Quality Education for a Healthier Scotland
Multidisciplinary
Human Factors & remote islands considerations
Mark JohnstonTraining and Research Officer
(Patient Safety)NHS Education for Scotland
[email protected] 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
[email protected] 656 3258
Workspace
Culture
Organisation
TaskTeamwork
Behaviours and AbilitiesAdapted from Catchpole
@markjohnston71
http://t.co/aSIEwiGD8n