Terema Human Factors in Risk Management Masterclass
Category: SAS Doctors - Other
Date: January 23rd 2014 8:30am until January 24th 2014 5:00pm
Location: Musgrove Park Academy, Musgrove Park Hospital, Taunton, Somerset TA1 5DA
The 2 day Human factors in risk management is a 2 day comprehensive course looking at how human factors and team work can lead to errors that we see in patient management at all levels. Although rare, these incidents cause major stress and financial burden for us as Doctors – and avoidable suffering and harm to patients.
Considering the major emphasise on avoidable “errors” and “Hospital never events” it is useful to have a course with quite a lot of interactive sessions to look into how human factors influence decision making and cause probabilities of errors. I have also requested Terema who is holding the course to briefly cover the legal implications and consequences of the same.
Due to the nature of the course the number of delegates is restricted. I would encourage those who are able to attend to do so. The course would be useful in today’s litigious environment and to improve patient care.
Patient Safety
Terema Human Factors in Risk Management Masterclass
Terema are the leading provider of human factors in Risk Management and Team Resource Management to the NHS. Our programmes concentrate on the practical application of safety related activity in a healthcare setting. In addition to work with practically all staff groups in a large number of NHS Trusts, we are a major provider of training within the Nurse Leadership in Urgent Care programme for the Department of Health.
This is a foundation course in human factors and team skills. We will introduce the concept of Team Resource Management and use some aviation examples to provide interest and illustrations that are non-threatening to healthcare professionals. Participants will be challenged to identify the parallels with their own working environment and to apply the ideas to their practice. Debate, personal examples and involvement will be encouraged.
For delegates new to Human Factors there is a 10 minute introductory video on the home page of the Terema website (www.terema.co.uk) and a further video about leadership in the resources section.
Masterclass Reading
Here is a short list of books which may be of interest to delegates although none are required texts for the Masterclass. We have placed them in order with the easiest to read and, to our minds, most accessible at the top.
Complications – A surgeon’s notes on an imperfect science: Atul Gawande 2003
Profile ISBN 978-1-84668-132-5
Blink – The power of thinking without thinking Malcolm Gladwell 2005
Time Warner ISBN 0-316-17232-4
Thinking Fast and Slow Daniel Kahneman 2012
Penguin ISBN 978-1-846-14606
Just Culture – Balancing Safety and Accountability; Sidney Dekker 2007
Ashgate ISBN 978-0-7546-7267-8
Counting Sheep - The science and pleasure of sleep and dreams Paul Martin 2003
Flamingo ISBN 978-0-00-655172-0
The Limits of Expertise – Rethinking pilot error… R Key Dismukes et al
Ashgate ISBN 978-0-7546-4965-6
The Decisive Moment – How the brain makes up its mind Jonah Lehrer 2009
Canongate ISBN 978-1-84767-315-2
Patient Safety Charles Vincent 2006
Elsevier ISBN 0-443-10120-5
The Human Contribution – Unsafe acts, accidents and heroic…James Reason 2008
Ashgate ISBN 978-0-7546-7402-3
Safety at the Sharp End – A guide to non-technical skills Rhona Flin et al 2008
Ashgate ISBN 978-0-7546-4600-6
There are also a number of documents or supporting material accessible from the resources of the:
Terema website www.terema.co.uk
The Clinical Human Factors Group - www.chfg.org
The NHS England (Encompasses Former NPSA and NHS IQ) - www.nrls.npsa.nhs.uk and www.england.nhs.uk
Institute for Healthcare Improvement (USA) - www.ihi.org
The Health Foundation - www.health.org.uk
However…………
Managing Human Factors is much more a behavioural exercise than an academic one.
At the end of each of the training modules, delegates will be challenged to identify how they could incorporate two ideas from the module into their professional activity.
By the end of the second day this list will have 12 items. We recognise that this magnitude of challenge is unrealistic so we ask that they prioritise to the three most powerful and achievable of the 12 and undertake those. These three will be copied to a postcard which will be returned to them, along with the certificate of attendance, a month after the Masterclass.
In the same package will be brief refresher notes from the Masterclass highlighting and developing areas which were of particular interest to each group of delegates.
Approximately a month later a further update covering additional material will be circulated.
A quick statement of what we are about
Patient Safety is a familiar mantra in every corner of the NHS. More than 75% of patient safety failures involve ‘human factors’, a category much wider than simple human error. Unfortunately, even highly skilled, knowledgeable and hard working health care workers deliver variable performance as a consequence of simply being human. In aviation, acknowledging, accepting and then seeking to manage this human vulnerability led to a field of expertise known as Crew Resource Management (CRM). In the healthcare context this is Team Resource Management (TRM).
Participants will receive a Certificate of Course Completion and be able to claim parallel accreditation for the 12 CPD points awarded by the Royal College of Physicians
Masterclass objectives
- To introduce the concept of Human Factors
- To introduce the vocabulary of Human Factors
- To show the link between Human Factors and safety
- To establish a link between effective team work and safety
- To lay the foundation for the development of essential team skills
Daily Programme Timetable
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Days 1 and 2 |
0830 - 0900 |
Registration with Coffee |
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0900 - 1030 |
Session 1 |
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1030 -1045 |
Break |
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1045 - 1300 |
Session 2 |
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1300 - 1350 |
Lunch |
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1350 - 1500 |
Session 3 |
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1500 - 1515 |
Break |
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1515 – 1700 |
Session 4 |
Course outline
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Day one |
Session One |
Welcome and Introduction to the course |
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Session Two |
Situation Awareness |
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Session Three |
Risk and Error Management |
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Session Four |
Communication |
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Day two |
Session One |
Personality |
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Session Two |
Choosing Behaviour |
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Session Three |
Human Factors Feedback |
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Session Four |
Overload, Tools and Teamwork |
Introduction - session objectives
- To understand that we are here to address safety
- To introduce ourselves
- To think about teamwork
- To understand the context of the programme
- To explain the structure of the course
- To allow participants to understand their part in the programme
Humans are genetically primed to learn by trial and error so error is ‘normal’. Human performance is variable in both the long and the short term. Management of these Human Factors is a professional responsibility. This responsibility includes working effectively in teams and a willingness to develop supporting systems and processes of work which avoid provoking error and which act to mitigate the consequence of error.
Situation Awareness - session objectives
- To develop a suitable vocabulary
- To understand what ‘Human Factors’ are
- To explore some Human Factors
- To introduce Team Resource Management
- To explore some TRM vocabulary
- To look at briefings as part of Situation Awareness
In order to gain some insights into human fallibility we will need a suitable vocabulary. The language of human factors will allow us to understand how individuals are affected by their life experience, by their environment, by their interaction with other people and by their interaction with technology and equipment. We can make our professional activities safer by acknowledging these influences, understanding how we are affected, and actively managing them. Human Factors awareness and good Team Skills are tried and tested ways of enhancing safety. They are part of our personal and collective responsibility for safety.
Risk & Error Management – session objectives
- To explore Human Error and the concept of the error chain
- To look at the sources of, and responses to, error
- To explore some error management techniques and how to make them work
- To understand the importance of error and risk reporting
- To understand the prerequisites of a reporting and learning culture
- To encourage active participation in error management and reporting.
There are three aspects to managing risk. In the wake of a Serious Untoward or Critical Incident a process of Root Cause Analysis will explore what happened and why it happened. This can be very time consuming and because it occurs after an incident there may be a highly charged atmosphere no-matter how diligently or fairly it is carried out.
When new equipment is introduced or a new situation arises a Risk Assessment will be undertaken. Understandably this is a fairly static and periodic exercise.
No working environment or process is risk, hazard or error free. In our daily lives we assess risk or hazard every few minutes and act on our decisions, sometimes we make mistakes. What we do everyday in our workplace will affect the safety of patients and colleagues alike. By managing our errors effectively we avoid adding links to the error chain.
Creating a learning, rather than a blaming environment, learning from errors rather than hiding them and taking responsibility to build defences against harm is a professional duty.
Communication - session objectives
- To explore effective communication
- To explore blocks to communication
- To explore ways of managing the blocks to communication
The fundamental purpose of effective communication is to create understanding in the minds of others. Accident and incident reports are littered with examples of distorted, misunderstood, missing or incomplete transfer of information between the parties. Our communication processes are fundamentally flawed. Even with access to the same information different individuals can reach different conclusions. Our ability to process information is affected by the amount of spare processing capacity available. In high workload situations we become less effective communicators - this has a direct impact on safety. Even in times of low workload there are times when the message will simply not get through.
If we understand the processes involved, then we have a chance to manage communication for greater effect. From the earlier modules we have seen that briefing is the most effective way to share and compare our Mental Models and in so doing enhance team Situation Awareness. We also have to recognise and respect the difference between social and professional modes of communication since they are profoundly different and critically important.
Personality – session objectives
- To introduce the concept of Emotional Intelligence
- To gain insight into our own preferences
- To appreciate that others have different preferences
The general consensus of opinion is that our personality is pretty much determined at birth and that with the exception of traumatic events, high voltage electricity or fairly powerful drugs is largely unchanged by life. Aspects of personality pre-dispose to preferences in the way in which we view, and deal with, the world. If these preferences are different from those of the people with whom we work or live there is an opportunity for synergy or conflict, dependant upon how we manage the differences.
Choosing Behaviour – session objectives
- To establish that personality is not the same as behaviour
- To establish that it is possible to choose behaviour
- To consider instinctive and learned behaviour
- To establish the nature of Adult behaviour
- To identify strategies for managing our behaviour
Poor or inappropriate behaviour is a source of tension in work or social life. Sometimes the behaviour would be unsatisfactory wherever it occurred but on other occasions it is merely inappropriate to the particular situation. A degree of social behaviour is necessary to the function of most work teams and a degree of professional behaviour has its place in social life. Choosing the behaviour most appropriate to a particular situation is a skill and in common with most skills it can be taught and will improve with practice.
Feedback – session objectives
- To establish that this is Human Factors feedback, not appraisal nor comments about technical skill
- To establish the need for feedback
- To consider how to give feedback
- To consider the response to bad or unwelcome news
- To encourage routine team feedback
- To encourage participants to start the process by asking for feedback
Human factors feedback is the jewel in the crown of personal development. Having read the situation you choose a particular behaviour. How do you know if your behaviour was effective? If it was effective you would want to know so that you could add it to your repertoire. If it was not effective you may consider a change next time. Either way, the way to test is to get someone else to tell you. Maybe you didn’t take the time to choose but instead reached for ‘the way you always do it’. That’s fine if it is appropriate, but just supposing that it is not. How will you find out? Will your team give you feedback uninvited?
Overload, Tools and Teamwork – session objectives
- To review the characteristics of effective teamwork
- To identify the link between Team-working skills and Emotional Intelligence
- To gain first hand experience of overload
- To explore tools and skills for enhancing team performance
Overload has a profoundly negative effect on performance. When overloaded we become incompetent and our judgement becomes poor. Effective individuals and teams manage overload. Teams which communicate effectively use standard language and structures to manage risk. Handover, briefing / debriefing, escalating concerns and the use of checklists can be made more effective by applying the correct techniques. Creating and maintaining a professional climate within an appropriate culture is everyone’s job. As leader or just team member, our responsibilities spread beyond the task being undertaken to the motivation, development and well-being of other team members.
Participants will receive a Certificate of Course Completion and be able to claim parallel accreditation for the 12 CPD points awarded by the Royal College of Physicians
IF YOU BOOK A PLACE PLEASE BE SURE TO ATTEND. THIS IS AN EXPENSIVE COURSE, DUE TO THE LIMITED PLACES. PLEASE DO NOT DEPRIVE SOMEONE ELSE A CHANCE TO ATTEND.
The course if free to SAS doctors.
Please contact SAS.Tutor@tst.nhs.uk,
Sreekumar
SAS Tutor, Musgrove Park Hospital, Taunton