Presentation on theme: "From implicit to explicit recognition of the value of Human Factors Education in NHS Dumfries & Galloway Maureen Stevenson Patient Safety & Improvement."— Presentation transcript:
1 From implicit to explicit recognition of the value of Human Factors Education in NHS Dumfries & GallowayMaureen StevensonPatient Safety & Improvement ManagerJean RobsonDirector of Medical Education
2 A Journey of Discovery Start with the aim in mind Did we really know what we wanted to achieveOrganic and adaptive
3 All Aboard Clinical Governance Risk Management Adverse Event ManagementThe care environmentMaking your care and work saferSystemsUnderstanding why things go wrongUnderstanding the importance of context and cultureTeamworkEnvironment & Process DesignTo Err is HumanAn Organisation with A MemoryCharles VincentJames Reason – Swiss cheese, organisational accident modelError v’s harm
4 First Steps Patient Safety Strategy & Systems Training SAE & RCA Culture & reportingHazard and risk identificationContributory factors frameworkPatient SafetyPutting the stripe in the toothpasteRM Process – Identify, assess, analyse, treat or control or eliminate. Communicate
6 Our Approach to Improvement SpreadHold the gainsImplementA P S DA P S DSustain the changeTest on larger scale/under different conditionsA P S DA P S DTest on very small scaleThese 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.PlanA P S DIdentify opportunity for changeA P S DA P S D
7 Full steam ahead Safety Culture & Acceptance Non technical skills trainingLearning from errorImprovement Science & Process DesignChecklists & BriefingsDesign & the physical environmentHuman Factors Training
9 Jean Robson Director of Medical Education and GP A Human Factors Training Course for NHS Dumfries and Galloway. Improving Reliability in Health CareJean RobsonDirector of Medical Educationand GP
10 Why? Foundation year doctors not reporting Consultants not reporting Nationally latent factors poorly identified
11 Conclusions from FY Questionnaire Knowledge is reasonableExperience could be improved - not all involved in discussion, and not all given feedback, not convinced that those reporting are treated fairlyMajority of incidents are not reported.
12 Known factors in failure to report PSIs Staff anxiety about impactFear of legal ramificationsConcern about upsetting others and exposing one’s own vulnerabilityBelief that professionalism = responsibilityNear missesInexperienceLack of trainingEarly stage of trainingCumbersome reporting systemsBeing 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-esteemJohn 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 doConvince them that NHS D&G BELIEVES that our staff come to work aiming to do a good jobAnd that when they make mistakes we really want to understand latent factors and address themTHIS MEANS THAT NHS DUMFRIES AND GALLOWAY IS COMMITTED TO MAKING CARE MORE RELIABLE NOT TO BLAME
19 HopesIncrease the understanding of human factors across the organisationEnsure a focus on developing reliabilityWanted a “credible” course to convince people to take 2 days outWanted 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 attendKnowledge – for a facultyMaterials – to deliver
21 What did we do? Worked with DART training solutions initially Adapted DART materials initiallyBuilt a facultyWrote our own materials
22 Course ObjectivesUnderstand the value of recognising Human Factors in medical error causation.Consider the performance influencing factors in which precipitate error and limit reliabilityDevelop strategies to reduce medical error and improve reliabilityKnow how to use recognised tools to improve reliabilityAlso 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 rulesMixed groupsBan interruptionsFree lunchCover the factors which increase chances of humans making errorsAND methods to mitigate against this.CME approval from Royal College of Anaethetists
24 Learning MethodsLearning Environment - Start with an example of something that has gone wrong for meSmall groupStimulate dissonance – pre course reading and homeworkLectures with lots of examples from facultyEncouragement to shareGames – funActions to take away
25 TopicsTopics covered Medical Error understanding Reliability Human perception Stress Fatigue Conflict Communication Team working Leadership Situational awareness Decision makingTools covered Briefs Debriefs Handover Checklists Induction Structured communication tools Cross training / Simulation Rotas Protocols
26 Who comes? Managers Doctors Nurses Pharmacists Secondary care Primary careHealth Board non-executives
27 FeedbackVery 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 madeintroduce a pharmacist handover in dispensary and dept brief and debrief each dayIntend to bring in a checklist for reviews with day hospital patientsWe 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 workCompilation 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 learningAvoiding 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 safeIt needs to be enjoyable and seen as worthwhileImportant to be multidisciplinaryImportant to cover tools to support changeHelps to identify some changes that participants can go away and implement