Human Factors Roundtable Event Met Suite, Leeds Metropolitan Hotel 13 th January 2016 e: academy@yhahsn.nhs.uk/ t: 01274 383926 www.improvementacademy.org Or visit our Academy Office: Bradford Institute for Health Research Temple Bank House / Duckworth Lane / Bradford / BD9 6RJ
Part of the Yorkshi Part of the Yorkshi kshire kshire e & Humber e & Humber ber AHSN ber AHSN Welcome Professor John Wright e: academy@yhahsn.nhs.uk/ t: 01274 383926 www.improvementacademy.org Or visit our Academy Office: Bradford Institute for Health Research Temple Bank House / Duckworth Lane / Bradford / BD9 6RJ
Housekeeping
Twitter hashtag #humanfactors
Morning Programme 10:20 The concept of human factors – Gerry Armitage 10:50 Mapping the terrain of human factors – Debbie Clark 11:20 Refreshment Break 11:35 Optimising safe performance – Rebecca Lawton 12:15 Human factors education – Debbie Clark/ Wayne Robson 13:00 Lunch #humanfactors
Afternoon Programme 13:45 Open Space – Whole Group 15:30 Gina’s Story – Lee Cutler 16:15 Next Steps – Debbie Clark 16:30 Close #humanfactors
Community of Practice on Human Factors Invitation to explore your interest in developing and/or participating in a CoP on Human Factors Join and explore the CCN Network HERE www.ia-cocreationnetwork.com Follow on Twitter @CCNetworkcom #CCNetwork
Introductions #humanfactors
The concept of Human Factors Professor Gerry Armitage University of Bradford and Bradford Institute for Health Research #humanfactors
Plan • Two illustrations • Definitions • Further reading
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ber 25 th th 1415 Aginco incourt urt Oc Octo tober 1415 • Local conditions • Skill mix • Equipment • Team or organisational culture #humanfactors
A more recent series of medication errors – 2011-12 • Penicillin to known penicillin-allergic patients • Involuntary automaticity; double checking • ‘B usiness rounds’ • Whole team responsibility #humanfactors
International Ergonomics Association (IEA) defines (ergonomics or) human factors as: ‘. .concerned with the ..interactions among humans and other elements of a system, and applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance ’ #humanfactors
Clinical Human Factors ‘ enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities, and application of that knowledge in clinical settings’ Ken Catchpole, 2010 #humanfactors
Further reading • Russ AL et al. The Science of Human Factors: separating fact from fiction . BMJ Quality and Safety 00 1-7. 2012 • Dekker S. Patient Safety: a human Factors approach . CRC/Taylor and Francis. 2011 #humanfactors
Mapping the terrain of Human Factors Debbie Clark #humanfactors
Session Overview • Look at range of HF applications in healthcare • Case study of applying some of these applications in Rotherham A&E Department • Table exercise on applying HF in you own ward, department or organisation #humanfactors
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Rotherham A&E Example • Rotherham A&E – a typical District General Hospital A&E with 70,000 patients per year • Over a year ago, a number of standard safety mechanisms and some simulation training were in place • Consultant working with two Simulation Fellows decided to: – take an overview of the existing situation from an HF viewpoint – look at the opportunities for incorporating more HF principles to improve patient safety #humanfactors
Rotherham - Existing Situation Training Working Practices Quality and Risk Management In situ Simulation Policies Quality and Safety Monthly 2hr rolling program Escalation guidelines Metrics 1/2hr quality improvement Clinical Guidelines: session CEM Audit Program - Regular updates TARN -Emergency guidelines on wall in resus: cardiac arrest, Mortality review: trauma team etc. Simulation Courses Incident reports Multidisciplinary: CRUMPET EM trainees: ACCS, CT3 paeds Checklists and ST4 courses Simulation Faculty Guided by risk assessment: Sedation, sepsis Actions from incidents Improvement actions: checklists, Human Factors guidelines , in situ sim , audit Training Feedback to staff, M and M Handover, briefing meetings Simulation as above and debriefing Standard text = existing
Potential HF Interventions Training Working Practices Quality and Risk Management In situ Simulation Policies Quality and Safety Monthly 2hr rolling program Metrics Escalation guidelines Weekly 1/2hr quality Clinical Guidelines: CEM Audit Program improvement session - Regular updates TARN Mock Arrest -Emergency guidelines on Mortality review: avoidable deaths wall in resus: cardiac arrest, trauma team etc. Incident reports including harm/no Simulation Courses harm ratio Senior review guideline Multidisciplinary: CRUMPET Safety attitude survey EM trainees: ACCS, CT3 paeds Pneumonia care bundle audit Checklists and ST4 courses Quality and Safety Suggestions Box Simulation Faculty Guided by risk assessment: Sedation, sepsis, first fit, discharge etc. Human Factors Actions from incidents Training Weekly 1/2hr quality Improvement actions: checklists, Simulation as above guidelines, posters, in situ sim, Handover, briefing briefing, audit E learning module and debriefing Feedback to staff: lesson of the Workshops week, summary information , M and Formal handovers using tool M meetings Teamwork Training and Safety briefing (daily) Handbook: Team STEPPS Must reduce risk whilst balancing Debrief following incidents unintended consequences Safety Notices and posters HF Work Based Assessment
Progress Training Working Practices Quality and Risk Management In situ Simulation Policies Quality and Safety Monthly 2hr rolling program Metrics Escalation guidelines Weekly 1/2hr quality Clinical Guidelines: CEM Audit Program improvement session - Regular updates TARN Mock Arrest -Emergency guidelines on Mortality review: avoidable deaths wall in resus: cardiac arrest, Incident reports including harm/no trauma team etc. Simulation Courses harm ratio Senior review guideline Multidisciplinary: CRUMPET Safety attitude survey EM trainees: ACCS, CT3 paeds Pneumonia care bundle audit Checklists and ST4 courses Quality and Safety Suggestions Box Simulation Faculty Guided by risk assessment: Sedation, sepsis, first fit, discharge etc. Human Factors Actions from incidents Training Weekly 1/2hr quality Improvement actions: checklists, Simulation as above guidelines, posters, in situ sim, Handover, briefing briefing, audit E learning module and debriefing Feedback to staff: lesson of the Workshops week, summary information , M and Formal handovers using tool M meetings Teamwork Training and Safety briefing (daily) Handbook: Team STEPPS Must reduce risk whilst balancing Debrief following incidents unintended consequences Safety Notices and posters HF Work Based Assessment
Conclusion • There is some HF thinking behind a number of existing practices. This HF component can be increased • There are opportunities to introduce new HF focussed practices such as checklists, culture surveys and safety huddles • Don’t try to do everything - use a survey, incident reports and other intelligence to choose a few key interventions to focus on #humanfactors
Table Exercise • Look at ‘HF methods and applications’ handout • Consider what you are currently doing in your Ward/Department/Trust (5mins) • Consider HF areas you could/should/must move into (5mins) • Feedback from tables (5mins) #humanfactors
Refreshments and Networking #humanfactors
Optimising safe performance through research Professor Rebecca Lawton #humanfactors
safety? Improving patient care
Assumptions that underpin our work • Every human being is fallible • Certain conditions make fallibility more likely • Not only do we fail unintentionally, we intentionally deviate from prescribed practice • Only a tiny minority of people engage in deliberate sabotage • Our work focuses on optimising the conditions and supporting staff to do the right thing #humanfactors
What does safe performance look like? • Full compliance with evidence based protocols/guidelines - • Error free practice • A team who question and seek to improve • A state of continuous monitoring and responding to local circumstances……. RESILIENCE • A team who are happy, support one another and strive to deliver patient-centred care #humanfactors
The Yorkshire Contributory Factors Framework (Lawton et al., 2012) Lawton e
Supporting staff to do the safe thing A behaviour change approach #humanfactors
An example: The case of nasogastric tubes • Audit September 2005-March 2010 of incidents relating to misplaced nasogastric tubes • 2011 NPSA issued a patient safety alert on the safe use of nasogastric tubes #humanfactors
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