1. Educational Solutions for Workforce Development Multidisciplinary Health Foundation SHINE Award 2012/13 Enhanced Significant Event Analyses: A Human Factors Systems Approach for Primary Care Paul Bowie, Elaine McNaughton, Deirdre Holly, David Bruce www.nes.scot.nhs.uk/shine/

2. Educational Solutions for Workforce Development Multidisciplinary What is a Significant Healthcare Event? Significant Event Patient Safety Incident Adverse Event (Avoidable Harm) Near Miss (Potential Harm) Purely Reflective Other Quality of Care Issue ‘Positive’ Event (Bowie et al, 2009; McKay et al, 2007)

3. Educational Solutions for Workforce Development Multidisciplinary Investigations of Significant Events Poorly Conducted: Issues and Impacts Incidents are highly selective (or non-engagement) Negative feedback (interferes with ability to assimilate & process information beyond the ‘self’ level) Second-victim syndrome (impact on health & wellbeing of clinician: guilt, embarrassment, shame…) Perceived blame culture (fear, distrust, punitive action, litigation…) Lack of a structured analytical framework (long standing issue) Many SEAs demonstrate a lack of ‘systems thinking’ Most clinicians attribute events to their own actions/inactions

4. Educational Solutions for Workforce Development Multidisciplinary Lack of meaningful and constructive investigations Missed opportunities to learn & improve (personal, team & organisational) SEA becomes a tick-box exercise Increased workforce stress, frustration & sick levels Wasted time, energy and resource Low engagement in formal incident reporting Investigations of Significant Events Poorly Conducted: Issues and Impacts

5. Educational Solutions for Workforce Development Multidisciplinary History of SEA (compared to hospital based techniques) Case-based discussion (Bradley, 1992; Pringle et al, 1994) Flanagan’s Critical Incident Technique (John C Flanagan, 1954) Embedded in practice (most professions) Quality of SEA (Bowie et al, 2009; McKay et al, 2007)

6. Educational Solutions for Workforce Development Multidisciplinary What We Set Out to Achieve We aimed to design and develop a theory-informed ‘guiding tool’ to support the SEA process in primary care settings.  Overcome SEA deficiencies by introducing human factors systems principles  Highlight and differentiate the interactions between the individual professional and the wider workplace and organisational issues at play.  Individual level: guide clinicians to reflect upon their emotional reactions - achieve a state of psychological readiness to move on.  Team level: a systems-centred analysis of the significant event.  Underlying assumptions: individuals and care teams would gain a deeper understanding of the human- system interactions contributing to events may lessen emotional reactions and the propensity to apportion personal blame may lead to more meaningful and effective action plans for improvement.

7. Educational Solutions for Workforce Development Multidisciplinary What did we do? Multi-professional steering group/project manager Tapped into existing human factors and safety science expertise Literature review Design of a conceptual framework (error theory and ergonomic model) Development of ‘guiding tools’ (individual & team levels) Recruitment of clinicians and managers (qualified and in-training) Testing Phase Evaluation Final project report

8. Educational Solutions for Workforce Development Multidisciplinary CONCEPTUAL FRAMEWORK PEOPLEACTIVITYENVIRONMENT  Individual e.g. physical, psychological, personality or social issues; cognitive factors, competence, skills, attitudes, risk perception, training issues  Team e.g. roles, support, communication, leadership  Patient e.g. clinical condition, physical, social, psychological, relationship factors  Others e.g. other health and social services  Complexity of work process or task, guidelines, policies and procedures e.g. not up-to-date, not available, unclear/unusable, not followed  Design or organisation of work process of system e.g. level of complexity, workload, poor design  Equipment e.g. positioning, not available, not working, not calibrated, usability issues  Work setting e.g. staffing, environmental conditions, workload or hours of work, design of physical environment, administrative and/or time factors  Organisational e.g. safety culture, priorities, external risks, organisational structure  Communication e.g. verbal, written, non verbal systems, poor communication, failure to communicate  Education and training e.g. supervision, competence, availability/accessibility, appropriateness  Societal, cultural and regulatory influences

9. Educational Solutions for Workforce Development Multidisciplinary THE GUIDING TOOLs - enhancedSEA Method The new approach is divided into three parts: 1. A Small Personal Booklet to help individuals reflect on the potential emotional impacts of a significant event - and their own role in the event - by using human factors principles to gain a clearer understanding of all of the contributory factors involved. 2. An A3 size Desk Pad for the care team, the sheets from which can be distributed to all those who attend a team meeting to analyse significant events. Each sheet contains instructions and prompts to guide the care team to take a systems-based approach to analysing the event in question and take notes on what was agreed – a small set of card prompts may also be used in conjunction. 3. A new written report format for enhancedSEA has been designed – to prompt a systems based analysis.

10. Educational Solutions for Workforce Development Multidisciplinary Evaluation – Completion Rates

11. Educational Solutions for Workforce Development Multidisciplinary Evaluation (n=117) StatementAgreement Levels (%) Using the enhancedSEA approach led to action that actually improved (or will improve) patient care 80 Personal Booklet I fully understood the purpose of this booklet 85 The booklet was practical to use in the workplace 72 I found the four cards inserted in the booklet to be helpful 55 I found the tool to be very relevant to dealing with the personal emotions related to a significant event 75 A3 Desk Pad I fully understood the purpose of this Desk Pad tool 72 The Desk Pad tool was practical to use in the workplace 55 Using the Desk Pad tool helped focus the SEA on system issues rather than just on the role of individuals 68 I found the tool to be very relevant to dealing with the personal emotions related to a significant event 60 enhanced-SEA Report Format The content of this Report Format was clearly written and easy to understand 77 I would recommend this Report Format to other colleagues 70 I will use this Report Format the next time I write up a significant event analysis 70

12. Educational Solutions for Workforce Development Multidisciplinary StatementPre-Post- I have a good understanding of what a "significant event" is in the context of my healthcare role 8295* I fully understand how to undertake and lead a significant event analysis 6695* Generally, being involved in a significant event in the workplace has a strong emotional impact on me 4443 Generally, being involved in a significant event in the workplace heightens my personal stress levels 4036 The procedures in this workplace are not clear on how to highlight significant events 2822 When a significant event is analysed, it feels like the person is being written up, not the problem 1913 Poor design of systems, rather than the actions of humans, is the biggest factor contributing to significant events in the workplace 3950* I have a good understanding of the discipline of “human factors” 3577* Highlighting significant events is a good way of identifying staff who need additional training 2434* I think undertaking SEA is a demanding and difficult task 4852 Evaluation (n=117) *P<0.05

13. Educational Solutions for Workforce Development Multidisciplinary Selected Evaluation Quotes “I think SEA is a difficult and demanding process but these tools simplified the process for me and made it easier to try to be more objective” “I think the human factors model is a very useful approach to looking at an SEA and without doubt caused me to think differently about this SEA and feel the outcomes were more meaningful”. “Very worthwhile. Definitely made the SEA feel more in depth / thorough. Whole team very approving. Developed some really useful action points” “If eSEA was recognised, it would be more beneficial and more useful than existing SEA” “We’ll look at things more closely, when an SEA comes in use, use of the eSEA will have greater impact, will influence initial discussions” “eSEA breaks stuff down further that you wouldn’t have considered....which I wouldn’t have considered before” “I found it made the process more laborious and confusing in some ways. I think the booklet was helpful but the report format needs to be simplified. Some of it felt like writing in order to fill in boxes. I think we would have come to the same conclusions if I had used our normal format”.

14. Educational Solutions for Workforce Development Multidisciplinary What has gone well? We made the project aims more realistic and manageable. By and large core group has stayed together and functioned well (?) Educational Leaders clearly interested, very supportive and helpful The approach developed based on solid theory and has high face validity (particularly amongst those informed in safety) Operational team – managed to call upon additional, valuable resource Health Foundation – relatively low maintenance Post-pilot implementation looks promising, but may take a while to embed Infrastructure to improve and build upon – a lasting legacy TROJAN HORSE STRATEGY

15. Educational Solutions for Workforce Development Multidisciplinary What could have been better/different? Website design and access issues – bit rushed Tool content and design – took longer than expected, not sure if we had a shared mental model of final output (but a Pilot) Impacted slightly on testing period – knocked some out of sync. (e.g. Pharmacy) Quality of design could be much better Different interpretations of ‘human factors’ science and role in project/and also of evaluation expectations Test numbers plucked out of thin air – over-confidence and naivety? Email bombardment irritated a fair few GPs wearing different hats!

16. Educational Solutions for Workforce Development Multidisciplinary Project Learning and Outputs Once evaluation feedback incorporated, enhancedSEA method ready for roll out – good interest from Educational Leaders/SPSP/Others Conference Presentations (e.g. Poster at RCGP, Oral at IEHF) Basic e-learning (BMJ Learning, NES website) Book Chapters (NES book and Good Practice GP Training Guide) Journal Submissions (conceptual framework, evaluation…) Team learning (human factors, logic models, error theory…) Organisational impacts (e.g. inter-professional working, good publicity)

17. Educational Solutions for Workforce Development Multidisciplinary Positive External Interest RCGP Scotland/Specialty Training/Dental Vocational Training for GPNs/PMs SPSP-PC and Scottish Government Department of Health in England/PS Toolkit NHS Boards NES Human Factors Conference – March 2014 Patient Safety Congress – Liverpool, May 2014 IEHF Spring Conference – Southampton, April 2014 Other regional and national conference invitations Feedback to all via Newsletter

18. Educational Solutions for Workforce Development Multidisciplinary Quick Questions? SMALL GROUP WORK

19. Educational Solutions for Workforce Development Multidisciplinary Quick Analysis A GP surgery decided to have their health visitor trained to administer childhood immunisations to ease their practice nurse’s workload. The health visitor started working under the supervision of another qualified health visitor after completing her training. A 3-month-old girl attended one of the ‘new’ immunisation clinics to receive her second booster. The clinic was very busy. The MMR and DTP/Hib vaccinations were placed on the same table. The health visitor picked up the ‘wrong’ vial while attempting to answer some of the mother’s general questions and accidentally administered the MMR rather than the required DTP/Hib vaccine. She realised her error when performing the ‘double-check’ of the vial after administering the vaccine. The health visitor immediately informed the GP and the parents and apologised for ‘my accident’. The GP and the health visitor contacted the local hospital paediatric department to check for likely complications and reassessed the child on several further occasions. The child did not suffer any harm and received the appropriate vaccinations a few days later. The actual and potential impacts People factors Activity factors Environment factors Learning issues (individual and practice level Action plan (system improvements)

20. Educational Solutions for Workforce Development Multidisciplinary THANK YOU VERY MUCH www.nes.scot.nhs.uk/shine/