Why we need to be more serious about acknowledging human limitations. (Guest blogger)
Hello, I'm David Wood – Associate Director of Safe Services at Cheshire and Wirral Partnership NHS Foundation Trust (CWP).
As a provider of Mental Health and Physical Health Community Services, healthcare of the types we deliver are essentially based on face-to-face human encounters; which are relatively low technology.This means that the people who deliver our services regularly manage risk autonomously and in environments which are anything but controlled.Now that's a challenge!
My working environment, on the other hand, is much more controlled (even if my day-to-day work is less so).Recently I found myself making a number of ill judgements which, whilst they did not cause any harm, troubled me greatly as I could not rationalise why; in effect, I had "lost control".Only days later, after attending an NHS Leadership Academy event, did I realise I needed to apply a degree of self compassion and accept that it was the pressured situation I was in; which included being distracted by factors at home, that compromised my decision making and my performance (having exacting standards and expectations of myself does not help, as anyone who works with me will tell you!).None of us has an internal switch; we bring our whole selves to work.
So, Human Factors are exacerbated by high pressure situations and mental workload, where we are all fallible.My learning was that to mitigate potential adverse impacts of this, you need to be self-aware. If you have distractions, in your work or home life (or both) even if you think you have "parked them", consider yourself at a greater risk of making a mistake. There are some tactical steps you can take; why not read Implementing human factors in healthcare for some tips.
The important thing to acknowledge here, as in my situation, is that the vast majority of people do not act with the intention to make a mistake, to cause harm, or not wanting to do the right thing – quite the contrary.The hazards that apply in working in either controlled environments or not, are making decisions in dynamic and intense situations.In a complex working environment like health, this problem is not going away!
There needs to be a coherent plan (to embed Human Factors training) underpinned by, as we'd argue in CWP, a long-term patient safety cultural campaign; in order to develop a positive patient safety culture.Both these things require high level leadership.We invested in our very own campaign called #CWPZeroHarm, to tackle unwarranted variation and improve reliability; supported by cultural change to empower us to put patient safety, clinical excellence and patient-centred care at the heart of all we do.The campaign promotes the idea that everyone, before they act, should "Stop, Think, Listen".These same principles of "stopping", "thinking" and "listening" happen to be one way of looking at mitigating the potential adverse impacts of Human Factors.
Part of our investment was in Human Factors training from the Board to those providing direct care.We have also recently invested in our own simulation suite, which will include mock-ups of care settings like people's own homes, to predict "what could go wrong". We have done this as we know simulation is highly effective in creating learned responses to situations, where pressure may affect a person's ability to think as clearly as they normally would. Key to this is training as teams wherever possible - Human Factors based team working is essential to promote safer care.
We have achieved many other things by applying Human Factors principles and practices.In the main these have come from the pledges made by what we call our Human Factors "culture carriers" – people who attended Human Factors awareness sessions and pledged to implement changes in their workplace.Examples include simple changes such as implementation of briefing, debriefing and safety case reviews; through to more ambitious changes such as enhancing clinical audits and reflective review processes, to capture the impact of Human Factors practices and therefore demonstrably improve safety in a number of critical areas - for example reducing the incidence of physical restraint by well over 50% and on a sustained basis.
Why do we need to be more serious about acknowledging human limitations? Well, when decision making is compromised this can significantly impact on the quality of care, clinical outcomes and potentially cause harm to both people who access and deliver healthcare.This all increases costs.This is where Human Factors offers ways to minimise and mitigate human limitations, and so reducing error and its consequences.
Healthcare has a lot to learn from systems which promote safety in high reliability industries like the aviation and nuclear industries.I'd like to see a system-wide adoption of Human Factors concepts to empower the whole care system. I was therefore pleased to be a consultee of Health Education England in exploring how Human Factors practices and principles can be included in the curricula and training frameworks for health professionals.This resulted in what I think is a milestone publication Improving Patient Safety Through Education and Training.
I will be working again with HEE's "Learning to be safer" programme on 14 July (2016) to develop plans to implement the Commission on Education and Training, for Patient Safety's twelve far-reaching recommendations, on improving patient safety through education and training.I hope that the key output will be tactical steps to ensure that Human Factors is not something that's standalone, rather it's something "we all do around here", as part of the design of processes, jobs and training.
The HEE cannot do this alone; all of us, no matter what level we are in the system need to commit to embedding an understanding of Human Factors.
We're in this together.Human Factors awareness has improved, but more needs to be done to make it our everyday business in delivering reliably safe healthcare.Good luck on your Human Factors journey!
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About our guest blogger:
David Wood is currently Associate Director of Safe Services at Cheshire and Wirral Partnership NHS Foundation Trust.His role is to lead the Trust strategically in relation to a portfolio of clinical and corporate governance, compliance, assurance and regulation which effectively contributes to the Trust's delivery of safe services.
He graduated from Keele University with a first degree in Biomedical Sciences and his career since has spanned 15 years during which time he has been employed in many diverse areas within the NHS, substantially in senior clinical governance lead roles (including North Staffordshire, Cambridgeshire, Cheshire/ Wirral) within mental health and learning disability services, primary care and community physical health services.
David has professional interests in strategic approaches to healthcare quality, and more recently professional practice including leadership, development and change as part of his Master of Science degree in Professional Studies.His dissertation was on early warning and pre-emptive systems to improve the safety of patients and reduce avoidable harm, graduating from the University of Chester in 2013 with a distinction.
David has a demonstrable track record in clinical quality and governance with extensive experience of quality improvement and change through strategy development and implementation.He was a former longstanding member of the Department of Health hosted National Audit Governance Group, is a professional reviewer of the standards of inpatient mental healthcare through the Royal College of Psychiatrists' Accreditation for Inpatient Mental Health Services initiative, and a regular Healthcare Quality Improvement Partnership consultee. David has recently become a director of assurance representative on the NHS Providers Quality Reference Group.