Atrainability Blog

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

Human Factors & Patient Safety Updates (Oct18)

In this edition:
  • Civility Saves Lives
  • Group GP appointments - a breeding ground for error?
  • Waverley BIG Awards Finalist
  • Human Factors in Practice
  • Free conference this November

Civility Saves Lives

Civility when dealing with colleagues and patients may seem like stating the obvious, but sometimes what should happen in theory isn't what happens in practice. 

Civility Saves Lives is the self-funded, collaborative project led by Dr Chris Turner, a Consultant in Emergency Medicine. 

Why does civility matter? Uncivil behaviour not only greatly impacts the reciepent, but it is also proven to have an extended impact beyond the recipent. At Atrainability, we refer to this as 'Mood Contagion'. 

Many professionals have been on the receiving end of rudeness, belittling and bullying. Most are told or feel like 'that's just the way it is'; but if the NHS truly wants a Culture Change behaviours and attitudes at all levels need to adjust. The project aims to raise awareness of what can be done, whilst sharing stories from other professionals as well as relevant, evidence based academic papers.

Atrainability's Trevor Dale has recently been speaking about the importance of civility at Patient Safety Collaborative for Kent, Surrey & Sussex. If you'd like to find out more about how Human Factors training and Civility fit hand in hand, request more information by emailing team@atrainability.co.uk. 

We also highly reccomend taking some time to look at Christine Porath's work. Her book 'Mastering Civility - A Manifesto for the Workplace' has recieved excellent reviews in The New York Times as well as from high profile authors and leaders.



​Group GP appointments - a breeding ground for error?

There has been a recent report about the NHS considering group GP appointments as an option to help alleviate the waiting time for patients and in an attempt to manage the growing shortage of GPs.

 Although further details on this are needed, we at Atrainability believe that this could very well be a potential breeding ground for Human Factors error, our main concerns from a Human Factors perspective include:


 • BEHAVIOUR & COMMUNICATION: The patient relationship with their GP, being confident to raise real concerns. How does the GP manage a room with some extraverted (verbose) people and some introverted (more private & more inwardly driven)?


 • SITUATION AWARENESS: Potential error when adding correct patient notes to correct individual files - how will this be managed from a group sessions?


 • CONFIRMATION BIAS: A group may have similar symptoms, but will this lead to the same path of care? The correct diagnosis? Could things be missed? 


Are you a GP? 

We'd appreciate your thoughts on the subject. Email us in confidence: team@atrainability.co.uk.



​Waverley BIG Awards Finalist


You may know that we've been training health and social care teams across the UK for the last 16 years, however you may not realise that we're classified as a small business. Which is why we are delighted to have been selected as a finalist for Waverley's B.I.G Awards 2018 in the category of 'Customer Delight'. We'll keep you updated on the results which will be announced on 19 October.


​Human Factors in Practice


We were recently copied in on communications from a client to another organisation who were enquirying about our services. We have been granted permission to share this with you: 

Sent 19 September 2018 
Subject: Human Factors in practice 

Hi __________ I'm sorry to have taken so long to reply. We are six weeks in to our annual CQC inspection activity – what is perverse is I am responding to you on today of all days as today is the first day of the actual well-led inspection! 

I have to say, embracing Human Factors was the start of our journey and absolutely the right place to start. There is no other way to, in NHS terms, make the shift from compliance to continuous improvement, or it is likely you would regress back to a compliance focus. Embracing Human Factors tackles capability, by that we mean confidence, competence and capacity. Most other approaches cannot do this and that means you lose staff engagement from the outset. 

I am glad to hear that you are looking to improve the safety culture in your organisation. That shows a lot of insight on your part – a lot of organisations tackle just "culture", which then takes things down an OD direction. Also, culture is a funny term, we do need to break it down into its component parts and Human Factors tackles component parts that other approaches cannot. 

As a direct consequence of our Human Factors work, we have now moved away from audit to improvement and now each team is worked with, as an MDT, to look at their safety performance and we also undertake a patient safety culture survey. This has revealed things to us that our typical assurance mechanisms have not, e.g. we would assume our incident reporting profile equals a safety positive culture, but perception of staff shows that there is still work to do. 

We have used The Health Foundation Model to help us improve how we measure and monitor safety, however having been on the journey, you can't just implement that, Human Factors needs to be grounded in all you do first. I have seen many organisations where Human Factors becomes something that is led by OD and becomes associated with "communication" – Human Factors is much more than that. 

Taking a look at your organisation, it looks like not only do you have a similar profile to us but your CQC ratings are almost identical. We are rated Outstanding for Caring which we put down to, in part, our work in relation to Human Factors. The Safe domain is always a difficult one to shift – let's hope this inspection changes that! Feel free to come and see us or we will come and see you, if you have any questions. We are also open to partnering on things. However I would revisit offers from Human Factors providers first as that really is the foundation. 

Of course my experience is of using Atrainability and there are many reasons for that, aforementioned, in-house approaches risk this being seen as a communication thing, whilst other companies do not tap into the SME that experts in the airline industry have. We have used Atrainability to train what we call "culture carriers" or then have spread and sustained this approach in what has then developed into our patient safety improvement (safety management system) work. 

Atrainability also did two bespoke sessions with our Board, as that demonstrated to our staff the commitment of the Board. So I would suggest you need a programme of works that tackles all levels of the organisation for this to work – we didn't know it at the time, but we used the dosing model which you are probably familiar with. That will help you present any proposals to your Board as this is an evidence based way of building capability in a sustainable way. 

Good luck on your Human Factors journey! 

David Wood, 
Associate Director of Safe Services Cheshire & Wirral Partnership NHS FT


​Reminder! Free Future of Healthcare Conference this November


​Atrainability are 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 The Future of Healthcare Conference, which is free to attend event on 6 November in Exeter. 

The conference brings you speakers from a wide spectrum of specialties. The aim is 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.

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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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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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