Building teams for safer careThe Productive Operating Theatre

TM

The challenge of organising national human factors training

Hugh Rogers FRCSConsultant UrologistSenior Associate, NHS Institute

How The Productive Operating Theatre has been developed

Understand the real issues and challenges.

Identified co-production partners

Observing and enquiring in high risk and lean organisationsTerminal 5, Unipart Other healthcare settings, USA

Generated and tested lots of ideas with the ‘field test sites’

Test the ideas as prototypes with the ‘Associate sites’

Consolidate the learning, consider delivery mechanisms,Publish & launch

Internal & external peer review. Regular learning sets

Ongoing ROI and benefits realisation capture

Launch in Sept 2009, followed by regional start-up events for NHS England

Since April 2010 initiated 10 cohorts of training and implementation support to 90 of 174 acute trusts in NHS England.Delivered Master Training internationally in Wales , Scotland, New Zealand and Northern Ireland. Coming to Australia, Canada and South Africa etc

We tested different approaches

• Commissioned HF training• On site coaching• Structured observations• Safety attitudes

questionnaires• Key interventions:

• Brief and de-brief• WHO checklist• SBAR

We wrote the guide (‘module’)Then we designed our own training

Outline workshop agendaLots of interactive elements, multi-media and group work

Psychologist + clinician

• How unsafe is healthcare• frequency of harm• complexity of disaster

• The psychology bit• humans as hazards and heroes• how errors occur• self-awareness exercise

• Implementation• the model for improvement• action planning

Examples:

Wrong Engine Kegworth Jan 1989

The complexity of disasters

Wrong Kidney LlanelliFeb 2000

‘The psychology bit’ Eight key human factors

Situation awareness

Also:• Colour changing card trick• Smoke filled room• The door

Merrill & Read

Analyticalformalmeasured + systematicseek accuracy / precisiondislike unpredictability and surprises

Driverbusiness likefast + decisiveseek controldislike inefficiency and indecision

Amiableconformingless rushed + easy going seek appreciationdislike insensitivity and impatience

Expressiveflamboyantfast + spontaneousseek recognitiondislike routine and boredom

Personal styles Controlsemotions

Ask Tell

Showsemotions

See the Improvement Leaders Guide

Implementation: The Model for Improvement