1. From implicit to explicit recognition of the value of Human Factors Education in NHS Dumfries & Galloway
Maureen Stevenson
Patient Safety & Improvement Manager
Jean Robson
Director of Medical Education

2. A Journey of Discovery Start with the aim in mind
Did we really know what we wanted to achieve
Organic and adaptive

3. All Aboard Clinical Governance Risk Management
Adverse Event Management
The care environment
Making your care and work safer
Systems
Understanding why things go wrong
Understanding the importance of context and culture
Teamwork
Environment & Process Design
To Err is Human
An Organisation with A Memory
Charles Vincent
James Reason – Swiss cheese, organisational accident model
Error v’s harm

4. First Steps Patient Safety Strategy & Systems Training SAE & RCA
Culture & reporting
Hazard and risk identification
Contributory factors framework
Patient Safety
Putting the stripe in the toothpaste
RM Process – Identify, assess, analyse, treat or control or eliminate. Communicate

6. Our Approach to Improvement
Spread
Hold the gains
Implement
A P S D
A P S D
Sustain the change
Test on larger scale/under different conditions
A P S D
A P S D
Test on very small scale
These are some of the steps that you may go through on an improvement project. Depending on the initial objectives of an improvement project, and their relevance beyond the team that initiated the project, you may go through some or all of these.
Last time we focussed on the first 3 steps. Now we are briefly going to look at the others, with particular reference to measurement.
PDSA cycles are a feature of ALL stages in the journey.
Plan
A P S D
Identify opportunity for change
A P S D
A P S D

7. Full steam ahead Safety Culture & Acceptance
Non technical skills training
Learning from error
Improvement Science & Process Design
Checklists & Briefings
Design & the physical environment
Human Factors Training

8. On the journey

9. Jean Robson Director of Medical Education and GP
A Human Factors Training Course for NHS Dumfries and Galloway. Improving Reliability in Health Care
Jean Robson
Director of Medical Education
and GP

10. Why? Foundation year doctors not reporting Consultants not reporting
Nationally latent factors poorly identified

11. Conclusions from FY Questionnaire
Knowledge is reasonable
Experience could be improved - not all involved in discussion, and not all given feedback, not convinced that those reporting are treated fairly
Majority of incidents are not reported.

12. Known factors in failure to report PSIs
Staff anxiety about impact
Fear of legal ramifications
Concern about upsetting others and exposing one’s own vulnerability
Belief that professionalism = responsibility
Near misses
Inexperience
Lack of training
Early stage of training
Cumbersome reporting systems
Being temporary staff, including those in training

13. What causes Junior Doctors Stress?
Stressors in residents include relationships with seniors and making medical mistakes (Satterfied JM and Becerra C)
The most frequently expressed emotions in residents are guilt, anxiety, and fear. Guilt usually triggered by not performing competently (Satterfied JM and Becerra C)
Medical errors are a threat to professional identity as well as safety (Dixon-Woods M et al).

14. Unable to generate enthusiasm for sharing concerns, errors or near misses.
Some become enthusiastic about patient safety when they work with an enthusiastic team.
But that generating interest across an organization is difficult.

15. Social Identify Approach.
Henri Tajfel – Social identity theory – to individuals belonging to a group is important in terms of self-esteem
John Turner – self-categorization theory - belonging to a group means buying into the behaviours, and attitudes of the group

16. Self-categorization for FY1
“Attaining a medical qualification is not enough for individuals to regard themselves as doctors, they need to feel that they have the skills and attributes that they associate with that group” Burford 2011

17. What does this mean for Patient Safety?
Does the fact that FY1s are developing a self-view which fits them into the category “Doctor” make it more difficult to say “this could have gone better”?
Is it all trainees?
Does reporting their mistakes inhibit their development of the new self-view?

18. What we needed to do Convince people that reporting was worthwhile
Convince them that reporting is what “good” clinicians do
Convince them that NHS D&G BELIEVES that our staff come to work aiming to do a good job
And that when they make mistakes we really want to understand latent factors and address them
THIS MEANS THAT NHS DUMFRIES AND GALLOWAY IS COMMITTED TO MAKING CARE MORE RELIABLE NOT TO BLAME

19. Hopes
Increase the understanding of human factors across the organisation
Ensure a focus on developing reliability
Wanted a “credible” course to convince people to take 2 days out
Wanted to take people out for 2 days and immerse them in it

20. What did we need? Money- for set up costs
Time - for those enthusiasts to develop and deliver course and participants to attend
Knowledge – for a faculty
Materials – to deliver

21. What did we do? Worked with DART training solutions initially
Adapted DART materials initially
Built a faculty
Wrote our own materials

22. Course Objectives
Understand the value of recognising Human Factors in medical error causation.
Consider the performance influencing factors in which precipitate error and limit reliability
Develop strategies to reduce medical error and improve reliability
Know how to use recognised tools to improve reliability
Also note that need to be able to train to improve resilience as well as reliability

23. The course Pre-course reading 2 day course Free
Safe environment – group rules
Mixed groups
Ban interruptions
Free lunch
Cover the factors which increase chances of humans making errors
AND methods to mitigate against this.
CME approval from Royal College of Anaethetists

24. Learning Methods
Learning Environment - Start with an example of something that has gone wrong for me
Small group
Stimulate dissonance – pre course reading and homework
Lectures with lots of examples from faculty
Encouragement to share
Games – fun
Actions to take away

25. Topics
Topics covered Medical Error understanding Reliability Human perception Stress Fatigue Conflict Communication Team working Leadership Situational awareness Decision making
Tools covered Briefs Debriefs Handover Checklists Induction Structured communication tools Cross training / Simulation Rotas Protocols

26. Who comes? Managers Doctors Nurses Pharmacists Secondary care
Primary care
Health Board non-executives

27. Feedback
Very positive – like multidisciplinary approach, like some activities, thought provoking, think everyone should do it. But some comment that it is a lot in 2 days!
Asked to help with sessions for departments or groups- GP trainers, X-ray team, risk managers, GPs, pharmacists

28. Things people intend to do when asked some time after the course
we are now more inclined to share and discuss with the rest of the team, errors that we have made
introduce a pharmacist handover in dispensary and dept brief and debrief each day
Intend to bring in a checklist for reviews with day hospital patients
We pilot our new audit of protocols in a small number of patients ahead of implementing them fully to find out what might go wrong and what unintended consequences might arise from our work
Compilation of a ‘hand-over’ check list at the overlap of each shift.

29. Challenges Time – for us and for participants Value
Tensions between reliability and learning
Avoiding second check becoming first check- resilience threat- tendencey to move away from safe practice

30. Where next? More people doing it!
Full 2 days for people in leadership positions, shorter course for others???
Add module on patient involvement?
Should it be part of mandatory training?????
Half day workshop for Health Board?
Mitigating against lost learning from error – feedback / reliability / resilience

31. Summary Evidence of need for Board wide training Needed to be credible
Needs to be safe
It needs to be enjoyable and seen as worthwhile
Important to be multidisciplinary
Important to cover tools to support change
Helps to identify some changes that participants can go away and implement