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This short 2 minute video testimonial is from a Doctor of Emergency Medicine reflecting on how she has seen the significant benefits of Atrainability Human Factors training

 

 

Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Trevor is a specialist in human factors teamwork training since its introduction in commercial aviation in 1990. Since 2002 when he formed Atrainability he has been working extensively in healthcare, with extensive experience in training and coaching clinical teams in a multitude of operating theatres across the UK in NHS and private hospitals.

Trevor enjoyed a full career as a pilot with British Airways, retiring as a senior Training Captain flying Boeing 747 aircraft in 2005. By then he had been a trainer in classroom, simulator and aircraft for over 12 years. In this time he had extensive experience in facilitating learning and with a small team developed a range of innovative train the trainer courses that have gone on the become mandated internationally in commercial aviation. It is these skills which have been widely recognised in healthcare and have been utilised in courses for such as the Royal College of Surgeons and a variety of research programmes conducted with teams at the RCS and the University of Oxford.

As a result of these he was approached to tender successfully for the development and design of the Productive Operating Theatre teamworking modules for the NHS Institute. His experience across healthcare is wide and far-reaching, including a specialty in Surgery, Radiology as well as Primary Care, Emergency Care, Critical Care, Mental Health and Secondary Care.

He is widely sought as a conference speaker internationally on the subject of human factors training in healthcare. Trevor is an active member of Lions Clubs for over 30 years and has been President of his local club twice.

Near hits and the tip of the iceberg

When things go wrong in healthcare - administering the wrong drug, treating the wrong patient, operating on the wrong site or patient - these are the mistakes we see. Sadly, avoidable harm is not decreasing and the annualised cost increasing in our litigious society. £2 billion outgoings for NHS Resolution in 2018, up from £1.7 billion the previous year.

What people often don't do is report the near misses, or near hits as we prefer to call them.

There's plenty of understandable reasons for not reporting the near hits.

Firstly, nothing has actually gone wrong. It's hard to report a near hit when it didn't result in a bad outcome for the patient.

Secondly, reporting systems tend to be very cumbersome and time-consuming; not something you would look forward to at the end of a long shift.

The boxes within these reporting systems don't always fit the scenario. When no actual harm has taken place, some of the older systems don't have a way to report the near hit from their drop-down boxes.

Another major reason healthcare professionals fail to report the near hits is because nothing tends to happen when the issue is raised. All too often, there's no reply to acknowledge the report or even say thank you.

If there is an acknowledgement, frequently nothing is seen to change. From a management point of view this can be frustrating because not all solutions can be visible. We know of a case of senior management following due process with a case of bullying but they can't publish that they put a warning on a personal file because naturally that is confidential. But staff see no change in behaviour of the culprit so don't waste time offering follow-up reports!

One more reason; when you report near hits, you don't always feel safe.

We are aware of one situation, involving a clinician working with a new colleague. They were chatting together, slightly distracted, and the new team member got the controlled drugs out in a different way.

The clinician knows they should have checked before administering the drugs, but they were distracted. They gave the wrong one of the two colourless solutions to the patient. Fortunately, there was no lasting harm to the patient, but this was a near hit.

The clinician decided to report the near hit. They were aware that the same had happened with some of their colleagues in the past. Human factors were involved, with a weakness in the drug-labelling system making the error easier to occur.

The result? After reporting the near hit, the clinician came under scrutiny from senior management. They were not thanked for raising the near hit. Instead, the management started looking into how many near hits the clinician had previously reported, comparing their frequency of reporting to management.

The irony in this is, they made the clinician who reported the near hit feel victimised. Yet management still went ahead and changed the process, to reduce the risk of the same near hit retaking place. Dishonest management in our opinion.

When I was flying jumbo jets with my former employer, there was a company policy of error reporting ethics. If you made a genuine human error and confessed it, you would not suffer any disciplinary action or consequence to your career.

If however you deliberately broke the rules or made an error then tried to hide it, you would be facing due process. And quite rightly too.

Airlines too, recognise the tip of the iceberg issue. If a near hit is reported, it's likely to be part of a much bigger problem, hiding below the surface.

The more comfortable thing for management to do is to discipline the last person involved; the nurse, doctor or pilot receives punitive action as a result.

The hard thing to do is to get to the true root cause of the issue.

Why did the person make the mistake that resulted in a near hit? Perhaps they were not adequately trained in the procedure. Indeed the process itself could be unfit for purpose. The staff member might have been working for many hours without a break. They could have been experiencing personal issues at home, with a sick or dying relative, distracting them from the task at hand. We know of one recent case where this was a major factor.

In the long term, it saves you money to take the hard option and tackle the system issue which may be indicated by the hidden mass of the iceberg, floating below the surface.

So please report near-misses or as we say regard them as near-hits. The message for managers is please encourage reporting and respond with compassion for the reporter. The bulk of the iceberg represents a threat to us all.

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Reacting to tragedy - the aviation experience

It is, of course, inappropriate to speculate on the possible cause of the tragic Ethiopian Airlines crash. However, the reaction offers lessons I believe.

The authorities in Ethiopia and China have grounded the same model virtually instantly until root causes are understood and appropriate measures have been taken.

It may be significant that the aircraft is the same new model as crashed in Indonesia in late 2018, or it may not. Risk management is the name of the game.

One of the contributing factors in Indonesia was the new safety feature built into the aircraft software. The concept was to improve the way the aircraft responds to an unwanted state and is supposed to be an aid.

It is called the Manoeuvring Characteristics Augmentation System (MCAS). It is designed to prevent the aircraft from falling out of the sky in an aerodynamic stall.

However, it appears that the manufacturer, Boeing, did not incorporate the knowledge of the system in its training to crews. Many qualified crews around the world have stated that they nothing about the system's existence.

To compound the problem, it appears that the Indonesian aircraft may have been despatched with a known technical problem which the ground engineers may not have been able to reproduce on the ground.

In other words, the safety system responded correctly, but the suspicion is that it was being fed erroneous data from a faulty sensor. In this case the AoA (angle of attack) sensor – which detects the airflow over the wings.

Some of you may be aware that a cost saving feature is that this latest model of Boeing 737 is deemed to require only 'differences' training if a crew is qualified on the earlier model. They do not do a full technical knowledge course just learn and are assessed on the differences.

It seems the new safety feature was not included. Human error by the manufacturer? The result in a non-technical sense is a loss of situation awareness – how and why the aircraft is reacting.

Those of you who remember the tragic Kegworth crash in January 1989 which started with the crew identifying the wrong engine in an unclear flight situation and ultimately crashing across the M1 motorway in England's East Midlands.

Of the 126 people aboard, 47 died, and 74 sustained serious injuries.

Implicated was the pilots not being aware that the right engine supplied the air conditioning to the flight deck as opposed to the left engine in previous models.

The smell of burning was a small misleading clue. They had only completed a very brief 'differences' course.

Airbus have also suffered accidents in the past because the aircraft was so advanced and complicated that crew struggled to understand how the plane was reacting.

History can repeat, but we learn the lessons the hard way.

I flew six different airliners from four different manufacturers in my career. Comprehending what was going on was sometimes tricky and fundamentally down to how well the crew knew the aircraft. In other words, training.

In other professions such as healthcare, we all involve people trying to comprehend what is going on.

Healthcare professionals face a much more difficult job because no two patients are the same even more so than with aircraft. Knowledge and understanding are crucial, especially in how any one of us can get it wrong and right.

Human factors has been mandatory training in aviation since 1995, and even that can't prevent everything. But it sure helps.

I've presented training packages to several NHS Boards and senior management teams. Not surprisingly cost is a feature. Some get it; some seem to struggle.

After all, finding a direct correlation between safety and training is not easy.

But precisely who initially said, "If you think training is expensive, try having an accident"? I'm not sure, but it has been attributed to many wise people over the years.

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What’s in a name?

In our everyday lives, people are typically polite to each other. At social events, we carry out personal introductions a matter of course.

So why is this behaviour not the norm in healthcare?

When working with healthcare teams that are sometimes experiencing challenges with safe team workings, we often observe a reluctance to introduce ourselves by name - especially our given first name.

When I joined my first airline employer in 1971 that was indeed the case.

The Captain was always addressed as Captain or Sir, on and off the aircraft.

I still vividly remember my first BOAC flight as a very lowly second officer under training. The Captain was a very senior manager and trainer, and he exacerbated the situation by referring to me to his chums in the bar in Manhattan as 'one of those bloody cadets still wet behind the ears'. What an excellent example to set.

It was an example I chose as a model of what not to do when I finally achieved Command 18 years later.

Furthermore, I made a point of never introducing colleagues as 'my First Officer' or 'My Cabin Crew'. These are professional people in their own right and deserve all the respect associated with it.

This is an important issue because failure to use given names in the workplace can create a significant barrier to people speaking up when they have doubts about safety.

Why would any professional want to place an additional block to open communication, especially if someone's' life could be at stake?

I met one senior clinician in the last few months who looked with abject horror when I suggested they make a point of introducing themselves by first name at a pre-surgery huddle! "I really don't think I could do that", she said! Why on earth not?!

The unit in question has an appalling staff attitude survey result, a string of 'Never-Events' and 'near-misses', a high sickness rate and high staff turnover. Go figure!

The excellent Rob Hackett in Australia had the astonishingly simple idea a while back of putting name and job title on his theatre hat. This has become known as 'the theatre cap challenge'. Odd isn't it that it should even be regarded as a 'challenge'!

It's quite amusing to hear all the excuses why people can't adopt this simple practice of the theatre cap challenge in their own unit.

Infection risk? Well, there is a chap out there making them integral in theatre caps. You could invest in a few to get you through the week if you like your own personalised hat.

Power is granted, respect is earned.

We must not forget either that using titles can help in difficult situations.

As an airline captain, there were many occasions where a colleague referring to me as Captain Dale was useful to re-establish appropriate hierarchy in front of passengers or an engineer.

The other week I was delivering a talk in Bath, to a room of around 100 healthcare professionals, ranging from medical students to retired senior consultants.

When I reached the end of my talk, I asked how people in the room felt about using first names? I explained that when you have to think about titles and ranks, you are creating an additional barrier to someone helping you out when you need them the most.

I don't mind if you introduce yourself as Professor John Smith, but I prefer if you call me Professor Smith. This might not be as beneficial as working on a first names basis, but it sure beats the all too common introduction, "We all know each other don't we?" which equates to "You all know me, don't you? .. and you don't matter".

Do get in touch to discuss how our human factors training for critical teams can help you maintain and enhance safety.

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The familiar tale of high staff turnover



I've been chatting to various clients and a regular subject that we return to is high staff turnover. 

Many organisations do not perform exit surveys and so understanding why people leave is a problem to start with. Perhaps they don't really want to know. It's easier to blame the NHS and pressure of work, targets etc.



For example, Atrainability worked closely with a world famous specialist hospital a little while ago which was suffering high turnover of junior nurses in a particular department.


The view from the top was: 

"The nurses come here to get our good name on their CV's and then move on."


However, anecdotally people were leaving because it was not a great place to work.

Team-working was verbally espoused but reality was somewhat different. Work as imagined was quite different to work as done depending on your level in the hierarchy. 

One nurse told us she had worked her entire shift without any offers of help, breaks or support while the band 6 and 7 nurses had a nice relaxing time. You can imagine the atmosphere when we presented our findings. 


This is by no means unique as many of you will know. 

This very week I've listened to my best friend's wife explaining that she is burned out and leaving the profession the she loves. The reasons? She is a specialist sister in intensive care who is often told to work in other departments. She has been sent to A & E, theatres, wards and even the other sites in her trust which is 20 miles away. 

She has simply had enough. 

What a tragedy which is personal, institutional and cultural for her and us all. 


In London there are 8000 nursing vacancies and huge doctor numbers too, so making your job one that people want to come to must be worth working on? 

Staff retention rather than repeated training costs is a very worthwhile investment, and turning from a Blame Culture to a Just Culture is a crucial start. 

A worthwhile part of team-working is delving in to emotional intelligence and a fundamental concept within that is of course self-awareness. 


Get in touch and discuss with us how we could help your teams, including the senior level of course. 


Trevor Dale, Human Factors Specialist

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Human Factors & Patient Safety Updates (Oct18)

In this edition:
  • Civility Saves Lives
  • Group GP appointments - a breeding ground for error?
  • Waverley BIG Awards Finalist
  • Human Factors in Practice
  • Free conference this November

Civility Saves Lives

Civility when dealing with colleagues and patients may seem like stating the obvious, but sometimes what should happen in theory isn't what happens in practice. 

Civility Saves Lives is the self-funded, collaborative project led by Dr Chris Turner, a Consultant in Emergency Medicine. 

Why does civility matter? Uncivil behaviour not only greatly impacts the reciepent, but it is also proven to have an extended impact beyond the recipent. At Atrainability, we refer to this as 'Mood Contagion'. 

Many professionals have been on the receiving end of rudeness, belittling and bullying. Most are told or feel like 'that's just the way it is'; but if the NHS truly wants a Culture Change behaviours and attitudes at all levels need to adjust. The project aims to raise awareness of what can be done, whilst sharing stories from other professionals as well as relevant, evidence based academic papers.

Atrainability's Trevor Dale has recently been speaking about the importance of civility at Patient Safety Collaborative for Kent, Surrey & Sussex. If you'd like to find out more about how Human Factors training and Civility fit hand in hand, request more information by emailing team@atrainability.co.uk. 

We also highly reccomend taking some time to look at Christine Porath's work. Her book 'Mastering Civility - A Manifesto for the Workplace' has recieved excellent reviews in The New York Times as well as from high profile authors and leaders.



​Group GP appointments - a breeding ground for error?

There has been a recent report about the NHS considering group GP appointments as an option to help alleviate the waiting time for patients and in an attempt to manage the growing shortage of GPs.

 Although further details on this are needed, we at Atrainability believe that this could very well be a potential breeding ground for Human Factors error, our main concerns from a Human Factors perspective include:


 • BEHAVIOUR & COMMUNICATION: The patient relationship with their GP, being confident to raise real concerns. How does the GP manage a room with some extraverted (verbose) people and some introverted (more private & more inwardly driven)?


 • SITUATION AWARENESS: Potential error when adding correct patient notes to correct individual files - how will this be managed from a group sessions?


 • CONFIRMATION BIAS: A group may have similar symptoms, but will this lead to the same path of care? The correct diagnosis? Could things be missed? 


Are you a GP? 

We'd appreciate your thoughts on the subject. Email us in confidence: team@atrainability.co.uk.



​Waverley BIG Awards Finalist


You may know that we've been training health and social care teams across the UK for the last 16 years, however you may not realise that we're classified as a small business. Which is why we are delighted to have been selected as a finalist for Waverley's B.I.G Awards 2018 in the category of 'Customer Delight'. We'll keep you updated on the results which will be announced on 19 October.


​Human Factors in Practice


We were recently copied in on communications from a client to another organisation who were enquirying about our services. We have been granted permission to share this with you: 

Sent 19 September 2018 
Subject: Human Factors in practice 

Hi __________ I'm sorry to have taken so long to reply. We are six weeks in to our annual CQC inspection activity – what is perverse is I am responding to you on today of all days as today is the first day of the actual well-led inspection! 

I have to say, embracing Human Factors was the start of our journey and absolutely the right place to start. There is no other way to, in NHS terms, make the shift from compliance to continuous improvement, or it is likely you would regress back to a compliance focus. Embracing Human Factors tackles capability, by that we mean confidence, competence and capacity. Most other approaches cannot do this and that means you lose staff engagement from the outset. 

I am glad to hear that you are looking to improve the safety culture in your organisation. That shows a lot of insight on your part – a lot of organisations tackle just "culture", which then takes things down an OD direction. Also, culture is a funny term, we do need to break it down into its component parts and Human Factors tackles component parts that other approaches cannot. 

As a direct consequence of our Human Factors work, we have now moved away from audit to improvement and now each team is worked with, as an MDT, to look at their safety performance and we also undertake a patient safety culture survey. This has revealed things to us that our typical assurance mechanisms have not, e.g. we would assume our incident reporting profile equals a safety positive culture, but perception of staff shows that there is still work to do. 

We have used The Health Foundation Model to help us improve how we measure and monitor safety, however having been on the journey, you can't just implement that, Human Factors needs to be grounded in all you do first. I have seen many organisations where Human Factors becomes something that is led by OD and becomes associated with "communication" – Human Factors is much more than that. 

Taking a look at your organisation, it looks like not only do you have a similar profile to us but your CQC ratings are almost identical. We are rated Outstanding for Caring which we put down to, in part, our work in relation to Human Factors. The Safe domain is always a difficult one to shift – let's hope this inspection changes that! Feel free to come and see us or we will come and see you, if you have any questions. We are also open to partnering on things. However I would revisit offers from Human Factors providers first as that really is the foundation. 

Of course my experience is of using Atrainability and there are many reasons for that, aforementioned, in-house approaches risk this being seen as a communication thing, whilst other companies do not tap into the SME that experts in the airline industry have. We have used Atrainability to train what we call "culture carriers" or then have spread and sustained this approach in what has then developed into our patient safety improvement (safety management system) work. 

Atrainability also did two bespoke sessions with our Board, as that demonstrated to our staff the commitment of the Board. So I would suggest you need a programme of works that tackles all levels of the organisation for this to work – we didn't know it at the time, but we used the dosing model which you are probably familiar with. That will help you present any proposals to your Board as this is an evidence based way of building capability in a sustainable way. 

Good luck on your Human Factors journey! 

David Wood, 
Associate Director of Safe Services Cheshire & Wirral Partnership NHS FT


​Reminder! Free Future of Healthcare Conference this November


​Atrainability are proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at The Future of Healthcare Conference, which is free to attend event on 6 November in Exeter. 

The conference brings you speakers from a wide spectrum of specialties. The aim is to inspire & teach NHS staff from all departments, as well as patients, on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance. Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter.

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The Tragic Cost of Avoidable Harm

As I'm writing this, it's only Wednesday, but we have already been made aware of four unrelated never-events at seperate healthcare providers. The unfortunate truth about committing to a Human Factors training programme is that many organisations put it off, until they receive a wake-up call in the form of a never-event, a near miss, bad press or from the CQC. Someone gets told this needs to be addressed, and that's when our phone starts ringing.



The first tragedy of so many harm related incidents is that on reflection they could have been avoided. 

That's one of the reasons this headline in the National Health Executive: "NHS pays out record £20m compensation for brain-injured teenager" caught our attention, but also because it's potentially the largest compensation pay-out in NHS history. 


The second tragedy of avoidable harm is that the suffering of all those involved doesn't end with the error.

The judgement suggests the error was avoidable. Hence Human Factors behaviours will likely have been suboptimal. In this particular case, not only did this nameless young lady have her full enjoyment of life tragically taken from her, but also her parents and entire family. 

We can only imagine the emotional toll that they have endured for the last eighteen years to have this life changing error acknowledged and receive some form of compensation towards her ongoing care. 

Let's also recognise the effect on the healthcare team involved. It's likely that disciplinary action would have been taken, but they have almost certainly been haunted by the knowledge that they could have avoided or trapped the error. 


The third tragedy of avoidable harm, is that it sadly continues to occur. 

There will always be mistakes in healthcare, but embracing a Human Factors mindset can enable your team to be confident in modifying the actions and behaviours that affect safety. 

Atrainability have over 16 years' experience in training and supporting healthcare teams on their individual journeys to truly learn, become more effective and begin to change behaviours for the better. If your teams are performing highly now, consider helping them to stay 'consciously competent' and avoid the trap of complacency.


Please get in touch and let's see how we can help your teams.


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Human Factors Courses for Foundation Doctors

The General Medical Council has reflected the importance of recognising Human Factors in the development of generic professional capabilities for post graduate medical curricula. 

The context for this is the GMC's core guidance for all doctors, good medical practice, which sets out what is expected of doctors including communication, partnership and working with patients. (National Quality Board Human Factors Concordat 2013) 

Many Deaneries have incorporated Atrainability's Human Factors modules in their curriculum, since 2012. The list is growing year by year and the repeat bookings speak for themselves. 


Atrainability are now taking bookings for Foundation Doctors Human Factors Training for the next academic year

Human Factors is strongly recommended to become a mandatory part of Medical Education and our courses match the Medical Leadership Competency Framework.

Focus points include: 

• how and why errors are made and practical tools to avoid and trap them 

• safe decision making during a stressful day 

• situation awareness - recognising the signs that things are going wrong and dealing with that situation 

• effective escalation - overcoming the barriers to open communication and shared understanding in a high workload environment 

• dealing with difficult people including, sadly, colleagues 


We have over 6 years' experience in delivering training aimed at the next generation of healthcare professionals in a manner that is tailored to their educational needs. 

The Human Factors behaviours related to safety are crucial both for the patient and also the professional confidence within the Doctor while they are in the most high risk part of their education. 

If you have already finalised training for 2018/2019, we'd be happy to discuss your training programme for the next academic year.

Some sample feedback from recent participants: 


"Outstanding course, incredibly useful" 


"This should be mandatory! Very interesting to learn how other industries such as aviation can apply to medicine" 


"Leadership & management is crucial but often overlooked in medical training. Clear, practical advice that I can start putting into practice now." 


"Useful to receive formal teaching in things that it seems we are expected to already be aware of e.g. challenging authority. Good presentation, kept engaged throughout." 


"Important concepts to reflect on, extremely useful to be exposed to this early on in our career" 


We would be happy to discuss your individual needs at your convenience. Please contact us here.

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Unprofessional behaviour in the workplace

The recent press reports of a 'toxic' atmosphere at St George's hospital in South London are distressing to say the least but unfortunately by no means isolated. 

Relations between colleagues in any profession can break down or face difficulties at times. However, healthcare professionals are often a keen focus for criticism in the media and so it's important not only to understand how to prevent unprofessional behaviour in the first place but also how to manage high-performing professionals into cooperative team-working when under pressure. 

In over 16 years of working with health and social care professionals across a wide spectrum of disciplines we have encountered far too many instances of uncivil behaviour sometimes directed at us and certainly at fellow team members. 

It is worthwhile mentioning that this applies at all levels and specialties and not as some apparently think, doctors alone. Currently we are working with organisations where problems exist within nursing bands. When trying to help teams understand the effects of uncivil behaviour we ask the following:


WHAT DOES IT MEAN TO HUMAN?      VS       WHAT DOES IT MEAN TO BE PROFESSIONAL?


Here are sample answers, by no means exclusive:

Maintaining high standards of professional behaviour is a major challenge in any high-pressure working environment. We will sometimes fail to get it right because we can not avoid being human.


MAKING EXCUSES...

One clinician sought to excuse his colleagues inappropriate behaviour by saying the surgery (neuro) he performed was very complex, high risk and stressful and that stress had to be vented somewhere; and so in this way he justified the bullying his colleague dished out to theatre teams! 

Thankfully, this clinician always behaved impeccably with patients and relatives but there is no excuse for undue criticism or abuse of colleagues.

Why does he think it is an appropriate way to behave?

Does he realise the impact he has on staff feeling that they can speak up in the unlikely (we hope) event of some avoidable error?

How will the added stress of working with someone difficult effect the performance and focus of the rest of the team?

If you look again at the 'What makes a professional' image; what makes him believe that he is practicing in a 'professional' manner?

More importantly, how can he be helped to gain self awareness? Certainly not by people making excuses for his behaviour and certainly not by team members keeping their heads down.

MANAGING HUMANS

Everyone has what we refer to as their personal 'stress bucket'. 

So in dealing with 'difficult' people, especially as a manager or team leader it can be helpful to consider why they behave this way. 

Could they be ill or facing huge personal stress, having a personal crisis? Could they lack insight or skill? Could they believe it to be acceptable because that's what they experienced? Could it be my fault? Winding them up? Could they just be plain awkward? 

The first step is to recognise the 'human' elements, treat everyone as an equal with dignity and compassion and by that try to encourage the 'difficult' people into the same behaviour.​

// View our Walking the Tightrope Course here. //


This can be easier said than done, especially if you're not in a management position but one of those perhaps at the blunt end of the behaviour.

In those circumstances the simplest advice would be to reframe your response to this behaviour. For inappropriate behaviour such as bullying or intimidation, it is common for individuals to be singled out as the 'victim'. 

Therefore sticking together as a team is crucial. It is certain that you are not the only one who has noticed or feel uncomfortable with the behaviour. As a collective it's important to not allow yourselves to become victims but to stand together and respond professionally, politely but firmly. 

As a common example if someone refuses to follow a procedure (such a safety checklist, briefing etc) declaring it a waste of time or they know better etc. Together the team needs to take the stance "I'm afraid we will not be going forward with this until this is done." 

Regardless of your faith in reporting systems there should be one that enables you to get support from your management, but any reporting with regards to inappropriate behaviour must be evidence based.


REPEATED UNCIVIL BEHAVIOUR

The NHS is notorious for having a culture where professionals are treated effectively like children. If you treat people in such a manner don't be surprised if you get a child-like response.

However if you treat people in an adult manner, as equals, with respect and understanding it is more difficult for them to maintain an unprofessional behaviour pattern.

At the same time it should be made clear that continued unprofessional behaviour and bullying cannot and will not be tolerated. This comes under the heading of duty of care to the rest of the staff. A fundamental management responsibility.


However, we know of a current situation where after evidence of repeated uncivil behaviour, a formal interview was undertaken with an official warning on file.

The staff member has returned to work, but the manager suspects no behaviour change has taken place and is not getting any further evidence from other staff because presumably they feel that nothing has been done and therefore why waste time making reports?

A conundrum indeed because managers cannot publish confidential personal reports for obvious reasons. Here we believe having a cadre of Human Factors Champions in the workplace could help.

They could be the interface in the workplace and offer advice and support to both staff and management.

So we return to a Just Culture - one where genuine human error is treated with understanding but equally failure to follow standard procedure habitually and inappropriate behaviour towards others is simply not on.


Make an enquiry about creating Human Factor Champions in your team here.

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Human Factors & Patient Safety Updates (Aug 2018)

Free conference for NHS staff this November

We're proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at this free to attend event on 6 November in Exeter. 

The future is uncertain. With the dawn of technology, will healthcare staff be usurped by advanced apps & artificial intelligence? What leadership strategies are in place to help NHS staff cope with the Salisbury Novichok incidents? How will joint working & mergers affect staff? 

This event explores Collaborative Networking - The Future Of Healthcare. This free conference brings you speakers from a wide spectrum of specialties. We aim to inspire & teach NHS staff from all departments as well as patients on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance.

Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter

Fixing a System Under Pressure

Everyone seems to say now that they have a 'Learning Culture' - but what is your SOURCE of Learning? 

The British Medical Association has recently shared some of the footage from The Future Vision for the NHS workshop ran last month. On the day around 50 members from across different parts of the medical profession came together to contribute ideas, experiences and examples to help inform the BMA's work to press for change in the NHS.

Watch a selection of videos from the event here, including 'Fixing a System Under Pressure' a short presentation from Atrainability.


Excellent Feedback from Serious Hazards of Transfusion Conference


​We were recently sent the official feedback from the SHOT blood service conference we spoke at in July. 

This year saw record numbers of delegates, which could be partly attributable to having more international delegates from the IHN meeting. 

There were 270 online submissions for the evaluation survey, which was a response rate of 85.7% (the evaluation survey was sent to 315 individuals, excluding exhibitors). 

Trevor Dale spoke at the conference about Walking the Tightrope.

The feedback on the conference was exceptionally positive, and we were very happy to receive top scores on most informative and best performance of the speakers.


Who's tweeting Human Factors...

One to follow: #learnnotblame is the fantastic campaign lead by Dr Cicely Cunningham launched by The Doctors Association UK, we'll definitely be following and supporting her progress as she raises important issues that's relevant to Human Factors values.

That's our round up of the updates from us for now, please get in touch and let's see how we can help your teams.

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Human Factors and Patient Safety Updates





PATIENT SAFETY TEAM OF THE YEAR

The winners of the HSJ 2018 Patient Safety Awards have been revealed. Well done to everyone who was nominated, commended or won! In particular, we'd like to congratulate the University Hospitals Coventry and Warwickshire Trust Patient safety and risk team. Their team have been awarded the Patient Safety Team of the Year. 


"Integrating Human Factors principles into our safety investigations has been a key part of the changes we have made. An understanding of these concepts is key to learning and improving as an organisation when things go wrong. We started our Human Factors journey two years ago with Atrainability and their Train the Trainers course, and this gave us the knowledge and confidence to develop a systems based investigation process that moves away from blame, towards learning and ensures that the patient is at the heart of what we do." 

- Stephen Tipper, Human Factors Programme Manager

Since instituting a raft of measures over the last year the incident reporting rate at the organisation has increased from 31 to 44 incidents per thousand bed days – in the top 25 per cent nationally. There have also been improvements in staff survey responses on feeling secure when raising concerns.

We of course can not take credit for their achievement but we are proud to have played a small part of their wider plan to make sustainable changes to patient safety with the 5 day Train the Trainer sessions we ran with them two years ago.

Read more about their changes and award here.


TRAINING WITH THE TEAM AT UHNM

Last week we ran 2x two-day Human Factors Awareness workshops for adult and children intensive care teams at UHNM. The courses were presented by our Founder, Trevor Dale and one of our new team members, Rick Craft.

During one of the two-day sessions, our trainers had the pleasure of talking with Emma Biddulph, a Play Specialist who is featured in an article in The Guardian on 70 years of the NHS. Emma told us:

"I came not knowing what to expect, but I found this course really interesting and useful. I plan to start implementing human factors learning asap in my daily practice."

Emma Biddulph, a Play Specialist
We're happy to report that 100% of the staff said they would 'Reccomend this training to a Colleague' and 100% also told us that as a result of the training it was likely or very likely that they would be able to apply the learning to their practice. Enquire about Human Factors Awareness Course

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