Roundtable Event Met Suite, Leeds Metropolitan Hotel 13 th January - - PowerPoint PPT Presentation

e: academy@yhahsn.nhs.uk/ t: 01274 383926

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Human Factors Roundtable Event

Met Suite, Leeds Metropolitan Hotel 13th January 2016

Part of the Yorkshi kshire e & Humber ber AHSN 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 kshire e & Humber ber AHSN

Welcome

Professor John Wright

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

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Plan

• Two illustrations
• Definitions
• Further reading

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• 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

• ‘Business 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

• n human behaviour and abilities, and

application of that knowledge in clinical settings’

Ken Catchpole, 2010

#humanfactors

• 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

Further reading

#humanfactors

Mapping the terrain of Human Factors #humanfactors Debbie Clark

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

#humanfactors

#humanfactors

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 Standard text = existing

In situ Simulation

Monthly 2hr rolling program 1/2hr quality improvement session

Human Factors Training

Simulation as above

Simulation Courses

Multidisciplinary: CRUMPET EM trainees: ACCS, CT3 paeds and ST4 courses Simulation Faculty

Policies

Escalation guidelines Clinical Guidelines:

• Regular updates
• Emergency guidelines on

wall in resus: cardiac arrest, trauma team etc.

Handover, briefing and debriefing Checklists

Guided by risk assessment: Sedation, sepsis

Actions from incidents

Improvement actions: checklists, guidelines, in situ sim, audit Feedback to staff, M and M meetings

Quality and Safety Metrics

CEM Audit Program TARN Mortality review: Incident reports

Potential HF Interventions

Training Working Practices Quality and Risk Management

In situ Simulation

Monthly 2hr rolling program Weekly 1/2hr quality improvement session Mock Arrest

Human Factors Training

Simulation as above E learning module Workshops Teamwork Training and Handbook: Team STEPPS Safety Notices and posters HF Work Based Assessment

Simulation Courses

Multidisciplinary: CRUMPET EM trainees: ACCS, CT3 paeds and ST4 courses Simulation Faculty

Policies

Escalation guidelines Clinical Guidelines:

• Regular updates
• Emergency guidelines on

wall in resus: cardiac arrest, trauma team etc. Senior review guideline

Handover, briefing and debriefing

Formal handovers using tool Safety briefing (daily) Debrief following incidents

Checklists

Guided by risk assessment: Sedation, sepsis, first fit, discharge etc. Weekly 1/2hr quality

Actions from incidents

Improvement actions: checklists, guidelines, posters, in situ sim, briefing, audit Feedback to staff: lesson of the week, summary information, M and M meetings Must reduce risk whilst balancing unintended consequences

Quality and Safety Metrics

CEM Audit Program TARN Mortality review: avoidable deaths Incident reports including harm/no harm ratio Safety attitude survey Pneumonia care bundle audit Quality and Safety Suggestions Box

Progress

Training Working Practices Quality and Risk Management

In situ Simulation

Monthly 2hr rolling program Weekly 1/2hr quality improvement session Mock Arrest

Human Factors Training

Simulation as above E learning module Workshops Teamwork Training and Handbook: Team STEPPS Safety Notices and posters HF Work Based Assessment

Simulation Courses

Multidisciplinary: CRUMPET EM trainees: ACCS, CT3 paeds and ST4 courses Simulation Faculty

Policies

Escalation guidelines Clinical Guidelines:

• Regular updates
• Emergency guidelines on

wall in resus: cardiac arrest, trauma team etc. Senior review guideline

Handover, briefing and debriefing

Formal handovers using tool Safety briefing (daily) Debrief following incidents

Checklists

Guided by risk assessment: Sedation, sepsis, first fit, discharge etc. Weekly 1/2hr quality

Actions from incidents

Improvement actions: checklists, guidelines, posters, in situ sim, briefing, audit Feedback to staff: lesson of the week, summary information, M and M meetings Must reduce risk whilst balancing unintended consequences

Quality and Safety Metrics

CEM Audit Program TARN Mortality review: avoidable deaths Incident reports including harm/no harm ratio Safety attitude survey Pneumonia care bundle audit Quality and Safety Suggestions Box

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)

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Refreshments and Networking

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Optimising safe performance through

research

Professor Rebecca Lawton

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Improving patient care

safety?

Assumptions that underpin

• ur 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

Domain Meaning Knowledge

Does the person know they should be doing behaviour X? Do they understand the evidence?

Skills

Does the person know how to do the behaviour (X)? How easy or difficult does the person find behaviour?

Beliefs about capabilities

How easy is it for the person to do X? Have they previously encountered problems? How confident are they that they can overcome difficulties?

Motivation and goals

How much do they want to do X? How much do they feel the need to do X? Are there incentives to do X? Are there competing priorities?

Environment

To what extent do physical or resource factors hinder X? Are there any competing tasks or time constraints?

Beliefs about consequences

What do they think will happen if they do X? What are the costs/consequences of doing X? Does the evidence suggest that doing X is a good thing?

Emotion

Does doing X evoke an emotional response? To what extent do emotional factors help or hinder X? How does emotion affect X?

Social influences

To what extent do social influences help or hinder X? Will the person observe others doing X?

Role/identity

How much is doing X part of the person’s identity? How much doing X important to the person?

Memory/attention

Can the person remember to do behaviour X? Do they usually do X?

Action planning

Does the person put plans in place to ensure they do the behaviour?

#humanfactors

Involve stakeholders

Medical directors and sharp end staff

Identify target behaviour

Audit and discussion

Identify barriers

Influences on Patient Safety Behaviours Questionnaire (IPSBQ)

Confirm barriers and generate intervention strategies

Focus groups

Support staff to implement and evaluate intervention

Joint approach Re-auditing Healthcare professionals not using pH as the first line method for checking tube position

Using Theories of Behaviour change to optimise safe behaviour (Taylor et al., 2013a,b)

#humanfactors

The evaluation

• Funded through the Health Innovation and Education Cluster and strategic

authority funding

• Four Trusts in Yorkshire and Humber volunteered to take part in a study to support

the implementation of NPSA alerts

• Three chose to focus on safe use of nasogastric tubes as one of two priorities

(others were safe use of midazolam, medicines reconcilliation)

• 18 month project, funded one RF and one RN to support audit

#humanfactors

Focus group results: interventions matched to barriers and BCTs (H1)

Barrier Strategy Behaviour change technique* Social influences

• Information presented at clinical governance

meetings by experts in the area

• Awareness day held within the Trust
• Posters with pictures of senior staff performing

correct behaviour

• Persuasive source
• Information about health

consequences, and social/ environmental consequences

• Prompts, cues, social support

(unspecified) Emotion

• Screensaver contained messages to elicit

anticipated regret and to reframe perspective on behaviour

• Anticipated regret
• Salience of consequences
• Framing/reframing

Environmental context and resources

• Radiology and ward protocols to empower staff
• Instructions, flow chart, measurement tool, who

placed NG, place to record pH values, etc.

• Splashscreen placed on intranet with prompt about

pH testing and link to all relevant documentation

• Prompts, triggers, cues
• Adding objects to the

environment Bcap (and knowledge and skills)

• Practical training complete for current FY1s
• E-learning package developed for junior doctors
• Instruction on how to perform a

behaviour

• Behavioural practice/rehearsal

Optimising Safe Performance

Audit information Hospital 1 Hospital 2 Hospital 3 Hospital 4 (Control) Pre Post Pre Post Pre Post Pre Post

Number of sets of notes audited 49 48 43 44 44 40 53 46 pH of aspirate from stomach 18% 63% 12% 73% 14% 33% 45% 46% Patient sent for X-ray 49% 23% 77% 9% 41% 40% 25% 20% Tube placed in radiology 36% 10% Information not documented 33% 14% 11% 18% 9% 17% 30% 34%

Target behaviour: Using pH as the first line method for checking tube position

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Relevant publications

• Taylor, N., Parveen, S., Robins, V., Slater, B., & Lawton, R. (2013).

Development and initial validation of the influences on patient safety behaviours questionnaire. Implementation Science, 8(1), 81.

• Taylor, N., Lawton, R., Slater, B., & Foy, R. (2013). The demonstration of

a theory-based approach to the design of localized patient safety

• interventions. Implementation Science, 8(1), 123.
• Dyson, J., Lawton, R., Jackson, C., & Cheater, F. (2013). Development of

a theory-based instrument to identify barriers and levers to best hand hygiene practice among healthcare practitioners. Implement Sci, 8, 111.

• Taylor, N., Lawton, R., Moore, S., Craig, J., Slater, B., Cracknell, A., ... &

Mohammed, M. A. (2014). Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC health services research, 14(1), 648.

#humanfactors

Generating impact

• Why behaviour change for safety – a short animation Achieving

Behaviour Change film

• Resources for healthcare teams available via the Improvement

Academy for Yorkshire and Humber website

• One day behaviour change workshops (attended by 300 health

professionals and managers in Y&H)

• Four national workshops in 2015 sponsored by NHS IQ

#humanfactors

Safe performance from the patients perspective

Patient Reporting and Action for a Safe Environment (PRASE)

#humanfactors

Developing PRASE: Collecting patient feedback

Patient Measure

• f Safety

44-item questionnaire:

• Communication
• Equipment & supplies
• Ward layout
• Delays
• Access to resources
• Staff training
• Information flow
• Organisation/ care planning
• Staff roles & responsibilities

Patient Incident Reporting Tool

• What happened, where and who

was involved?

• WHY was this a safety concern for

them?

• What can be done to PREVENT it

happening again?

• Patient’s perspective on

preventability and severity

Example items from the PMOS

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The PRASE Intervention Cycle?

Patient Measure of Safety Patient Incident Reporting Tool

Patient experience of safety measured Information collated and fed back to wards Feedback considered in Action Planning Group Action Planning Group - plan, implement, monitor changes

Mid-Point Meeting Start up Meeting

SUMMARY REPORT - Overall safety profile from questionnaire responses

#humanfactors

The Evaluation

Feedback collected from 25 patients on 33 wards across 3 hospital Trusts: Feedback collected 3 times over 18 months 17 intervention wards met to consider patient feedback and action plan to improve patient safety, quality and experience Effectiveness = improvements to patient feedback scores over time, more positive safety culture and higher %harm free care scores

#humanfactors

• A - Discard the issue
• B - Do something about the issue (within current constraints)
• C - Challenge the underlying causes of the issue (cultural,

physical or structural)

Issue e.g. noise at night

A B C

Time taken to ‘resolve’ issue

Action planning meeting analysis – what do teams ‘do’ with feedback? #humanfactors

Findings

• Patients very happy to provide feedback – 86%

response rate, but measure quite challenging for some

• Fidelity of intervention poor – only 4 of 17 wards met as

a multi-disciplinary team on both occasions, made an action plan and implemented it

• No significant effect of the intervention on % harm free

care, although larger difference in pre-post scores (5.3%) for those wards who implemented PRASE

• So, promising results although more work needed to

support implementation

• NEXT STEPS

#humanfactors

What are the next steps for roll out of PRASE?

• A 33 item and 10 item

PMOS measure currently being developed http://yqsr.org/impact/

#humanfactors

Relevant Publications

• Lawton, R., McEachan, R. R., Giles, S. J., Sirriyeh, R., Watt, I. S., & Wright, J. (2012).

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ quality & safety, bmjqs-2011.

• Ward, J. K., & Armitage, G. (2012). Can patients report patient safety incidents in a

hospital setting? A systematic review. BMJ quality & safety, 21(8), 685-699.

• McEachan, R. R., Lawton, R. J., O’Hara, J. K., Armitage, G., Giles, S., Parveen, S.,

Watt, I. S., & Wright, J. (2013). Developing a reliable and valid patient measure of safety in hospitals (PMOS): a validation study. BMJ quality & safety, bmjqs-2013.

• Giles, S. J., Lawton, R. J., Din, I., & McEachan, R. R. (2013). Developing a patient

measure of safety (PMOS). BMJ quality & safety, 22(7), 554-562.

• Lawton, R., O'Hara, J. K., Sheard, L., Reynolds, C., Cocks, K., Armitage, G., & Wright,
• J. (2015). Can staff and patient perspectives on hospital safety predict harm-free

care? An analysis of staff and patient survey data and routinely collected outcomes. BMJ quality & safety, bmjqs-2014.

#humanfactors

Knowing what safe looks like at the individual, team and service level

A positive deviance approach

#humanfactors

Positive deviance – what is it?

Spot it Understand it Disseminate it

#humanfactors

Four projects currently underway

• 1. Elderly care wards across Yorkshire and

Humber

• 2. Hip and knee replacement services across

Yorkshire and Humber

• 3. GP surgeries who do well across 8 QOF targets
• 4. Healthcare professionals who have won Health

Service Journal award for innovation in 2014 or 2015 #humanfactors

Aims

• To develop robust methods for identifying positive

deviants

• To develop methods for understanding what it is that

they do to achieve success

• To consider the extent to which it is possible to spread

success

#humanfactors

Relevant publications

• Lawton, R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive deviance:

a different approach to achieving patient safety. BMJ quality & safety, bmjqs-2014.

• Baxter, R., Taylor, N., Kellar, I., & Lawton, R. (2015). What methods are used to apply

positive deviance within healthcare organisations? A systematic review. BMJ quality & safety, bmjqs-2015

• Baxter, R., Taylor, N., Kellar, I., & Lawton, R. (2015). Learning from positively deviant

wards to improve patient safety: an observational study protocol. BMJ open, 5(12), e009650.

#humanfactors

Projects that are just getting

• ff the ground
• The role of the patient in GP consultations involving possible

cancer diagnosis (Jane Heyhoe)

• Emotion and diagnostic decision making in critical care (Jane

Heyhoe and Daniel Stephenson)

• An intervention to support second victims of patient safety

incidents

• Using patient experience data to foster local improvement

(NIHR HS&DR)

#humanfactors

Improving patient care

Providing Human Factors Education

Debbie Clark and Wayne Robson

# humanfactors

Plan

• Overview
• Human factors training – TeamSTEPPS
• Simulation

#humanfactors

‘Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals , including managers and executives.’

(National Advisory Group on the Safety of Patients in England, 2013)

#humanfactors

Safety Science Education for All

Managers and executives Frontline teams - Nursing, Medics, Allied Health Professionals Pre registration -Nursing, Medics, Allied Health Professionals

#humanfactors

Local Example – Sheffield Hallam University

#humanfactors

Life long learning for frontline teams

• Provide specific human factors education
• Clinical focus
• Exploit opportunities
• Post registration Courses
• Mandatory Updates
• Online learning

#humanfactors

Life long learning for Mangers and Executives

• Provide specific human factors education
• Focus on open culture
• Safer system design
• Closing the gap between ‘work as imagined’

and ‘work as done’

• Strategically move towards becoming a High

Reliability Organisation #humanfactors

TeamSTEPPS - a solution to implementing human factors ?

Wayne Robson #humanfactors

Key Principles TeamSTEPPS

#humanfactors

Ready to use resources

http://www.teamsteppsportal.org/teamstepps- materials

Master Trainer Course https://tslms.org/login/index.php #humanfactors

Barnsley’s plan

• Secure organisational commitment to HF training
• A way of supporting NatSSIPs
• Secure organisational commitment to trying

TeamSTEPPS with some high risk teams /areas and to training key number of individuals as master trainers

#humanfactors

Barnsley’s plan

• Two people are undergoing online master

trainer course

• Monthly HF session for Trust staff (to support

Nat SIPPS) Offers an opportunity to try out some of TeamSTEPPs materials

• Culture Survey

#humanfactors

Increasing Capability & Capacity

Team training works

#humanfactors

Traditional Simulation

• Simulation as an educational technique
• Experiential learning
• Often single discipline
• Centre based
• Technical skills
• Non-technical skills

#humanfactors

In-situ Simulation

• Uses the real team and the real workplace
• Multidisciplinary - can involve large teams
• Greater focus on non-technical skills?
• Looks at the work environment, equipment, resources etc.
• Can uncover latent error

#humanfactors

Quality Improvement In situ Simulation Latent Errors Identified Quality Governance Mechanism

#humanfactors

Conclusion

• Simulation can be used to uncover safety and

quality issues and also to resolve these issues

• Simulation gives time and ‘permission’ to

discuss work in a way that rarely happens

• utside simulation
• Can demonstrate issues in a way that is more

widely and clearly understood #humanfactors

Table Discussions

Discuss human factors education in your organisation: – Which organisations are providing education? – Who is attending? Thinking about human factors education more broadly, what are the: – Gaps? – Duplications? – Challenges? – Opportunities?

#humanfactors

Lunch and Networking

#humanfactors

Open Space

Angela Green

#humanfactors

Your Space, now over to You to fill it!

About Open Space

• Concept developed from recognition of the value of

networking and connecting with each other

• Much more than a giant coffee break
• Purposeful creation of the time and space to enable this
• Open Space principles work well when:
• there is a broad purpose but no agenda - delegates

generate their own agenda

#humanfactors

Suitable Conditions for Open Space

• Complexity, in terms of the tasks to be done or
• utcomes achieved
• Diversity, in terms of the people involved and/or

needed to make any solution work

• Conflict, real or potential, meaning people really

care about the central issue or purpose

• Urgency, meaning that the time to act was

"yesterday"

#humanfactors

Format of Open Space

• Proposer of the topic leads facilitation of the

table discussion

• Agree on table who and how you will record

notes and actions

• Remember The Law of Two Feet -

If you find yourself in any situation where you are neither

learning nor contributing, use your two feet, go someplace else, no rules

• Feedback – opportunity to highlight the top 5

best conversations in the room

#humanfactors

Bulletin Board

Table Topic of conversation Proposer 1 2 3 4 5 6 7 8 9 10 Extra

#humanfactors

Gina’s Story

Lee Cutler Doncaster and Bassetlaw Hospitals NHS Foundation Trust

#humanfactors

Next steps

#humanfactors

Thank you for attending

Please complete the evaluation form in your pack,

and return your badges before leaving

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Future Events

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Contact Details

t: 01274 383926 e: academy@yhahsn.nhs.uk www.improvementacademy.org @Improve_Academy #humanfactors