsolicited feedback from an ODP in paediatric theatres:
 
"I just wanted to say how much I enjoyed the training session. I think Ben delivered a really good session and I personally learned a great deal. It has given me some good ideas of ways we can improve our day to day practice within our department and has inspired me to look further into the human factors training principals and background.
If you could pass my thanks on to him that would be appreciated."

The icing on the cake, though, is that the Executive Board are all attending alongside all the 600 staff. 
Now that shows what leadership should be and will undoubtedly have a profound positive effect.

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Reporting Near Misses - Untoward Incident or Known Complication?

The benefits of reporting near misses are surely beyond dispute. Each close shave is a learning opportunity which should be shared with others. Does every doctor need to experience problems first hand and patients endure possible harm in order to gain a high level? 

I have recently heard of an incident in maxilla-facial surgery which has disquieted me. A senior consultant decided to perform two lengthy operations in one day and incur a significant overrun to the detriment of the theatre teams. It had been possible to ask a fellow senior surgeon to take on one case and indeed such an offer had been made. The offer was impolitely refused.
The second procedure was commenced at 4 pm and involved a neck dissection. Unfortunately a small tear was made in the lower end of the jugular vein where it joined the subclavian vein. The anatomy was non-normal in that the vein was above the clavicle rather than under.
 
There was considerable haemorrhage which was not controllable. Vascular surgeons were called and the vessel was approached from the anterior chest wall, but were unable to control the bleeding. Eventually orthopaedic surgeons were called to divide the clavicle and the tear was over-sewed. The patient lost 18 units of blood and the cell-saver was used successfully to replace lost blood. The anaesthetist performed very well in difficult circumstances.
 
What could be learned?

The surgeon did not consider this a reportable incident and indeed was most vociferous in wishing it not to be reported. One must ask why? Does it indicate fear of the local culture? Or is it something more ego-driven?
 
What would you consider the professional response?
 
Surely if this is a recognised non-normal anatomical situation it should be shared to help junior doctors learn to avoid it happening to them?
 
How can we make it ‘safe’ to report near-misses and move the whole culture closer to the aviation model where incident reporting is actively encouraged? 

We specialise in training for debriefing to learn. Blame serves little useful purpose unless people are wilfully ignoring rules and due process.
 
Training utilises the greatest resource – a team member who may have made a mistake despite trying their best not to. What a resource to help the whole organisation learn! Shame to waste it.

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Lighting the Blue Touchpaper

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!

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Real positive change at the frontline

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  Communication

Ø  Dealing with difficult people

Ø  Leadership & team-working

Ø  Briefing & Checklists

Ø  Debriefing for Learning

It 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.
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