Strategic actions for safer care - Clinical Human Factors Group
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Strategic actions for safer care - Clinical Human Factors Group

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A learning resource for BoardsGetting to grips with the human factor:Strategic actions for safer careMay 2013AcknowledgementThe CHFG would like to thank all those who have contributed to this learningresource, from its early beginnings through to its publication. It has been a collectiveeffort that has engaged our active supporters, CEO’s, Directors and Non-ExecutiveDirectors from the NHS, academics, writers and designers. On behalf of patients wewould like to thank everyone who has shared their insights, information and input- without their respective contributions, we would not have been able to producethis ‘Learning Resource for Boards.The Clinical Human Factors GroupIn the last five years, the Clinical Human Factors Group (CHFG), amongst others, hasraised awareness of the importance of applying human factors to the design ofhealthcare systems. The Clinical Human Factors Group is a broad coalition ofhealthcare professionals, managers and service users who have partnered withexperts in human factors from healthcare and other high-risk industries to campaignfor a healthcare system that places an understanding of human factors at the heartof improving clinical, managerial and organisational practice. You can find furtherinformation on the work of the CHFG at guide was commissioned by the Clinical Human Factors Groupand supported with funding from The Health Foundation© 2013 Clinical Human Factors GroupAll rights reserved. The Clinical Human Factors Groupis a charitable trust, Registered No. 1123424.Contact us at

Getting to grips with the human factorCONTENTSForeword 4Introduction 51: Human factors what they are and why they are important 62: The Board’s role in human factors 153: How to gain assurance not reassurance 244: Taking action 29References 33[Pre publication copy] 3

Getting to grips with the human factorFOREWORDEnsuring effective, compassionate care and treatment, while keeping patients free fromavoidable harm is the essence of any healthcare system.The vast majority of patients using NHS services experience great care but the evidence isclear that there are still too many occasions where care and treatment falls below anacceptable standard.Delivering healthcare is becoming increasingly challenging and complex.Inevitably things will go wrong and we have to accept that errors will occur because staffare human. Staff often achieve, remarkable results in spite of, rather than because of theirorganisation’s systems and processes.Healthcare Systems are often poorly designed, or prone to failure when overloaded.Our collective challenge is to recognise the “human“ factors and skilfully apply provenapproaches that simultaneously improve system and individual performance, tacklevariation and improve the reliability of patient care.The board plays a key role in creating an organisational culture that supports front lineclinical teams to do the right thing, first time, every time. This guide will facilitate a betterunderstanding of the vital contribution that human factors science makes in delivering thiscrucial objective.The guide is a practical tool using vignettes to demonstrate the role of the board in settingthe cultural tone to enhance reliability, how error can be designed out and how humanfactors will deliver improvements in patient safety, experience and productivity.We commend the guide to you as a vital tool for every board. It provides a useful andpractical framework through which human factors science can deliver real benefits forpatients and staff.Sir Stephen MossChair DH Human Factors Reference GroupFormer Chair Mid Staffordshire NHS Foundation TrustPeter HomaChief ExecutiveNottingham University Hospitals NHS[Pre publication copy]

Getting to grips with the human factorINTRODUCTIONIncreasing attention has been paid to improving the safety culture of the NHS. Campaigns,inquiries into failing healthcare organisations and the work of organisations such as theHealth Foundation have resulted in a growing recognition that boards have a fundamentalimpact on the safety of their organisation’s systems, processes, equipment and controls bysetting the cultural norms and management practices.As Executive and Non-Executive Directors, you all have your part to play in taking strategicactions for safer care. This guide is intended to help you get to grips with the human factorthat is a natural phenomenon, increase your awareness and understanding of the science,and prepare you for the actions that you will want to take to fulfil your responsibility to thepeople in your care.The Clinical Human factors Group has developed this learning resource for the Boards ofhealth organisations in order to:• Raise awareness and stimulate dialogue about human factors• Demonstrate how human factors impact on quality, safety and productivity inhealthcare• Encourage Boards to invest time and resource in human factors• Identify the contribution Boards and their individual members can and should bemaking in this area• Act as a signpost to additional resources.The learning resource has been designed to be succinct and accessible. It offers questionsfor Board members to ask of themselves and their organisation and suggests learningactivities for Boards and individual directors to undertake. It includes real case studies andsignposts other useful resources.[Pre publication copy] 5

Getting to grips with the human factor1HUMAN FACTORS.WHAT THEY ARE ANDWHY THEY ARE IMPORTANTThe following blog by Jocelyn Cornwell, Director of the Point of Care programme at theKing’s Fund, illustrates the typical challenges facing board members.Letter to a friend, a non-executive director on the board of an NHS Foundation Trust 1It’s three weeks since Robert Francis published his report and I know you are reallyworried about the hospital: about nursing care, about the mortality rate, and whether,before you arrived, people left the trust having signed gagging clauses. Most of all, youare worried about staff and how you can convince them the board does mean to put‘patients first’ when they look around and see that elsewhere in the NHS nothingseems to change and its business as usual.If your hospital is anything like the ones I’m hearing from, managers are telling you it’san angry place. I hear that patients and relatives have started to film interactions withstaff on their phones whilst others are threatening to go straight to the press if theydon’t see the director of nursing in the next ten minutes. The Care Quality Commissionand the Strategic Health Authority are keeping the temperature at boiling point withunannounced visits almost daily and the commissioners are demanding to know everydetail of what is happening in the trust. I know you are concerned about the pressurestaff are under, and don’t want to make it worse. But you worry about your ownresponsibility for the safety and quality of patient care in the hospital. What can youdo?My advice is to remember that you are the eyes and ears of the outsider but you haveprivileged access to the inside of the hospital. That is your value to patients, to theexecutives and to the board. Use it well but take your time – thoughtful reflectionabout what can go wrong and why is all too rare, and we need lots more of it at everylevel of the system. Read chapter 20 of Francis’ report and his excellent account of whata common culture looks like to guide your own inquiry into the culture of the trust.With your fellow directors, develop a medium to long-term plan based on what youfind.Commit yourself to a year-long schedule of informal visits to wards, clinics anddepartments throughout the hospital. Try to visit at different times of day and night andon different days of the week. Introduce yourself to the staff on arrival and then,quietly and unobtrusively, observe what is happening. You may think this is impossible:that managers will resent you and feel undermined, that staff will behave differentlybecause you are there, that you ought not to disturb patients. Remind yourself whenyou need to that your role is different from the managers’, because you are notcompelled to take action. You have a right and a responsibility to use your eyes andears: sit or stand quietly to one side, for only a few minutes and you will be surprised athow quickly people forget you are[Pre publication copy]

Getting to grips with the human factorDr Mark Newbold, Chief Executive of the Heart ofEngland has said in the professional press that hepersonally spoke with new staff at his trust duringtheir induction.“My final word with them is always that you canhave any number of procedures and policies butthe ultimate failsafe is the 11,000 of them”.As a result he receives 3-4 safety concerns fromstaff a month.How many do staff report to you?Boards have a critical role in relation to safety (Monitor,2010). Critical because they set the agenda, level ofinvestment, culture and strategy for safety.Executive and non-executive directors are individuallyand collectively accountable for patient safety and areexpected to ensure appropriate governance systems.Healthcare organisations in the UK and internationallyare investing in human factors education andinterventions as part of good governance.Further reading and resources• Health and Safety Executive (2011) Highreliability organisations• A review of the literature• Health Foundation (2011) High reliabilityorganisations: Research Scan[Pre publication copy]

Getting to grips with the human factorWhat are human factors?Human factors are all the people issues – how we see, hear, think and function physically- as well as the interrelationship of people and their environment and to each other whichneed to be considered to optimise performance and assure safety. In healthcare theserange from the design of tools such as medical devices, to services and systems as well asthe working environment and working practices such as rotas, roles, team behaviours andso on.Dr Ken Catchpole, a human factors expert offersthis definition:“the factors that enhance clinical performancethrough an understanding of the effects ofteamwork, tasks, equipment, workspace, culture,and organisation on human behaviour and abilities,and application of that knowledge in clinicalsettings.”Human factors research investigates and applies knowledge about human behaviour,abilities, limitations, and other characteristics to the design of tools, machines, systems,tasks, and jobs, and environments to ensure productive, safe, comfortable, and effectivehuman use. So a human factors perspective helps highlight why a piece of clinicalequipment that hasn’t taken human strengths and limitations into account in its design ora work environment and shift pattern that is disruptive and stressful is likely to lead to lessthan optimal human performance and is likely to result in error and compromise patientsafety. A human factors approach also assists our understanding of the positive aspects ofhuman abilities and performance.Erik Hollnagel, an internationally recognised human factors expert, argues that accidentsoccur as a consequence of the trade-offs people make between efficiency andthoroughness, something he calls the ETTO (Efficiency Thoroughness Trade-off) principle.These trade-offs are not random; they are regular, effective and learnt. Hollnagel believesthat studying these trade-offs is vital to be able to prevent errors.Further reading and resources• Erik Hollnagel - To Err Is Human:The ETTO Principle•• Safer care: human factors forhealthcare[Pre publication copy] 9

Getting to grips with the human factorHuman factors are important in:• System, service and product design• Assessment of new procedures, services etc• Staffing and ways of working• Learning and development• Incident investigation• Organisational culture.Boards need to lead the way in embedding ahuman factors approach, fostering the cultureand commitment required to address systemsissues and provide the processes and tools tofacilitate behaviour change.Experience from other safetycritical industries, such as aviationand nuclear power, has shownthat systems, facilities andequipment are safer if they aredesigned to match the abilitiesand behaviour of the people whouse them, to help prevent humanerror. In particular, experience hasshown that the more that ‘humanfactors’ are considered, the saferthe system will be.The case for human factors approachesAttention to human factors has transformed safety in Formula 1 motor racing. It has leadto a design approach founded on an understanding of the cognitive and physicalcapabilities of people.The case study below, demonstrates how taking a systematic approach to analysing thingsthat go wrong and making safety improvements has reduced mortality and morbidity.Case study: How a Human factors approach transformed safety in Formula 1High profile deaths in Formula 1 motor racing had prompted senior managers toreflect on safety in the sport. Professor Sid Watkins was appointed as the senior doctorin 1978. His brief was to improve safety.In the 1960s, fire was the biggest risk to racing drivers. In the 1970s, a series of safetydesign modifications were introduced to Formula 1 racing cars. As a result, since 1978there has only been one moderate burn injury and two minor burn injuries.In the 24 years before 1982, 24 drivers died at a F1 racing circuit.Since the early 1980s, a multi-disciplinary team of bioengineers, safety experts,(including human factors experts), and engineers have worked together with F1 teamsto ensure both the circuits and cars are designed to meet human capabilities. Forexample, in the early 1980’s there were over 40 circuits which had G Forces of over 4or 5 in the cornering aspects. F1 circuits have now been re-designed so there is nocircuit with a lateral G force of 4. Simulation and crash testing is also used to test theimpact of a crash on the driver.In the last 12 years, there has been zero mortality amongst drivers in Formula 1 andthere has been a significant reduction in the number of spinal injuries suffered[Pre publication copy]

Getting to grips with the human factorAs illustrated in the example from Formula 1on the previous page, human factors enable usto understand why people make errors andhow systems impact on safety. Using humanfactors approaches in healthcare improvespatient safety through better design ofequipment and working practices andincreases the opportunities for learning whenthings go wrong. Human factors techniquescan also assist in predicting what might gowrong in the design of new systems andprocesses. Investing in human factorsapproaches has clear business benefits andassists in meeting regulatory requirements too.Further reading andresources• Professor Watkins’s talk onthe evolution of safety inFormula 1 at the RiskyBusiness conference in2010 business benefitsThe business benefits of a human factors approach which have been indentified inhealthcare and other industries are that it:• offers a different lens through which to examine the organisation• pre-empts costly disasters• reduces error• encourages a positive reputation• improves safety• increases effectiveness• increases patient satisfaction• increases staff productivity, morale and retention• reduces cost.All health systems are currently grappling with quality, safety, effectiveness, patient andstaff experience, leadership and organisational culture. Human factors approaches arefundamental to success in each of these domains.[Pre publication copy] 11

Getting to grips with the human factorThe vignette describes two Chairs in two different organisations who are facing verydifferent situations. However, what is common to both is that an understanding of humanfactors would help them to improve patient safety in their respective trusts. The first has toresolve a Board culture where a steep authority gradient stops executives speaking up,where there is a Chief Executive who seeks confirming evidence that this is a ‘goodorganisation’ and ignores negative indicators (known as ‘confirmation bias’). One of thethreats facing this organisation is that ‘groupthink’ will set in at Board level.In contrast, the Chair of the other organisation, leads what outwardly appears to be a highperforming organisation. Her challenge is to create a culture where everyone understandsthat patient safety is a job never done. She needs to lead the organisation to maintain afocus on improving patient safety and experience at a time when the Board’s and othersattention is likely to be deflected towards efficiency and cost saving targets.Further reading and resources• Human factors and patient safety culture[Pre publication copy] 13

Getting to grips with the human factorBoards embody and are the culture carriers oftheir organisations. Effective boards shape apositive culture for the board and theorganisation. Board influence on theorganisational ‘safety culture’ is well-recognised inthe international research literature. Boardscontribute by visibly engaging with the qualityagenda, for example by participating in ‘executivewalk rounds’ where board members – executiveand non-executive – discuss safety issues withfrontline staff; by hearing patient and staff storiesat the board; by giving attention to systems anddesign issues as well as performance data; and byresourcing appropriate learning and developmentprogrammes for staff.In the safety arena the importance of Boardsestablishing a ‘just’ and informed rather than a‘no blame’ culture is emphasised (Marx, 2001). Ajust culture is one that avoids casting blame and/or penalising individuals for genuine mistakes thatmay signal system failures (including deficienciesin training) so that the organisation can learnabout and correct such failures.In its response to the 2013 Mid StaffordshireFoundation Trust Public Inquiry report thegovernment has announced plans for a statutoryduty of candour. (Department of Health, 2013).This is intended to ensure open and earlydisclosure of errors. It would require healthcareproviders to tell people if they believe treatmentor care or indeed the absence/omission of eitherthese has caused death or serious injury.Commentators increasinglydoubt that there is such athing as a single NHS Cultureacross the service or indeedin a particular organisationinstead there are oftensignificantly different culturesamongst different staffgroups and in different partsof organisations.INSERT IMAGEWhat unintendedconsequences might followfrom the implementation ofa statutory duty of candour?How will you prepare yourorganisation for this change?Further reading and resources• Safety culture: What is it and how do we monitor and measure it? A summary oflearning from a Health Foundation roundtable• Marx D. Patient safety and the “just culture”: a primer for health care executives.April 17, 2001.[Pre publication copy]

Getting to grips with the human factor2THE BOARD’S ROLE INHUMAN FACTORS“making it easy for the frontline to do the right thing – first time, every time” (HR Director)Organisations won’t be able to achieve the highest standards of quality and safety withouttheir Board embedding human factors thinking in their strategic approach to improvingpatient safety. Boards should:• Prioritise safety and quality• Have a strategy for human factors• Be accountable for human factors• Shape the safety culture• Ensure a just culture• Have the right sorts of conversations with each other and all levels of the organisation• Provide visible leadership• Give human factors their commitment• ListenMake resources - time, money and people - available.Modelling Human factors from the topAlthough the Director of Nursing/Chief Nurse and/or the Medical Director havetraditionally been the identified lead for safety and quality in healthcare organisations, allboard members are accountable for quality and safety. The vignettes below have beendeveloped specifically to illustrate how this responsibility and accountability for quality andsafety can be enacted in Finance and HR Director roles.Designing systems that save lives and money: the finance directorThe Finance Director in an NHS Foundation Trust is the executive director accountable forachieving its cost and efficiency savings programme. The finance team have identifiedseveral areas where significant savings could be made, two of which are reducing thehospital’s emergency readmission rate and improving the approach to investing in the ITinfrastructure so that money is not wasted on technology that does not meet the needs ofclinical and non-clinical teams.The introduction of non-payment penalties for patients who are readmitted within 30 daysof discharge has resulted in significant financial losses for the organisation. The Trust’smean readmission rate is 11%, which compares unfavourably to top performing peerorganisations whose readmission rate is 7%. Data from the Trust’s performance team hasshown that over 50% of patients who are readmitted within 30 days are ‘preventablereadmissions.’ That is to say, they are suffering from complications relating to pain control,medication non-compliance, in-dwelling catheter management and minor woundinfections that could be treated in the community. Information on what patients should doif they experience minor symptoms is not well communicated to patients before they aredischarged from hospital and communication to community care providers is alsoinadequate.[Pre publication copy] 15

Getting to grips with the human factorPoor decision making around IT investments has been an area where the Trust hasincurred significant financial waste in the past. Investment in an electronic patient recordsystem which clinicians found unreliable led to clinical staff reverting to using paperrecords. Similarly, the Trust has incurred unforeseen costs and patient safety risks whenother IT systems have been introduced that did not meet the needs of clinical teams. Theroot cause of the problem is that the IT team do not engage healthcare teams early on indecision making about IT solutions.The Finance Director sets up a multi-disciplinary group to work with the IT team onmaking the IT systems in the hospital as intuitive to use as a smartphone.Developing an open, fair and supportive culture: the HR directorThe HR Director at a District General Hospital is concerned that the Annual NHS StaffSurvey data has shown that the Trust is in the bottom 5% of Trust’s for staff reporting thatthey have experienced bullying and harassment in the last six months. It also shows thatthe Trust is in the top 20% of Trusts on a measure of the frequency with which staff areexpected to work extra shifts to cover sickness absence and high nursing vacancy rates.She is aware that some senior managers and consultants have been rude to colleague,patients and carers. Staff surveyed also reported that they would not report a patientsafety incident through the local incident reporting system because the hospital’s culture isone of blame and punishment, rather than learning and improvement.The HR Director wants to improve the staff experience. She is concerned that conscientiousward nurses are expected to work extra shifts to cover sickness absence and high vacancyrates in some areas. This in turn is having a negative impact on nursing staff turnover rates– which are higher than in other similar organisations – and is leading to poor morale. Shealso wants to resolve the bullying and harassment issue and create teams where everyonefeels valued and listened to.The HR Director sources information on the relationship between tiredness, shift patternsand its impact on human performance so that she can persuade senior nursing colleaguesthat current practice is unsafe. She works with consultants and senior managers in theorganisation to set the expectation that the organisation will not tolerate any staffincluding consultants and senior managers being rude to colleagues, patients and carers.She involves managers at all levels in the organisation in developing a high profile, crossorganisational campaign with a supportive infrastructure designed to increase thereporting of safety concerns.Further reading and resources• The Joint Commission (2012) ImprovingPatient and Worker Safety: Opportunities forSynergy, Collaboration and Innovation.’[Pre publication copy]

Getting to grips with the human factorGetting human factors on the agendaInterest in human factors has often been provoked by experiencing a disaster or neverevent. Our goal in this resource is to get human factors on the board agenda of everyhealthcare organisation before disaster strikesCase Study: Learning from the Deepwater Horizon oil spill in the Gulf of MexicoNick Coleman is a former Vice President at BP, responsible for corporate safety performance reportingand former non-exec chair of the Royal Brompton & Harefield Trust’s Risk & Safety Committee. At atalk at the Risky Business conference in 2010, Mr Coleman describes five lessons from the DeepwaterHorizon oil spill in the Gulf of Mexico:Lesson 1: Recounting the decision making in the hours leading up to the oil release, Colemandescribes how the lack of clarity about who was the leader contributed to the disaster. The platform’soperators were presented with conflicting information on gas pressure traces in the hours leading upto the blowout. A blue trace indicated that everything was fine, a second green coloured traceindicated there was a problem. The operators in the control room, accepted the blue trace withoutanyone in the room questioning the decision to ignore the increasing green trace. So who was incharge and why did none of the team members question the decision to discount the information inthe green pressure trace? The first lesson from Deepwater Horizon relates to ‘ensuring there are nodotted lines in your organisation.’ It is vital to understand who is in charge and to have clear lines ofaccountability for safety.Lesson 2: relates to how Board members interact and assimilate information from risk registers. Therisk of a major blow out on an oil platform was a known safety risk. It had been documented insafety reports reviewed by senior managers at BP. However, Coleman’s point was that seniormanagers at BP did not seek to ‘understand oblivion.’ They did not interrogate risk registerinformation and assimilate what it was telling them about potential incidents. His advice to otherBoard members is, don’t just sit there and nod when the risk register is presented to you as anexecutive team. Seek to understand the message it is conveying.Lesson 3: relates to the need to actively manage risks or to ‘shift the blobs,’ as Coleman describes it.Put simply, if Boards do not respond to risks and manage them then an incident will occur. Don’t letrisks lie dormant on your risk register. All too often safety information is presented to Boards butassurance is not sought that action plans will result in timely risk mitigation.Lesson 4: involves learning after an incident has occurred. Coleman comments that all too oftenincident investigations only identify a third of the root causes that caused the incident. Is this the casein your organisation?Lesson 5: pertains to understanding your safety culture. Coleman notes that organisations can have aplethora of policies and procedures but these are worthless if the safety culture is not just andinformed. Only by understanding and improving organisational and team cultures can we preventthings going wrong in the future.Further reading and resources• You can view Nick Coleman’s presentation at:[Pre publication copy]

Getting to grips with the human factorPatient StoriesSince the national focus on safety many boards start their proceedings with a patient story.Patient stories are stories told by patients from their own perspective and may focus on anexcellent healthcare experience but more often concern an unsatisfactory experiencewhich may have resulted in significant physical or emotional harm. The intention of usingpatient stories in this way is to remind members of the purpose of the organisation andhelp them gain a fuller understanding of the services the organisation provides and howthey might be improved.Questions for ReflectionDo you start each Boardmeeting with a patient story?If so is there evidence oflistening, learning and actionresulting from these stories?Might you consideradditional/alternativeapproaches to gain thepatient perspective?For example one Chair of alarge trust is known to walkaround the wards out ofhours talking to patients andstaff and finds this moreuseful than a patient story ingaining an accurate pictureof how services arefunctioning.Recent conversations with Board members haveindicated that beginning every board meeting with apatient story has become formulaic with the dangerthat the critical messages are not properly heard.Critically, evidence of action as a consequence of thesepatient stories is often scant.Complaints are a valuable source of feedback. It isessential that Boards pay attention to the narrativecontent of complaints as well as the incidence, trendsand time taken to respond. The narrative content mayinclude useful human factors insights such asinformation about the time of day, the type ofequipment etc. All Board members should review asample of complaints each year as well as the letters ofappreciation and thanks which may have also beenreceived.Patient stories can also be used to complementquantitative data reports. This can be a powerful wayof increasing the focus on and engagement with thefundamental human aspects of quality and safetyissues.Seeking insights from many different data sources andperspectives is important. Triangulating data in thisway increases the robustness and credibility of theconclusions drawn regarding the organisation’sperformance.One big US healthcare provider added names ofpatients who had been injured or had died to itsrun chart of serious safety events and showed it toemployees and the board.“When you make people’s mouths go dry andrecognize that it’s their lives, their families atrisk—that is a very powerful moment.”[Pre publication copy] 19

Getting to grips with the human factorStaff stories‘What matters to staff in the NHS’ (DH, 2008) is that they have:• the resources to deliver quality care for patients• the support they need to do a good job• a worthwhile job with the chance to develop• the opportunity to improve the way we work.There is a high degree of overlap between staff and patient satisfaction in healthorganisations. Some healthcare organisations are beginning to use staff stories in theirBoard meetings as a tool for organisational learning, and increasing Board engagementwith the organisation’s staff and their experience of working in the organisation. What arethe mechanisms you and your Board use for listening to staff and patients?Learning ActivitiesInsights from human factors research indicates that how the Board itself works andthe behaviours board members adopt and accept has an impact on the broader safetyculture of the organisation.1. Take time out at the end of each Board meeting to review the effectiveness of thediscussion and consider what steps could be taken to make the next discussionmore effective.2. Schedule time for regular reviews with support and advice from an external peerand or board development expert, on how your Board is operating andperforming3. Encourage board members to observe/participate in other boards in the healthsector and beyond and to bring back this[Pre publication copy]

Getting to grips with the human factorValues driven leadership“processes are essential but values and behaviour are critical” (DH, 2010) Review of earlywarning systemsInvestigating but not learning: the chief nurses safety challengeThe Chief Nurse at a Mental Health and Community Care organisation has been in post forthree years. Following several serious incidents involving both medication administrationand failure to recognise and escalate abnormal vital signs, the Board have asked the ChiefNurse to develop an action plan to improve community nursing compliance with themedication and vital signs policies. Recommendations from serious incident reports havealready been implemented; several nurses involved in past incidents have been retrainedand subject to disciplinary action. This has not reduced the frequency or severity ofincidents and the Chief Nurse is concerned that the serious incident investigations are notidentifying solutions that address the root causes of the incidents. Her perception is thatthe investigations tend to focus on the errors made by frontline care providers and do notaddress what are perceived to be ‘unresolvable’ systems issues.She sets up a series of conversations with nurses working in the community hospitals tofind out their views about working in the organisation and the challenges they face. Thisalerted her to several issues not mentioned in Serious Incident reports including, (i)nursingworkload (ii) a fatigued workforce with nurses who have covered extra shifts to keep theservice running in the face of winter pressures (iii) difficulties accessing the latest versionsof Trust policies and procedures and (iv) cultural issues whereby nurses are reluctant toescalate safety concerns to medical colleagues because when they do so they arepatronised and ignored. Tackling these issues now forms the basis of her action plan.This vignette illustrates the value of seeking out information on human factors such asworkload and shift patterns in any investigation process.Further reading and resources• Breaking the rules: understanding non-compliance with policies and guidelines• Human Factors. Why is fatigue important? the tightrope between targets and patient safety: the chief executive’srealityThe Chief Executive at a Foundation Trust is under pressure to resolve recent poorperformance on meeting the Accident and Emergency (A&E) waiting times target. Boardperformance data shows that there has been a recent decline in the Trust’s performanceon meeting the four hour A&E waiting target. Monitor has downgraded the Trust to beingred rated on the A&E target on the last two successive quarterly performance ratings. TheChief Executive has been called into meet with the commissioners and Monitor to accountfor the high incidence of A&E breaches over the last three quarters. Negative mediaattention has also increased pressure at Board level to sort the problem out.[Pre publication copy] 21

Getting to grips with the human factorShe commissions a detailed analysis. This reveals that one of the main causes of theincreased number of A&E breaches is poor flow. Patients cannot be transferred from A&Eto the wards because it is difficult to locate a bed. All too often patient discharges fromwards are frequently delayed because patients are waiting for their take away medications(TTAs), an occupational therapy assessment, district nurse referral documentation to becompleted or a ward round to take place to confirm that a patient is well enough to bedischarged home. It also reveals that delayed transfers from A&E are creating patientsafety risks such as hurried handovers from A&E to other clinical areas and a huge increasein the number of outliers.This vignette illustrates the importance of rigorous and detailed analysis in understandingthe story behind the data. It also demonstrates the interconnected nature of efficiency,quality and safety. Focusing on one measure of efficiency in this case A&E waiting timescan have a negative impact on other safety and quality issues such as adequacy ofhandover and patients not being treated in a clinical environment appropriate to theirneeds.The medical director’s cultural revolutionThe Medical Director at a District General Hospital is concerned that the results of theannual maternity services survey have shown that a high percentage of women report anegative experience of childbirth after giving birth on the labour ward. Survey results showthat women have reported feeling a lack of confidence and trust in the staff, being leftalone during labour at a time when they were feeling worried and not being involved indecision making.Other safety indicator data has also given the medical director cause for concern: Therehas been an increase in the number of complaints relating to the attitudes of bothobstetricians and midwives. Four serious incidents involving post-partum haemorrhage arecurrently being investigated. Workforce data on staffing levels shows a midwife vacancyrate of 15% but there is no recruitment plan in place. The medical director has alsoreceived an anonymous letter from a member of the team claiming that there is a cultureof bullying on the labour ward. The letter also raised concerns about the safety of the4000 deliveries per annum target, given that the midwifery workforce is tired and stressedbecause they are covering additional shifts week in, week out.Anecdotal evidence gathered from conversations with the Clinical Director for maternityservices and the Matron for Midwifery have also rung alarm bells. The Clinical Director andMatron attribute the survey findings and increase in complaints to women havingunrealistic expectations of childbirth. The Clinical Director has said that post-partumhaemorrhages tend to occur in clusters and ‘we just had a bad run.’ The midwife turnoverrate is accepted because ‘it has always been that way in midwifery. We have always hadproblems retaining staff.’To address these concerns the Medical Director realises he is likely to have most impact byworking together with the Director of Nursing to jointly address the leadership, cultural,staffing and recruitment issues on the labour[Pre publication copy]

Getting to grips with the human factorThis vignette illustrates the value of triangulating data from a wide range of sources suchas patient experience, staff experience and workforce data as well as clinical outcomemeasures in order to identify and understand causes for concern. It also demonstrates thatsafe, high quality care relies on effective multi-professional working at all levels of theorganisation from the frontline to the Board.Further reading and resources• Leonard, M. And Frankel, A. (2012) How can leaders influence a safety culture?Thought paper May 2012 Mayo Clinic in the USregularly tops surveys ofclinicians as being anexcellent place to work. Itprides itself on its deeplyembedded organisationalculture ‘the Mayo way’.Staff are recruited explicitlyfor the fit between theirvalues and the values ofthe organisation andsenior leaders aredeliberately appointedfrom within to preservethe organisation’s valuesA human factors perspective requires Boards to:• define the goals and values of the organisation andmake them live and breathe from ‘Board to ward’• Ensure compliance with regulatory requirements• Make safety a primary non-negotiable goal anddemonstrate visible and consistent commitment thisgoal• Make time for safety, provide resources for acomprehensive safety programme and measureimprovement over time• Show concern for people, hold people accountableand zero tolerance for inappropriate/unprofessionalbehaviours• Create psychological safety, encourage participatorystyles in middle-managers and clinical leaders• Recruit people with the right values.If all directors take human factors seriously then therest of the organisation will too.[Pre publication copy] 23

Getting to grips with the human factor3HOW TO GAINASSURANCE NOTREASSURANCEA contributor to a recent HSJ roundtable observed that the NHS should place as muchemphasis on checks of clinical quality as finance “We have a huge industry devoted tocollecting information about what we do in order to write it down on a piece of paper,send it to a commissioner and get the bill. We’ve a lot of people working in financialprobity, we don’t have the same number of people working in clinical probity”.Benchmarks,trends, varianceand comparisonsare essential inorder to interpretdata and put itinto context.Triangulation ofsources of dataand intelligence isvital to gain arounded picture.There are many useful sources of data and intelligence about thequality and safety of health services. These include:• Deanery and Local Education and Training Board reports• Healthwatch intelligence• Peer Reviews• Staff feedback in the National Staff Survey• Intelligence from professional regulators• Complaints data• Health & Wellbeing Boards• Clinical Networks and Senates• Safeguarding Boards• Comments on NHS Choices• Comments in blogs and conversations on twitter.Boards need sufficient of the right sort of information at the right level of detail to beconfident in the performance of the organisation. They are expected to maintain a soundsystem of internal control to safeguard patient safety and service quality and to audit thesearrangements. Insights from inquiries into adverse events nationally and globally indicatethat the staff of the organisation often know when things are likely to or are already goingwrong but for this information to be acted upon individuals need to feel that it is safe toraise concerns and managers and Boards need to listen to them..Learning ActivityReview the use of committees toensure that major decisions whichshould be made by boards are notdelegate in board meetings?[Pre publication copy]

Getting to grips with the human factorFurther reading and resources• Vincent. C and Burnett, S. (2013) How do we know healthcare is safe?Measurement of patient safety.• How to measure for improving outcomes: a guide for commissioners• The Intelligent Board the best part of a decade, leadership/executive walkrounds have been adopted bymany healthcare organisations as part of their patient safety initiatives. Walkrounds areintended to provide an informal method for leaders to talk with front-line staff aboutsafety issues in the organization and show their support for staff-reported errors. Thewalkround process seeks to:• Increase the awareness of safety issues by frontline staff• Make safety a priority for the Board• Educate staff about patient safety concepts such as nonpunitive reporting• Obtain and act on information elicited from staff about safety problems and issues• Close the gap between those who make and prevent error and those who have thepower to change the system.As with the patient stories, discussed earlier, Boards report different degrees of support forwalkrounds. Some Board members say these have become far more like ‘Royal visits’ andthat a more informal set of visits and chats is likely to generate more useful informationabout the human factors issues as is an informal ‘coffee morning’ with students andtrainees.Learning ActivityTry scheduling somethematic discussions atBoard meetings eg aboutthe experience of frail olderpeople using your servicesas well as speciality andfunction related discussions,notice the different issuesand concerns this type offocus brings to the fore.Why not involve HR andfinance staff in reviewingyour safety and quality dataas well as medicine andnursing to get a more fullyrounded perspective on thedata?The NHS Commissioning Board has publiclyregistered its concern about the recent NHS staffsurvey results relating to the reporting of errors,near misses and incidents. However when theseresults are compared to the previous years in2012 86% of staff felt encouraged by theirorganisation to report errors, near misses andincidents (up 3% on 2011) and 61% (up from57% in 2011) thought that action was taken toprevent similar errors occurring in the future.Is the NHS Commissioning Board’s concernjustified by the data?What are the particular figures for yourorganisation?What other information might be useful to you inhelping you to interpret your organisation’sresults?[Pre publication copy]

Getting to grips with the human factorBenchmarking within your organisation andexternallyBeing able to monitor your organisation’s performance and compare results to targets andother providers is vital in understanding areas of good practice as well as potential risks.Benchmarking has been used successfully in other safety critical industries such as the oilindustry to provide a vehicle and stimulus for the participating companies to pursueimprovements in safety and enable peer group comparisons to be made. First, a set ofindicators was developed to measure the human and organisational factors that can havean impact on offshore safety. This then provided a means by which the participatingorganisations could compare their relative performance and examine the reasons for thedifferences in safety performance. The data was then used to identify and share bestpractice (Mearns et al, 2003).A variety of benchmarking services are currently available to NHS organisations. Forexample the NHS Benchmarking Network is a subscription service established in 1996 to provide a structure that would enableNHS organisations to share best practice and learn from each other. NHS Comparators is a national resourceand is part of the Secondary Uses Service (SUS), jointly delivered by the NHS InformationCentre and NHS Connecting for Health. It provides comparator data for NHScommissioning and provider organisations, enabling users to investigate aspects of localactivity, costs and outcomes. It is designed to be supplemented by information available inlocal systems.In 2012 the Foundation Trust NetworkBenchmarking Study brought together 11acute trusts with A&E services ranging frommajor specialist trauma centres to primarycare-led urgent care centres. Usingcomparable and validated information ontheir services these trusts shared bestpractice and developed action plans toimprove their services.[Pre publication copy] 27

Getting to grips with the human factorLearning from outside of the health sectorSafety critical industries such asmining, nuclear, rail and aviationindustries have been engagingactively with human factors for manyyears. Reviewing evidence fromaccidents, such as the King’s Crossunderground fire, the capsize of theHerald of Free Enterprise and theClapham Junction railway accident,the Advisory Committee on theSafety of Nuclear Installationsconcluded that human factorsshould be systematically considered.Benefits reported from assessingHuman factors in this way include:• reductions in incidents, accidentsand errors• improvements in safety andusability• development of cost effectivedesign solutions• reductions in risk-taking.Lessons from other safety criticalindustries can be of value to healthorganisations because they havealready developed research andpractical knowledge of the use ofhuman factors approaches and thereare already examples of techniquesthat were developed within onesafety critical industry have beensuccessfully applied in healthcaresuch as the application of CrewResource Management training toclinical teams in a variety of clinicalareas.Ciaran Devane, Chief Executive ofMacmillan Cancer Support and nonexecutive director of the NationalCommissioning Board has said that “RobertFrancis mentioned at the Commons healthcommittee the CEO of a nuclear powercompany who went out of his way to thankpeople who gave him bad safety news. Itreminded me of a friend who is an officer inthe US Navy. He works in naval reactors andthey do not wear uniforms. It is a signal toany sailor with anything to say aboutnuclear safety that rank is not problem.Safety is always the first item on theagenda”.Learning ActivityCarrying out an organisational raidAn Organisational Raid is a cross-sector visitwhich enables representatives from oneorganisation to “raid” another organisationin a different sector to obtain quick,first-hand experience of what they do, howthey do it and why. Organisational raidsoffer a quick and practical way to seedifferent approaches, innovative ideas andto explore how another organisation tacklesparticular challenges.Organisational raids provide a safeenvironment in which to share best practice,discuss know-how, experience andproblems, and challenge conventionalthinking. Organisational raids, for exampleto organisations in the transport or energyindustry can help health organisationsexplore how Human factors approachesmight be applied in their own[Pre publication copy]

Getting to grips with the human factor4TAKING ACTIONTrain companies publish performance data. Building sites publish zero harm statistics.Initiatives such as the NHS Institute’s ‘Productive ward’ and the Institute for HealthcareImprovement’s ‘Transforming care at the bedside’ have resulted in wards and departmentsdisplaying their figures for falls, healthcare acquired infections and pressure ulcers etcpublicly on white boards in ward and department corridors. The public increasingly expectopenness. However Boards vary hugely in what is discussed in closed and open sessions,the amount of information shared on board decisions and the organisation’s performancethat is made public.Case StudyWhen Paul Levy became CEO of Beth Israel Deaconess in Boston, US the organisationwas facing financial crisis, had deep seated problems with quality and safety, poorstaff morale and fractious relationships between managers and clinicians. Levy’sapproach to developing a culture of transparency and accountability was fundamentalto turning the organisation around. He published quality and safety data for thehospital as a whole and for specific departments on the hospital’s website. Levy alsoused a blog to engage the public and the media in a dialogue about quality and safety.In 2008 when an operation was carried out on the wrong side of a patient theexistence of the error was immediately conveyed to all staff in a letter from Levy andthe Director of Healthcare Quality. The letter was also published in the Boston Globenewspaper to bring the issue fully out into the open.Learning ActivityThe public expects openness andtransparency with the onlyexceptions being matters that mustremain confidential such aspersonnel or commercially sensitiveinformation.What more could your board do tobe open and transparent?[Pre publication copy] 29

Getting to grips with the human factorChallenging complacencyMeasuring what matters: the non-executive director’s checklist dilemmaA non-executive director has recently taken on the role of chairing the hospital’s Patient SafetyCommittee. The Committee receive quality and safety dashboard data, broken down per clinicalservice which is reviewed on a monthly basis, clinical audit, complaints, claims, incident reportand serious incident investigation data, information on compliance with national alerts andpatient safety initiatives and reports from safety related subcommittees (for example, theTransfusion Committee and the Safe Medicines Committee).At the last meeting, the Patient Safety Committee received a quarterly audit report on compliancewith the WHO Surgical Safety Checklist. The report showed that operating theatres wereachieving 80% compliance in the sign-in section of the checklist, 85% compliance in the time outsection and 65% compliance in the sign-out section. No data on compliance with briefings anddebriefings was included in the audit report. The two previous quarterly reports had shownsimilar rates of compliance. The hospital is currently investigating two wrong site surgery NeverEvents (one in orthopaedics and one in thoracic surgery). Feedback from patient safety executivewalk-rounds has shown that briefings and debriefings are routinely not carried out, that thetime-out is completed without the surgeons in theatre and that many operating theatre staff viewthe checklist as ‘a tick-box exercise.’As Chair of the Patient Safety Committee, the non-executive director has questioned theapproach to auditing the checklist. To her, the audits seem too focused on ‘measuring whethertheatre teams have completed the tick boxes on the form’ as opposed to measuring whether thechecklist is being used as a platform for a team conversation. The committee discussed thedifference between measuring compliance versus measuring effectiveness: The non-executivedirector believes that the current audit approach only measures compliance. It does not providethe Patient Safety Committee with assurance that operating theatre teams are using the checklistas the foundation for a team conversation about patient safety. The initial response of the PatientSafety and Performance Teams to this observation was that ‘we audit compliance this waybecause it is what the commissioners require us to do.’The non-executive director realises that she needs assurance that: (i) operating theatre teamsunderstand the purpose of the checklist and are using it as the foundation for a safetyconversation. (ii) that the approach to auditing the checklist provides assurance that it is beingused correctly and is not simply a measure of form completion. She has consequently requestedan urgent and comprehensive review of the implementation of the checklist in the hospital onbehalf of The Patient Safety Committee.As a Board do you operate a complianceor an improvement culture?Are you aware of any ‘work arounds’staff may be engaged in eg how staffdecide when the clock starts and stopsin A&E ie when a trolley becomes a bed,using room/bed numbers rather thanidentity bands to identify patients whenadministering medication, if not howwould you find out?Further reading and resources• Toft, B. and Mascie-Taylor, H. (2005)Involuntary automaticity: a work-systeminduced risk to safe health care• How to avoid mistakes in surgery[Pre publication copy]

Getting to grips with the human factorEnabling action“If telling worked then we wouldn’t have a problem ...”(Director of Nursing in a large acute Trust)An important element of organisationaldevelopment is identifying the behavioursit should be possible to see as aconsequence of the change beingimplemented. For example one of theobservable behaviours demonstrating theadoption of a human factors approach inthe Board could be: all directors activelypromote ways of relating to each otherand the wider organisation that areestablished good practice in high reliabilityorganisations such as encouraging highlevels of support and challenge. Similarlyan observable behaviour whichdemonstrates a human factors approachat the front line could be: A ward nursespeaks up to a consultant during themorning ward round to offer informationthat has been overlooked (eg the results ofan urgent CT scan). The consultant takesthe new information on board and thanksthe ward nurse for making him aware ofthis issue.‘When an organisation succeeds, itsmanagers usually attribute success tothemselves... Success narrowsperceptions, changes attitudes, feedsconfidence into a single way of doingbusiness, breeds over-confidence in theefficacy of current abilities and practices,and makes leaders and others intolerantof opposing points of view. The problemis that if people assume that successdemonstrates competence, they aremore likely to drift into complacency,inattention, and predictable routines.What they don’t realise is thatcomplacency increases the likelihoodthat unexpected events will goundetected and accumulate into biggerproblems.’(Cited in a 2011 EvidenceCentre review of High ReliabilityOrganisations)To conclude, human factors issues frequently identified in all health organisations are:• Staff feeling unable to speak up• Organisations not listening to feedback from patients and stakeholders• Complacency• Paying too much attention to positive feedback• Staff overworked and tired• Poor access to policies and up to date information• Bed and waiting time pressures• Staff shortages and high turnover• Poor IT systems• Financial pressures• Bullying cultures• Data but no information.Perhaps because of the pressures on time and resources, staff sometimes report thatimplementation of new and safer practices relies too much on email edicts and threats.What will you do differently as a consequence of reading this resource?Further reading and resources• ‘What good looks like - observed behaviours of organisations that apply humanfactors in their daily work’ at[Pre publication copy] 31

Getting to grips with the human factorSummary questions for reflection1. How would I evaluate my/ the Boards knowledge of human factors?2. How do I/the Board demonstrate our commitment to using human factorslearning in what we do?3. What do I/the Board do to ensure human factors considerations are integratedinto all of our activities including IT, education and learning, workforce planning,procurement and so on ?4. What have I/the Board done to ensure the organisation receives, attends to andapplies competent Human factors advice and attention from the front line to theBoard?5. How am I/the Board ensuring that we are designing systems that are errortolerant?6. How are we using human factors to inform procurement, purchasing andstandardisation?7. How confident am I/the Board that our staff are consulted properly on mattersrelated to human factors and that their concerns are reaching the appropriatelevel including the Board?8. What systems are in place to ensure human factors are fully assessed and thatappropriate monitoring and control measures are established and maintained?9. How well do I/the Board know what is happening at the front line and whatinformation is available to me/us about this?10. Where organisational change is likely to have significant human factorsimplications, such as changes in working patterns and rotas, how are humanfactors approaches used to assess and address risks?11. What targets for improvement in utilisation of human factors has the Board set?12. How do we benchmark our human factors performance against others in thesector and beyond?[Pre publication copy]

Getting to grips with the human factorREFERENCES• Cornwell, J. (2013) Letter to a friend, a non-executive director on the board of an NHSFoundation Trust• Department of Health (2013) Patients first and foremost. The initial governmentresponse to the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry• Irvine, D. (2012) Foreword. Pathway peer review to improve quality. Thought Paper• Marx D. Patient safety and the “just culture”: a primer for health care executives. April17, 2001.• Mearns, K., Whitaker, S.M., Flin, R. (2003) Safety climate, safety management practiceand safety performance in offshore environments Safety Science 41, 641–680• Monitor (2010) The role of boards in improving patient safety.’s%20role%20in%20patient%20safety%20June%202010.pdf[Pre publication copy] 33

Getting to grips with the human factorADDITIONAL RESOURCESAvailable to download at www.patientsafetyfirst.nhs.ukAvailable to download at[Pre publication copy]

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A learning resource for BoardsGetting to grips with the human factor:Strategic actions for safer careMay 2013This guide was commissioned by the Clinical Human Factors Groupand supported with funding from The Health Foundation© 2013 Clinical Human Factors GroupAll rights reserved. The Clinical Human Factors Groupis a charitable trust, Registered No. 1123424.Contact us at

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