Embed Size (px)
DESCRIPTION
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. A Journey of Discovery. Start with the aim in mind - PowerPoint PPT Presentation
Citation preview
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
A Journey of Discovery
• Start with the aim in mind
• Did we really know what we wanted to achieve
• Organic and adaptive
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
First Steps
Strategy & Systems
Training
SAE & RCA
Culture & reporting
Hazard and risk identification
Contributory factors
framework
Patient Safety
A P S D
A P S D
A P S D
A P S D A P S D A
P
S D
A P S DIdentify opportunity for change
Plan
Test on very small scale
Test on larger scale/under different conditions
Sustain the change
Implement
Hold the gains
Spread
Our Approach to Improvement
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
A Human Factors Training Coursefor NHS Dumfries and Galloway.
Improving Reliability in Health Care
Jean RobsonDirector of Medical Education
and GP
Why?
• Foundation year doctors not reporting• Consultants not reporting• Nationally latent factors poorly identified
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.
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
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).
• 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.
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
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
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?
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 themTHIS MEANS THAT NHS DUMFRIES AND GALLOWAY IS
COMMITTED TO MAKING CARE MORE RELIABLE NOT TO BLAME
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
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
What did we do?
• Worked with DART training solutions initially• Adapted DART materials initially• Built a faculty• Wrote our own materials
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
The course
• Pre-course reading • 2 day course
FreeSafe 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
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
TopicsTopics covered
Medical Error understandingReliabilityHuman perceptionStressFatigueConflictCommunicationTeam workingLeadershipSituational awarenessDecision making
Tools coveredBriefsDebriefsHandoverChecklistsInductionStructured communication toolsCross training / SimulationRotasProtocols
Who comes?
• Managers• Doctors• Nurses• Pharmacists• Secondary care• Primary care• Health Board non-executives
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
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
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
introduce a pharmacist handover in dispensary and dept brief and
debrief each day
Compilation of a ‘hand-over’ check list at the overlap of each shift.
Intend to bring in a checklist for reviews with day hospital patients
Challenges
• Time – for us and for participants• Value • Tensions between reliability and learning
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
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
