How to Apply Human Factors Thinking to Everyday Working from Board to Front Line
Date: Friday, September 07, 2018
Venue: Aintree Racecourse (The Princess Suite)
Speakers: Professor Jane Reid, Clinical Consultant Wessex Patient Safety Collaborative, Visiting Faculty Bournemouth University, NED Salisbury Hospital NHS Foundation Trust Peter Ledwith, Senior Improvement Adviser, AQuA
Professor Jane Reid, Clinical Consultant Wessex Patient Safety Collaborative, Visiting Faculty Bournemouth University, NED Salisbury Hospital NHS Foundation Trust
Peter Ledwith, Senior Improvement Adviser, AQuA
How to Apply Human Factors thinking to everyday work from Board to front line – To err is human.
Professor Jane Reid, Clinical Consultant, Wessex Patient Safety Collaborative network, Visiting Faculty, Bournemouth University, NED Salisbury Hospital NHS FT gave an introduction to Human Factors to enable delegates to have conversations back in your own organisation around human factors and integrate some of the principles of human factors into health and social care.
When you look at investigations into serious incidents you find three main recommendations
1. Communicate the learning
2. Review the protocol
3. Education and training
Rarely do investigations recommend looking at the fallibility of people to make it easier for people to do the right thing.
The Human Factors! The catalyst: In health care, Mid Staffs was our catalyst. The recommendations from the Francis Inquiry helped to raise the importance of human factors. The following definition helps understand what human factors is:
‘In a work context human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work.’ Clinical Human Factors Group 2019.
Human factors and quality improvement: There is a relationship between human factors and quality improvement which is important. Human factors looks at the people in the system and how things can be organised to make it easier to do the right thing and harder to do the wrong thing. This leads to change. Not all change is an improvement though. Change must be evidence based to be an improvement with a commitment made to measurement. This is also important because moving to a just culture is about understanding the system and the context.
Human factors and the workforce: There is a relationship between human factors and the workforce. Safety and harm come from the same place. Ultimately it is about the human impact. There is a view that patient safety will not be achieved without staff support and wellbeing. Compassion fatigue happens when staff aren’t supported. Compassion and human factors go hand in hand.
‘There are two primary choices in life: to accept the conditions as they exist or accept the responsibility for changing them.’ Denis Waitley, National Quality Board.
Challenge : How can you make human factors part of the common language in your workplace?
Peter Ledwith, Senior Improvement Adviser, AQuA has a background in the Aviation Industry. He presented methodologies for human factors integration in health care. 25 years ago the aviation industry talked about human factors a lot but hadn’t really done anything about it.
The catalyst: The tipping point in the Aviation industry was the Nimrod review 10 years ago. Interestingly, the recommendations at that time are similar to the issues in the NHS. For example, the observations were that the merger of teams and organisations produced confusion and a lack of standardisation and there was a lack of an accountable officer. The same issues repeat themselves.
An engaged safety culture: The recommendation from the review was the need to develop an engaged safety culture. To make cultural shift happen you need to involve everyone and it stands on five pillars.
1. Reporting culture and the action that comes on the back of it
2. Just culture – which is about fairness and appropriate blame. People have to trust that it is fair and they will be fairly treated.
3. Flexible culture
4. Learning culture
5. Questioning culture
Error causation and Performance Influencing Factors: Peter shared the Swiss cheese model of error causation to help analyse when there are failures and the successive layers of defence. Failure may be due to policy, procedures or active failures. He shared a number of performance influencing factors (PIFs), both organisational and mental. Humans are only 80% reliable. When you add PIFs you move into the error zone. When you set up systems to reduce the PIFs you reduce the error zone (not eradicate it!). It is important we focus here.
Violations and culture: ‘We have to do it this way because…’ becomes part of culture which is then normalised. What people have to do to get the job done is the practical drift from the baseline performance. Patients waiting on A&E corridors were discussed as an example of this.
Jane then led a session on: Creating a patient safety culture and how to create the conditions for staff to speak up and the extent to which it is known by staff the violations and migration in organisations and whether staff own them. When we go to work people have 3 ‘buckets’, self, context and task. The fuller each bucket is the more likely there are to be errors. The question is how welcome is the ‘self’ bucket at work and yet to ignore it may lead to increased error and failure.
Challenge: What is the migration in your organisation from the expected safe practice as defined by legal and professional standards?
Migrations lead to a large range of borderline or illegal practices that compromise patient safety. Too stringent implementation can lead to violation and migration.
Staff who have direct contact with patients and are the last line of defence and act as harm absorbers. Perhaps staff need to celebrate the learning for when things go right (not just review when things go wrong!) and do the right thing again the next day based upon the learning.
Setting the tone for your organisation and identifying personal learning: Peter and Jane asked the delegates to set the tone for their own organisation and identify the learning from this event that they intend to take back to their workplace.
• What conversations do you need to have to integrate human factors into your practice?
• How safe is it to speak up in your care environment using a scale of 0-10?
• How can you shift from a blame to a just culture?
Updated by: Administrator on 26, Feb 26, 2018