An HF approach to Qi
2013-2016 Theatre safety project
Neal Jones
Assistant Director of Patient Safety
The problem!
• 12/13 The organisation had multiple surgical never events.
• There were significant parallels in the error causation factors.
• Human Factors elements were identified as prime error causation components
The drivers of error
• Healthcare should be a high-reliability industry
• Unfortunately literature shows that it is fraught with error, can be unsafe, and at times is not effective
• The potential for error and system failure is always there
• Things happen on a daily basis: staff go off sick, equipment doesn’t work, people forget to do something - we are all human no matter how diligent
• This is a normal part of a complex healthcare system
Human Factors design philosophy
Safe patients
Safe Staff
Just/open and learning Culture
Resilient workforce Cognisant of self and
team performance limitations
Environment, equipment and
process designed to support workforce
(Person centred design)
Our approach
A. Creating a culture in which staff can make timely interventions and compensate for system failures is a key pre-requisite to developing high reliability.
B. Designing out system failures to reduce the stressors placed upon the workforce and enhance clinical performance.
The project plan
• A human factors based re-design of the identified failing safe
systems • Improve culture and confidence of workforce – improve staff
retention and staff satisfaction
• Targeted intra-professional human factors team training for every member of the Theatre clinical workforce to:- – Increase error reporting through cultural change – Create a resilient workforce that can identify and mitigate risks in real
time. – 342 theatre staff trained in HF since October 2013
• NHS traditional approach to error reduction =
– Add more boxes to be ticked irrespective of the frequency of the error type.
• Additional complexity = reduced compliance and increased risk.
• Goal- remove wasteful steps create space for safety
The Project team
• Medical Director • Assistant Director of Patient Safety • Directorate Manager Theatres • 2 x Surgeons • 2 x Anaesthetists • 2 x Scrub nurses • 2x ODP’s • 2 x Dual roles • 2 x Theatre managers
• + regular listening exercises across teams
(DORR- methodology)
– Deconstruct RCA’s to identify the system drivers of unwanted behaviour/error causation.
– Observe normal practice to differentiate
between the exception and the norm
– Refine/Redesign the systems to mitigate the unwanted behaviours
– Re-train the teams in the new systems
H - Have you noticed this?
A - Ask did you hear my concern/suggestion?
L - Let them know this is a patient safety issue
T - Tell them to STOP until it is agreed that it is safe to continue
Human factors trained student ODP utilised HALT to prevent a surgical never event
The HALT tool has been utilised over 150 times to protect patients since its introduction
The course
• Full team training model
• Discussion based program to explore the teams current practice and behaviours, and form contextual learning that can be implemented to enhance the teams safety performance with immediate effect.
The content
• 08:30 Registration & Coffee • 09:00 Welcome & Housekeeping • 09:15 Human factors in Health Care • 10:30 Coffee • 10:45 Human performance effectors • 11:45 Situational awareness • 12:45 Lunch • 13:30 Decision making • 14:30 Team dynamics • 15:30 Coffee • 15:45 How to use/Checklists/Halt tool • 16:30 Video based theatre error case discussion • 17:00 Close
Long term performance 2012-2015
0
50
100
150
200
250
300
350
400
450
2012/2013 2013/2014 2014/2015Total Errors reported 189 414 429
Axi
s Ti
tle
Total Errors reported
126% Increase in error reporting of since project implementation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2012/2013 2013/2014 2014/2015No harm 68% 85% 87%
% o
f e
rro
rs N
o h
arm
Annualised % of total errors that resulted in No harm
27% increase in episodes of No harm since project implementation
0%
5%
10%
15%
20%
25%
30%
2012/2013 2013/2014 2014/2015Low harm 27% 12.50% 11%
% o
f e
rro
rs l
ow
har
m
Annualised % of total errors that resulted in Low harm
59% Decrease in episodes of Low harm since project implementation
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
2012/2013 2013/2014 2014/2015Moderate Harm 3.70% 2.17% 1.10%
% o
f e
rro
rs m
od
era
te h
arm
Annualised % of total errors that resulted in moderate harm
70% Decrease in episodes of Moderate harm since project implementation
Episodes of patient harm 12/13 V’s 15/16
Year No harm Low harm Moderate Severe Death Never event
12/13 213 49 12 1 0 3
15/16 395 27 3 0 0 0
% variance
85% 44% 75% 100% N/A
52% increase in overall error reporting
Year 13/14 14/15 15/16
UK Never events
338 306 340+
StHK 0 0 0
Fiscal Year Theatre activity % increase from start
date
2012/13 27,636 ↔
2013/14 30,851 ↑ 11%
2014/15 31,305 ↑ 13%
2015/16 31,842 ↑15%