The CHFG are delighted to announce the publication of a second ‘How To’ guide.

‘Implementing human factors in healthcare – Taking further steps’, is the second volume of the ‘How to’ guide that was originally published in 2009. Whilst the original volume focused on giving a broad brush overview of human factors, ‘Taking further steps’ is very much seen as a follow on volume. The resource shares practical experience of applying human factors in healthcare and provides more examples and case studies to demonstrate the implementation of human factors in healthcare.

This recognises that many healthcare organisations have made headway in implementing human factors, and there is a real demand for more information about the potential ways in which human factors methods can be applied to improve patient safety.

The new resource can be found here Implementing human factors in healthcare – How to guide – volume 2

A booklet has also been produced that has extracts of case studies and implementation tips from the full resource. This can be found here Booklet of case studies and implementation tips 

The first volume, published in 2009 can be found here

The CHFG is pleased to announce the publication of a new resource, specifically targeting Hospital Boards. “Getting to grips with human factors – strategic actions for safer care”, is a learning resource that recognises the fundamental impact Boards have on safety within their organisation. The aim of the resource is to encourage Boards to invest time and resource in Human Factors, by raising awareness of Human Factors, and demonstrating how Human Factors impact on quality, safety and productivity in healthcare.

It is intended to be thought provoking, encouraging Board members to think about themselves and their organisation whilst also providing practical actions Boards and individual members can and should be making in this area.

Here is a link to a pre-publication version of the resource Getting to grips with human factors – strategic actions for safer care

The resource has been developed alongside a presentation, so that the concepts are easily shared.  Here is the presentation for PC users Boards learning resource for PC, and here is a version for Mac users Boards learning resource for MACs 

Patient Safety PhD studentship: Feedback and learning from incident reporting

Department of Surgery and Cancer

The Department of Surgery and Cancer at Imperial College London is offering one 3-year studentship funded by a grant from the NHS Commissioning Board.  The PhD research will take place within the context of development of the UK National Reporting and Learning (NRLS) system, originally developed by the NHS National Patient Safety Agency and currently hosted at Imperial College Healthcare NHS Trust.  A substantial programme of work is underway at Imperial College to develop the research base for effective incident reporting and learning in the NHS to underpin future operational developments in the UK NRLS.  Critically, the PhD will focus upon enhancing feedback and learning from incident reporting, in order to better understand the processes by which information on patient safety issues can be translated into effective local action to improve the reliability of care.

The broad aims of the PhD programme are as follows:

1)     To review and evaluate current feedback processes;

2)     To investigate and understand the mechanisms by which feedback impacts upon professional and organisational behaviour;

3)     To explore and evaluate enhanced feedback methods in order to establish a basis for future development of the national reporting programme.

The PhD student will be supervised by Dr Jonathan Benn and Prof Charles Vincent in the Department of Surgery and Cancer (Head of Dept: Prof George Hanna).  Through the NRLS research programme at Imperial, the PhD student will benefit from strong links to the Institute for Global Health Innovation at Imperial (Director: Prof Lord Ara Darzi) and the NIHR Centre for Patient Safety and Service Quality (Director: Prof Charles Vincent).  The student will be expected to play a full and active role in the academic life of the Department and associated research centres.

The studentship will pay UK/EU tuition fees and a starting stipend of £17,500.

Potential PhD sub-studies:

• Extension of existing research synthesis in the area of feedback from incident reporting in healthcare (see: Benn, et al. (2009) Qual Saf Health Care; 18: 11-21)
• Retrospective analysis of previous NRLS safety alerts and feedback upon incident reporting rates using a statistical approach (e.g. time series analysis)
• Theoretically informed survey study and qualitative research into the impact of different feedback characteristics upon professional and organisational behaviour.
• Mixed methods case studies supporting development and evaluation of tools to enhance the local impact of national feedback from incident reporting.

The successful candidate will possess a 2:1 undergraduate degree and MSc or equivalent qualification in a health services or social sciences related discipline.  Experience in patient safety or health services research is desirable. The successful candidate will be able to demonstrate strong motivation and capability to independently pursue development, execution and publication of robust research using a range of methods.

The studentship is available to UK nationals or EU nationals, who have lived in the UK for at least three years immediately preceding the date of an award. For general eligibility details please see the following Research Council terms and conditions:http://www.rcuk.ac.uk/ResearchCareers/postgrad/Pages/home.aspx

Owing to funding restrictions applications from overseas candidates cannot be considered.

If you wish to discuss the studentship informally, please contact:

Dr Jonathan Benn: j.benn@imperial.ac.uk

All students will belong to the Graduate School which provides a full programme of training in research and transferable skills. Further details of the Department can be found at: http://www3.imperial.ac.uk/graduateschools

You should send one hard copy, and an electronic version, of a full CV, including names of two referees, and a letter stating why you are interested in conducting PhD research in this area to Dr Jonathan Benn (j.benn@imperial.ac.uk).

Please note that candidates must fulfil College admissions criteria. For an informal discussion please contact our postgraduate admissions team at pgmedreg@imperial.ac.uk

Closing Date: 10 May 2013   Studies to commence at the soonest opportunity.

Over the last few weeks – just as people are still trying to understand what Francis means and when the NHS is dealing with it’s own structural changes – we’ve seen safety very publicly rear its head again in a most unpleasant way.

Surgery at Leeds General Infirmary was suspended because data suggested there were safety problems. Was this the right thing to do? And what can we learn from it?

As always, let me look at the problem from another perspective. Earlier this year a major aeroplane manufacturer had to ground every single one of their new airliners because of a couple of potentially significant incidents. No one was killed or injured, yet to ground the plane was a major step.

My first question is: what data was used to make the grounding decision? Simply that two incidents occurred which, under slightly-altered circumstances, could have been much more serious? In that case, it was enough ‘data’ to make the decision.

My second question is this: what were the implications of grounding the planes? Well there’s an enormous cost to the manufacturer and to the airline business of doing this (costs for one airline alone were running into the millions per month). And for passengers it was inconvenient as schedules had to be changed or delayed. But to quote from aviation, ‘if you think that’s expensive then try having an accident’.

Healthcare has one big difference. If you suddenly cut capacity it’s not just ‘a little inconvenient’, but it’s also potentially dangerous – perhaps life-saving operations can’t take place and people could die by default. So what do you do?

Clearly there’s a risk balance to consider. But that risk balance isn’t just about the here and now of the Leeds case, it’s also in balancing the risk of the message it sends out to everyone practicing in the NHS. If unsafe care is allowed to continue because it’s more convenient then we might as well stay in the dangerous past.

The argument about Leeds has centered on ‘the data’. What does it show?,Shouldn’t patients be allowed to judge or, as some have suggested, do patients really understand the data?

My own opinion is that as a patient I’m not an expert on surgery or statistics. I expect professionals to make those judgements and tell me the outcome – yes or no, surgery within acceptable practice or not.

But – and I’ve warned about this in previous blogs – you can’t just use figures and ‘hard’ data to judge safety. If you achieve safe outcomes it doesn’t mean you will do each time. It’s the process that’s important.

For example, are surgical teams behaving in acceptable ways with each other and following best practice to ensure safety? Are they using the WHO Checklist correctly? This sort of judgement can only be made by observation or perhaps what we sometimes call ‘enhanced oversight’ in aviation.

And if the outcome of a review like that in Leeds is that the processes aren’t good, then the next question is ‘what is it that makes their current practice acceptable to them?’ Is it training, the culture and leadership of the organisation etc? Or is the problem elsewhere in the organisation and not with the surgical team at all? Remember, safety problems are almost always the result of a range of causal factors, not just one root cause.

I have complete confidence that the aviation regulators, airlines and manufacturers will deliver safe aeroplanes to me and my passengers, and that when problems occur that they’ll be dealt with in a thorough way to ensure that safety can be consistently delivered – through science and knowledge, not luck. Processes and practices at multiple levels allow me to put my trust in it.

Do you have the same trust in healthcare?

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group, follow on Twitter @MartinBromiley.

As massive growth in civil aviation continues, is the real threat to aviation safety the criminalisation of aircraft accidents? 

Published in the Royal Aeronautical Society‘s monthly journal, Aerospace International, Caroline Malty reports on whether a worldwide Just Culture is achievable – her report can be read in full HERE.

For further information about this article or any other questions, you can contact Guy Hirst on guyhirst@icloud.com

The recent BBC Horizon programme, How to Avoid Mistakes in Surgery, will no longer be available on iPlayer (from 18/04/13). However, some kind person has uploaded it to YouTube and it can be viewed here: How to Avoid Mistakes in Surgery. 

BBC Active distributes licences and programmes to educational institutions, charities, businesses, museums and festivals for educational and training purposes but are unable to distribute to individuals. If your organisation wishes to have a copy of this programme for educational and training purposes, it can be purchased HERE.

BBC Active licences worldwide and the cost of a licence and programme on DVD is £195.00 + VAT and a £10.00 courier charge.

Please visit BBC Active website direct to purchase a copy (CHFG doesn’t hold any copies for redistribution).

Aviate, navigate, communicate – where medicine is going wrong.

Aviators have a mantra in the event of emergency – aviate, navigate, communicate.  In short, fly the plane, everything else can wait.  In an era of glass cockpits – flight decks in which computers dominate – and the role of the pilot have been oft times subordinated in the name of safety, why are there a rising number of significant accidents in perfectly flyable aircraft.

Witness why Air France flight 447 fell into the Atlantic Ocean in 2009 when it encountered severe turbulence; not because the modern aeroplane was unable to navigate those conditions but because the pilots, faced with the ‘Swiss Cheese’ compounding of minor failures in bad weather could not muster the seemingly basic skills of an aviator – indeed, for more than 60 seconds the pilots of the doomed aircraft input diametrically opposite control

Medicine is heading the same way – we appear to face a generation of physicians taught to fly the tests and protocols, but whose basic hands-on skills are eroded.  The glass cockpit dilemma is coming home to roost in a new place.

In 1972, 2 seminal fatal accidents changed the aviation industry’s attitude towards the hitherto often moustachioed seat-of-the-pants era commercial pilot – frequently an ex-military flyer, these (almost exclusively) men reigned supreme on a flight deck in which rank and age held sway.  First, a perfectly serviceable BEA Trident crashed outside London, seconds after take-off.  Later the same year, a nearly new Lockheed Tri-Star foundered in the Florida Everglades, a victim of a 10 cent light bulb.  There was however a more stark and frightening commonality – the men in the left hand seat of both aircraft were demigods of their trade – both were highly experienced, trusted captains, log books brimming with hours, spoken about in hushed tones by their peers and especially juniors.  Both men were beyond reproach and this Delphic-oracle position was the root cause of the unnecessary deaths that befell them and their passengers – they were feared beyond challenge by juniors, challenge that would almost certainly have prevented both accidents.

The aviation industry was jolted into addressing the sudden realisation that the weakest link appeared to be the human one derived from issues of nature and nurture – a new specialty of Crew Resource Management was born and pilot recruitment focus moved towards the team player, not the martinet.  The impact on human factors incidents was dramatic, but notable pockets remain – Korean Air was a stand-out for some years, today it’s a safety leader following radical human factors change.  A no-blame culture remains an unobtainable goal, but the positive trajectory of incident reporting thrives nonetheless.

So how the comparison.  Medicine is slowly becoming a true evidenced-based science, yet remains taught in so many ways as a see one/do one/teach one apprenticeship with good and bad traits learnt at the elbow of the master.  Accidents in medicine involve single patients, not hundreds of passengers; hospital catastrophes rarely fill newspaper column inches.  Medical change is incremental through the established review and learning processes – change by trickle-down.  Aviation learning by contrast is step-wise and often dramatic, played out in the public domain with international regulatory enforcement.

Three decades ago, aviation began its next big safety leap with the introduction of highly computerised cockpits in which the plethora of information was condensed on PC screens, replacing a morass of ‘steam’ dials.  A new era dawned claimed the protagonists – one manufacturer (Airbus) took an even longer leap, disconnecting the mechanical link between pilot and the control surfaces of the wings – pulleys and rods replaced by joysticks and electricity.  The ‘uncrashable’ aircraft was born – the known weakness of the human was subordinated and a new level of safety arrived.  Then in 1988 one such immaculate aircraft crashed at a French airshow and the cause remains a topic of vigorous debate.  For sure, nothing mechanical broke on the fated plane.  And 21 years later, a larger but similarly fly-by-wire Airbus also in Air France colours (AF 447) plunged into a freezing ocean.

Something strange is happening – glass cockpit safety appears no better, statistically perhaps worse than steam gauges and mechanical links of old.  Pilots seemingly have forgotten how to aviate.  Yet, following 1972 and the changes in recruitment and training, those same pilots communicate within a team better than at any time in flying’s first century.

As a junior doctor, I was introduced to the miracle of pulse oximetry, the non-invasive measurement of blood oxygen levels.  A new generation was dawning and I was happy to believe I could trust the sage numbers and reassuring tone of this ever-watchful companion.  Then I started to notice something odd – the numbers became the focus, the comforter for the clinician.  If the numbers are OK, no one needs worry.  And with this began a seeming decline in the focus on basic, time-tested clinical skills – at worst I once saw a patient die because a doctor treated those reassuring numbers to the exclusion of frank clinical signs.

Medicine and aviation share so many similarities – few other industries pay the people at the front end the most, depend on those people for their core, critical activity and see those employees make or break the business.  And we naturally try to manage and direct the actions of these trusted professional through well-honed procedures and protocols.  As a trainee anaesthetist I was taught the ‘cockpit checks’ that preceded any procedure and recall how those checks had followed the checklists devised for commercial pilots.

Humans love and need safety blankets – we cope poorly as a species with too many points of uncertainty and yearn for workload reductions.  Pulse oximeters and glass cockpits are our reassurance – we seek out their comfort, we trust them 100%, we consider them infallible.  And in so doing we appear to have happily revoked those basis skills that when all else fails offer the final safety net.  For the pilot, the seat of the pants ability to aviate with partial information; for the doctor, the experience of laying hands or stethoscope on the patient before choosing from  a battery of tests.

I’m writing this article sitting on day 10 alongside a young friend in the acute surgical ward of one of the US’s finest hospitals.  A semi-professional athlete, she required an unusual (for her age) emergency procedure. Her pre-operative diagnostic and nursing care were exemplary; her surgery and anaesthesia beyond reproach.  Then everything changed.  The protocols kicked in and her expected rapid recovery trajectory stalled and entered a flat spin.  Through a series of events (each singly sensible, but collectively foolish), she received so much water that her body became bloated, her lungs soaked, her belly rigid, her pain poorly controlled.  Nurses bound by computerised orders were unable to respond to the simple issues they saw.  Her medical team seemed unable to grasp developments – their responses were ever more hidebound by cherished protocols (more suited to a 70 year old) and an introspective silo mentality.  Between these professional silos fell pain control orders, leaving a hitherto fit woman rendered often hysterical and bed bound.

I recently found a letter written to me in 1988 by the Chairman of Surgery of one of the major US teaching hospitals – I had spent a brief period as a sallow trainee in his esteemed department to learn skills I could not garner in the UK.  I was surprised to find I had been taught as an undergraduate the ability to diagnose with my hands, eyes and ears – this highly experienced American surgeon spotted the same and noted how poor had become the ability of US-trained doctors to diagnose without invasive, costly tests.  Now nearly a quarter of a century later my personal experience says we have regressed.      

Evidence-based practice is a wonderful aspiration – that we base clinical practice on the accumulated and ever-growing body of clinical expertise and peer-based review, not the individual whim is wise.  But when that faith in evidence-based protocols becomes blind to individual variation we are made slaves to the bell curve.  We cling to the comforters and silence our inner doubts – we have externalised the doubt since the alternatives are unattractive.

Our doctors are forgetting to aviate and communicate; navigation has become their chief guiding light.  As aviators have learned all too often, the maps are often wrong.  Are our doctors too dependent, too trusting of navigation aids whose provenance is imperfect and in so doing have they foregone cherished skills?  In US hospitals alone, medical errors are estimated to kill the equivalent of two AF447 crashes each day – but what of the unnecessary suffering delays, complications, costs, disability – it must be many multiples greater in scale.

Aviation learnt in 1972 the folly of complex systems led by flawed humans; it changed profoundly.  Yet now, some of the more recent tenets of flight safety are again under scrutiny – we cannot take for granted the hard-fought gains, nor fall victim to the hubris of human ego.  Medicine must and can learn from flying – or is it too wedded to the wrong maps?

The original blog post can be viewed HERE.

Jeremy Stone is an MD, MBA. He trained as a surgeon and anaesthetist/intensivist, practised in the UK, US and Europe and developed research specialities in aviation medicine and blood flow measurement.  An experienced CEO, he worked for a leading global strategy consulting firm across multiple disciplines and sectors, including large healthcare system and hospital change programmes.  Jeremy is a pilot and serial entrepreneur, with a particular interest in translational learning between unrelated disciplines and subjects.  He has built and owned medical, financial service and aviation companies, whilst developing academic interests in healthcare policy and aviation human factors.  He is the co-author of the United Kingdom Prime Minister’s Healthcare Innovation Strategy, 2012.  Jeremy is a Maven/Connector and prolific writer who lives between London and San Francisco.

© Jeremy Stone, 2012

Implementing the Recommendations from Francis

Assessing and Transforming the Culture of an NHS Service

Tuesday 9th July 2013, London

This conference focuses on assessing and improving the culture of your NHS organisation or service. Interactive masterclass sessions, case studies and presentations will focus on how you understand culture, values and the relationship between culture and behaviour. How you can implement a culture change programme to ensure a compassionate, open and honest service where staff are motivated and empowered to lead for quality improvement and patient safety. You will leave the conference with a practical toolkit of approaches to help you face the challenge of this difficult issue.

A flyer, with further information, can be downloaded HERE, or visit: http://www.healthcareconferencesuk.co.uk/assessing-transforming-nhs-culture or contact kerry@healthcareconferencesuk.co.uk.  Follow the conference on Twitter #NHSCulture.

A 20% discount* is available to registrants via CHFG, please quote ref: huck20chfg when booking. (*cannot be used in conjunction with any other offer.)

The University of Oxford are holding a short CPD course on Human Factors, Teamwork & Communications in May as part of the new MSc in Surgical Science and Practice but which can also be taken separately by non-surgical clinicians as a short course.

The course will be 5 days long and will be led by Ken Catchpole.

Further details of the course and how to apply can be found HERE.

Make a date in your diaries.  Thursday 21st March 9pm BBC2 – Horizon

Francis has presented an amazing opportunity for healthcare, if people are able to grasp it. Looking from just over the fence has allowed me to observe behaviours, especially over the last few weeks, and I’m not sure that everyone is able to grasp that opportunity. Too close to the action sometimes blots out the bigger picture.

As a ‘harmed relative’ coming from another safety critical industry, I’ve been able to keep that bigger picture throughout not just the last few post-Francis weeks, but also since my late wife died. Sometimes it’s worthwhile taking a moment out to reflect. I hope this coming Thursday evening will offer you that opportunity.

About two years ago I approached Dr Kevin Fong with an idea for a BBC scientific programme, and at last it’s happened. Since September I’ve been working with Kevin and the BBC Horizon team to pull together a programme about human factors in healthcare. It looks at how learning about the human in the system and the system itself can bring about enormous improvements in safety and outcomes that technology and medical science can only aspire to.

Kevin and the Horizon team have produced something inspirational yet scientific, and – just as importantly – is by a clinician, for clinicians. It’s written in a way that will appeal to both those in healthcare and the public. It uses a tragic death to highlight human factors that all of us are prone to, and looks at how we can learn from others both in and outside healthcare to make a real difference in the future.

Although the BBC Management chose a surgery based title for the programme to gain mass public appeal the lessons of this programme are for everyone in healthcare.

It would wonderful if you could pass on details of the programme to anyone you know who works in healthcare. My goal is that by the end of this week, every one of the 1 million or so people who work in healthcare in the UK will be able to watch it (whether on Thursday or on iPlayer).

About 30 years ago, as a very new pilot I watched a television programme called ‘The Wrong Stuff’. This Horizon produced programme talked about the final frontier of safety in aviation. Planes weren’t crashing because of technical problems, it was the human that was the weak link. Over the years human factors science has taken its place at the top table in aviation. The National Patient Safety Advisory Group announced recently by the Prime Minister – to be lead by Dr Don Berwick – includes a number of long term supporters of the CHFG such as Prof Jim Reason and Prof Charles Vincent, as well as others who’ve been working in the background to support us.

Human factors is getting on the top table in healthcare.

‘How to avoid mistakes in Surgery’ will be on BBC Two on Thursday 21 March at 9pm.