1. Quality Education for a Healthier Scotland Multidisciplinary Making it easier to do the right thing Michelle Clark Training and Research Officer (Health Psychology) NHS Education for Scotland michelle.clark@nes.scot.nhs.uk Mark Johnston Training and Research Officer (Patient Safety) NHS Education for Scotland mark.johnston@nes.scot.nhs.uk 0131 656 3258 Workspace Culture Organisation Task Teamwork Impact on behaviours and abilities Adapted from Catchpole @markjohnston71

2. Quality Education for a Healthier Scotland Multidisciplinary Human Factors case study – Hand hygiene behaviours of final year medical students

3. Quality Education for a Healthier Scotland Multidisciplinary Pilot study – what we did Final year medical students at University of Dundee Medical School Mixed methodology Quantitative (n=30) Questionnaire assessing Predictors of HH behaviour Barriers & levers to HH behaviour Qualitative (n=9) Based on students’ final year ‘ward simulation exercise’ assessment video ‘Self-explanatory’ interview Categorical content analysis using HF & Health Psychology theory frameworks.

4. Quality Education for a Healthier Scotland Multidisciplinary Results – Questionnaire Predictors of behaviour Attitudes Normative beliefs Perceived behavioural control Behaviour intentions Behaviour Theory of Planned Behaviour (Ajzen & Fishbein, 1980)

5. Quality Education for a Healthier Scotland Multidisciplinary Results – Quantitative Barriers & Levers (Theoretical Domains Framework (TDF) Michie et al 2008) The higher the number of barriers, the less HH behaviour is carried out Compared TDF domains based on levels of compliance (high or low) ** Mean scores

6. Quality Education for a Healthier Scotland Multidisciplinary Results – Qualitative ‘Self-explanatory’ interview Observable HH behaviour low (despite high self reported HH) Individual factors Positive impact Attitudes & beliefs (capabilities & consequences of HH) Motivation Negative impact Stress & anxiety Human cognition & memory (mental load, dual processing, primacy effects Task related factors Negative Impact Multiple tasks Switching between multiple patients Changing symptom presentation Problem solving nature of tasks Environment factors Positive Impact Multiple gel bottles Prominent location Negative Impact Layout of ward Layout of paperwork/forms.

7. Quality Education for a Healthier Scotland Multidisciplinary HH Pilot study (cautious) conclusions Clear intention-behaviour gap (self report & observed HH behaviour) Cognitive factors & beliefs about capabilities are barriers to HH (in this group) Making several decisions within a high pressure situation lead to high cognitive load which negatively affects memory – automaticity not achieved Need to believe you are capable of performing HH Attitudes towards HH & Social influence (especially from influential staff members) can predict HH behaviour Primacy effect evident in practice of WHO 5 moments, but not recency effect (forgot moments 4&5).

8. Quality Education for a Healthier Scotland Multidisciplinary Implications... Teaching of Hand Hygiene behaviour Impact of stress/anxiety and cognitive load on HH behaviour & make behaviour automatic even in stressful situations Other prompts to remind & encourage habits at more of the WHO moments.

9. Quality Education for a Healthier Scotland Multidisciplinary Bad people? Error occurs due to Systemic and Systemic induced Individual failure Negligence is not the same as error, both may result in harm So, some thoughts on why…?

10. Quality Education for a Healthier Scotland Multidisciplinary 105 HF facilitators workshop Sept 11

11. Quality Education for a Healthier Scotland Multidisciplinary You’re amazing!

12. Quality Education for a Healthier Scotland Multidisciplinary Why do we make mistakes? Sometimes we do the wrong thing, consciously and sub-consciously

13. Quality Education for a Healthier Scotland Multidisciplinary

14. Quality Education for a Healthier Scotland Multidisciplinary <1% 5% 50% 80% 100% percent of drivers PERFORMANCE Individual Autonomy The posted speed limit is 60 mph- the ‘legal’ space Driving 64 mph -the illegal- normal space Driving 75 mph – the ‘illegal- illegal’ space (for almost all of us!) VERY UNSAFE SPACE Individual Pressures Perceived Vulnerability Belief in Systems- guidelines Accident Driving 100 mph illegal for all Borderline Tolerated Conditions of Use Adapted from Rene Amalberti Normalisation of Deviance

15. Quality Education for a Healthier Scotland Multidisciplinary Even experts make mistakes

16. Quality Education for a Healthier Scotland Multidisciplinary Human Factors A common language “Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings” (Catchpole 2010) “Making it easy to do the right thing” (Bromiley 2011) Organisational/ Management -Safety Culture -Managers’ Leadership -Organisation communication Work/Environment -Work environment and hazards (ergonomics) Workgroup/Team -Teamwork structures & processes -Team Leadership Individual Worker -Cognitive skills Situation awareness Decision making - Personal resources Management of stress Management of fatigue (Flin, Patey 2012)

17. Quality Education for a Healthier Scotland Multidisciplinary The first lesson in reducing harm is the realisation that we will and do make mistakes ‘It’s the downside of having a brain!’ Reason

18. Quality Education for a Healthier Scotland Multidisciplinary Multi-tasking - Our lazy brains would rather default to system 1 2 x 2= 17 x 379= 4…System 1 6443…System 2. Kahneman 2012

19. Quality Education for a Healthier Scotland Multidisciplinary Card suit change game Groups of three 1 Person deals cards, turning them face up in rapid succession and estimates the passing of time If you deal all the cards deal them again 1 person estimates the passing of time with no aid and counts the number of times the cards change suit. 1 person times the activity using an aid and then focuses only on recording the suit changes When told to finish, separately record the time and number of suit changes and compare your results

20. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Work/Environment -Work environment and hazards (ergonomics)

21. Quality Education for a Healthier Scotland Multidisciplinary ‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’ Reason J. BMJ. 2000 March 18; 320(7237): 768–770.

22. Quality Education for a Healthier Scotland Multidisciplinary Everyone, everywhere, every time Good human factors design in health care accommodates everyone Not just the calm, rested experienced healthcare worker But also the inexperienced health-care worker who might be stressed, fatigued and rushing.

23. Quality Education for a Healthier Scotland Multidisciplinary

24. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) Organisational/ Management -Safety Culture -Managers’ Leadership -Organisation communication (Flin, Patey 2012)

25. Quality Education for a Healthier Scotland Multidisciplinary ‘We cannot change the condition of those who do the work, but we can change the culture within which they work’

26. Quality Education for a Healthier Scotland Multidisciplinary Silo working? Doctors Managers Nurses What is your culture?

27. Quality Education for a Healthier Scotland Multidisciplinary Hierarchies?

28. Quality Education for a Healthier Scotland Multidisciplinary Do we pay attention to the Swiss cheese or do we blame? Our learned behaviour is to blame an individual Society, peers, media Imperfect System Our colleagues, ourselves?

29. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Workgroup/Team -Teamwork -Team Leadership

30. Quality Education for a Healthier Scotland Multidisciplinary Lessons for Leadership in changing culture Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours. Berwick Report 2013

31. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Workgroup/Team Structures & processes

32. Quality Education for a Healthier Scotland Multidisciplinary Examples in healthcare… Prescribing and dispensing Hand-over/hand-off information Movement of patients Order of tests Preparation of medication If all of the processes associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.

33. Quality Education for a Healthier Scotland Multidisciplinary Making it easier to do the right thing PDSA example: Christopher Christopher to urinate into the toilet bowl 100% of the time by 30th June 2010. Aim: Toilet training

34. Quality Education for a Healthier Scotland Multidisciplinary PDSA template Describe your first (or next) test of change: Person responsible When to be done Where to be done Demonstrate the correct way to urinate into the bowl and indicate the negative aspects of missing the bowl MetonightDownstairs toilet  List the tasks needed to set up this test of change Person responsible When to be done Where to be done Christopher availableMetonightDownstairs WC Predict what will happen when the test is carried out What will determine if prediction succeeds Christopher will show understanding of process and execute correctly The floor will be dry

35. Quality Education for a Healthier Scotland Multidisciplinary Example: DSA Do Christopher thought the demonstration amusing and ignored it Study 0% compliance with the new process 0% reliability level Act Seek out ideas, develop new test cycle.

36. Quality Education for a Healthier Scotland Multidisciplinary Example: next PDSA cycle http://www.amazon.co.uk/toilet-training-target-stickers- Happeedays/dp/B002GZAWUK/ref=pd_sim_by_3 A Human Factors approach!

37. Quality Education for a Healthier Scotland Multidisciplinary Making it easier to do the right thing Michelle Clark Training and Research Officer (Health Psychology) NHS Education for Scotland michelle.clark@nes.scot.nhs.uk Mark Johnston Training and Research Officer (Patient Safety) NHS Education for Scotland mark.johnston@nes.scot.nhs.uk 0131 656 3258 Workspace Culture Organisation Task Teamwork Impact on behaviours and abilities Adapted from Catchpole @markjohnston71