Maureen Stevenson Patient Safety & Improvement Manager Jean Robson Director of Medical Education

1. From implicit to explicit recognition of the value of Human Factors Education in NHS Dumfries & Galloway Maureen Stevenson Patient Safety & Improvement Manager Jean Robson Director of Medical Education

2. A Journey of Discovery • Start with the aim in mind • Did we really know what we wanted to achieve • Organic and adaptive

3. All Aboard • Clinical Governance • Risk Management • Adverse Event Management • The care environment • Making your care and work safer • Systems • Understanding why things go wrong • Understanding the importance of context and culture • Teamwork • Environment & Process Design

4. First Steps

6. Our Approach to Improvement Spread Hold the gains A P S D Implement A P S D Sustain the change A P S D Test on larger scale/under different conditions A P S D Test on very small scale A P S D Plan A P S D Identify opportunity for change A P S D

7. Full steam ahead • Safety Culture & Acceptance • Non technical skills training • Learning from error • Improvement Science & Process Design • Checklists & Briefings • Design & the physical environment • Human Factors Training

8. On the journey

9. A Human Factors Training Coursefor NHS Dumfries and Galloway.Improving Reliability in Health Care Jean Robson Director of Medical Education and GP

10. Why? • Foundation year doctors not reporting • Consultants not reporting • Nationally latent factors poorly identified

11. Conclusions from FY Questionnaire • Knowledge is reasonable • Experience could be improved - not all involved in discussion, and not all given feedback, not convinced that those reporting are treated fairly • Majority of incidents are not reported.

12. Known factors in failure to report PSIs • Staff anxiety about impact • Fear of legal ramifications • Concern about upsetting others and exposing one’s own vulnerability • Belief that professionalism = responsibility • Near misses • Inexperience • Lack of training • Early stage of training • Cumbersome reporting systems • Being temporary staff, including those in training

13. What causes Junior Doctors Stress? • Stressors in residents include relationships with seniors and making medical mistakes (Satterfied JM and Becerra C) • The most frequently expressed emotions in residents are guilt, anxiety, and fear. Guilt usually triggered by not performing competently (Satterfied JM and Becerra C) • Medical errors are a threat to professional identity as well as safety (Dixon-Woods M et al).

14. Unable to generate enthusiasm for sharing concerns, errors or near misses. • Some become enthusiastic about patient safety when they work with an enthusiastic team. • But that generating interest across an organization is difficult.

15. Social Identify Approach. • Henri Tajfel – Social identity theory – to individuals belonging to a group is important in terms of self-esteem • John Turner – self-categorization theory - belonging to a group means buying into the behaviours, and attitudes of the group

16. Self-categorization for FY1 “Attaining a medical qualification is not enough for individuals to regard themselves as doctors, they need to feel that they have the skills and attributes that they associate with that group” Burford 2011

17. What does this mean for Patient Safety? • Does the fact that FY1s are developing a self-view which fits them into the category “Doctor” make it more difficult to say “this could have gone better”? • Is it all trainees? • Does reporting their mistakes inhibit their development of the new self-view?

18. What we needed to do • Convince people that reporting was worthwhile • Convince them that reporting is what “good” clinicians do • Convince them that NHS D&G BELIEVES that our staff come to work aiming to do a good job • And that when they make mistakes we really want to understand latent factors and address them THIS MEANS THAT NHS DUMFRIES AND GALLOWAY IS COMMITTED TO MAKING CARE MORE RELIABLE NOT TO BLAME

19. Hopes • Increase the understanding of human factors across the organisation • Ensure a focus on developing reliability • Wanted a “credible” course to convince people to take 2 days out • Wanted to take people out for 2 days and immerse them in it

20. What did we need? • Money- for set up costs • Time - for those enthusiasts to develop and deliver course and participants to attend • Knowledge – for a faculty • Materials – to deliver

21. What did we do? • Worked with DART training solutions initially • Adapted DART materials initially • Built a faculty • Wrote our own materials

22. Course Objectives • Understand the value of recognising Human Factors in medical error causation. • Consider the performance influencing factors in which precipitate error and limit reliability • Develop strategies to reduce medical error and improve reliability • Know how to use recognised tools to improve reliability

23. The course • Pre-course reading • 2 day course • Free • Safe environment – group rules • Mixed groups • Ban interruptions • Free lunch • Cover the factors which increase chances of humans making errors • AND methods to mitigate against this. • CME approval from Royal College of Anaethetists

24. Learning Methods • Learning Environment - Start with an example of something that has gone wrong for me • Small group • Stimulate dissonance – pre course reading and homework • Lectures with lots of examples from faculty • Encouragement to share • Games – fun • Actions to take away

25. Topics Topics covered Medical Error understanding Reliability Human perception Stress Fatigue Conflict Communication Team working Leadership Situational awareness Decision making Tools covered Briefs Debriefs Handover Checklists Induction Structured communication tools Cross training / Simulation Rotas Protocols

26. Who comes? • Managers • Doctors • Nurses • Pharmacists • Secondary care • Primary care • Health Board non-executives

27. Feedback • Very positive – like multidisciplinary approach, like some activities, thought provoking, think everyone should do it. But some comment that it is a lot in 2 days! • Asked to help with sessions for departments or groups- GP trainers, X-ray team, risk managers, GPs, pharmacists

28. Things people intend to do when asked some time after the course we are now more inclined to share and discuss with the rest of the team, errors that we have made We pilot our new audit of protocols in a small number of patients ahead of implementing them fully to find out what might go wrong and what unintended consequences might arise from our work introduce a pharmacist handover in dispensary and dept brief and debrief each day Intend to bring in a checklist for reviews with day hospital patients Compilation of a ‘hand-over’ check list at the overlap of each shift.

29. Challenges • Time – for us and for participants • Value • Tensions between reliability and learning

30. Where next? • More people doing it! • Full 2 days for people in leadership positions, shorter course for others??? • Add module on patient involvement? • Should it be part of mandatory training????? • Half day workshop for Health Board? • Mitigating against lost learning from error – feedback / reliability / resilience

31. Summary • Evidence of need for Board wide training • Needed to be credible • Needs to be safe • It needs to be enjoyable and seen as worthwhile • Important to be multidisciplinary • Important to cover tools to support change • Helps to identify some changes that participants can go away and implement