Human Factors & remote islands considerations

Quality Education for a Healthier Scotland

Multidisciplinary

Human Factors & remote islands considerations

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

mark.johnston@nes.scot.nhs.uk0131 656 3258

Workspace

Culture

Organisation

TaskTeamwork

Behaviours and AbilitiesAdapted from Catchpole

@markjohnston71

Quality Education for a Healthier Scotland

MultidisciplinaryPre-requisite and/or reflective learning

E-learning course (for details see handout)

• Introduction to Patient Safety• Managing Human Error

Suggested reading and resources (for details see handout)

Quality Education for a Healthier Scotland

Multidisciplinary

Learning Outcomes

At the end of the session you will be able to

• Define Human Factors • Describe how factors impacting on an individual may increase

the likelihood of error• Explain the systemic factors that increase the likelihood of error

During the session you will

• Participate in discussion with delegates

Quality Education for a Healthier Scotland

MultidisciplinaryHow safe is healthcare?

What percentage of patients entering acute care will suffer an adverse event?

NES 2013

The picture in primary care…

• 11% of prescriptions may contain a mistake• 5% of hospital admissions are caused by

medication issuesBowie, P. 2010

10%

Quality Education for a Healthier Scotland

Multidisciplinary

Bad people?

Error occurs due to Systemic and Systemic induced Individual failure

Negligence is not the same as error, both may result in harm

Why do all those avoidableharms happen?

Quality Education for a Healthier Scotland

Multidisciplinary

65 HF facilitators workshop Sept 11

Quality Education for a Healthier Scotland

MultidisciplinaryWhy do we make mistakes?

• Sometimes we do the wrong thing, consciously and sub-consciously

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

Multidisciplinary

Even experts make mistakes

Quality Education for a Healthier Scotland

MultidisciplinaryWhy do we make mistakes?

The system may be set up to fail

‘every system is perfectly designed to achieve the results it gets’

Peter Senge.

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

MultidisciplinaryYour amazing!

Quality Education for a Healthier Scotland

MultidisciplinaryWhy do we make mistakes?

• Sometimes we do the wrong thing, consciously and sub-consciously

Quality Education for a Healthier Scotland

Multidisciplinary

<1% 5% 50% 80% 100% percent of driversPERFORMANCE

Indi

vidu

al A

uton

omy

The posted speed limit is 60 mph- the ‘legal’ space

Driving 64 mph-the illegal-

normal space

Driving75 mph – the ‘illegal-illegal’ space (for almost all of us!)

VE

RY

UN

SAFE

SPA

CE

IndividualPressures

PerceivedVulnerability

Belief inSystems-guidelines

Accident

Driving 100 mphillegal for all Borderline Tolerated

Conditions of Use

Adapted from Rene Amalberti

Quality Education for a Healthier Scotland

Multidisciplinary

Human FactorsA common language

“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” (Catchpole 2010)

“Making it easy to do the right thing” (Bromiley 2011)

Organisational/ Management-Safety Culture

-Managers’ Leadership-Organisation communication

Work/Environment-Work environment

and hazards(ergonomics)

Workgroup/Team-Teamwork

structures & processes-Team Leadership

Individual Worker-Cognitive skills

• Situation awareness• Decision making- Personal resources

• Management of stress• Management of fatigue

(Flin, Patey 2012)

Quality Education for a Healthier Scotland

MultidisciplinaryThe amazing colour changing card trick

http://www.youtube.com/watch?annotation_id=annotation_262395&feature=iv&src_vid=voAntzB7EwE&v=v3iPrBrGSJM

Quality Education for a Healthier Scotland

Multidisciplinary

The first lesson in reducing harm is the realisation that we will and do make mistakes

‘It’s the downside of having a brain!’

Reason

Quality Education for a Healthier Scotland

MultidisciplinaryScenario 1

• Read the summary of the GP incident(Wrong address delays resuscitation)

• Why do you think this near miss happened?

• What would you do to minimise its occurrence in future?

Quality Education for a Healthier Scotland

Multidisciplinary

Where can we start?

“Making it easy to do the right thing” (Bromiley 2011)

(Flin, Patey 2012)

Work/Environment-Work environment

and hazards(ergonomics)

Quality Education for a Healthier Scotland

Multidisciplinary

‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’

Reason J. BMJ. 2000 March 18; 320(7237): 768–770.

Quality Education for a Healthier Scotland

MultidisciplinaryEveryone, everywhere, every time

Good human factors design in health care accommodates everyone

Not just the calm, rested experienced healthcare worker

But also the inexperienced health-care worker whomight be stressed, fatigued and rushing.

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

Multidisciplinary

Where can we start?

“Making it easy to do the right thing” (Bromiley 2011)

Organisational/ Management

-Safety Culture-Managers’ Leadership

-Organisation communication

(Flin, Patey 2012)

Quality Education for a Healthier Scotland

Multidisciplinary

‘We cannot change the condition of those who do the work, but we can change the culture within which they work’

Quality Education for a Healthier Scotland

Multidisciplinary

Silo working?

Doctors

Admin

Nurses

What is your culture?

Quality Education for a Healthier Scotland

Multidisciplinary

Hierarchies?

Quality Education for a Healthier Scotland

Multidisciplinary

Do we pay attention to the Swiss cheese or do we blame?

Our learned behaviour is to blame an individual

Society

System

End point (HCS Colleagues)?

Quality Education for a Healthier Scotland

Multidisciplinary

Lessons for Leadership inchanging culture

Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.

Berwick Report 2013

Quality Education for a Healthier Scotland

Multidisciplinary

Where can we start?

“Making it easy to do the right thing” (Bromiley 2011)

(Flin, Patey 2012)

Workgroup/Team

Structures & processes

Quality Education for a Healthier Scotland

MultidisciplinaryExamples in healthcare…

• Prescribing and dispensing

• Hand-over/hand-off information

• Movement of patients

• Order of tests

• Preparation of medication

• If all of the processes associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

Multidisciplinary

Systems thinking - The patients perspective?

• Value for the patient

• Hand-offs• Accountability for the end-to-end experience

• Job roles

Organisational/departmental boundaries

A B C D E

Diagnostic process

Emergency care process

Treatment process

Quality Education for a Healthier Scotland

Multidisciplinary

Aggregation of marginal gains

• Small improvements in a number of different aspects of what we do can have a huge impact to the overall performance of the team

Sir Dave Brailsford - Performance director of British Cycling and the

general manager of Team Sky.

Improve 100 things by 1%

Don’t try to fix the whole system!

Quality Education for a Healthier Scotland

MultidisciplinaryScenario 2

• Read the summary of the GP (comms errors) incident

• What would you do to minimise its occurrence in future?

Quality Education for a Healthier Scotland

Multidisciplinary

Making it easier to do the right thingPDSA example: Christopher

Christopher to urinate into the toilet bowl 100% of the time by 30th June 2010.

Aim:

Toilet training

Quality Education for a Healthier Scotland

Multidisciplinary

PDSA templateDescribe your first (or next) test of change:

Person responsible

When to be done

Where tobe done

Demonstrate the correct way to urinate into the bowl and indicate the negative aspects of missing the bowl

Me tonight Downstairs toilet

List the tasks needed to set up this test of change

Person responsible

When to be done

Where to be done

Christopher available Me tonight

Downstairs WC

Predict what will happen when the test is carried out

What will determine if prediction succeeds

Christopher will show understanding of process and execute correctly

The floor will be dry

Quality Education for a Healthier Scotland

Multidisciplinary

Example: DSADoChristopher thought the demonstration amusing and ignored it

Study0% compliance with the new process0% reliability level

ActSeek out ideas, develop new test cycle.

Quality Education for a Healthier Scotland

Multidisciplinary

Example: next PDSA cycle

http://www.amazon.co.uk/toilet-training-target-stickers-Happeedays/dp/B002GZAWUK/ref=pd_sim_by_3

A Human Factors approach!

Quality Education for a Healthier Scotland

Multidisciplinary

Human Factors & remote islands considerations

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

mark.johnston@nes.scot.nhs.uk0131 656 3258

Workspace

Culture

Organisation

TaskTeamwork

Behaviours and AbilitiesAdapted from Catchpole

@markjohnston71

http://t.co/aSIEwiGD8n