1. Human Factors In a maternity service Making it happen Dr. Harriet Nicholls Consultant Anaesthetist Luton and Dunstable Hospital NHS Foundation Trust

2. How we’ve done it What we’ve gained Process –Raising awareness –Training –Introducing and spreading behaviours –Developing behaviours –Communications Achievements

3. Process – Raising awareness Senior management Heads of department Risk management Staff groups Walking down the corridor

4. Process – Training Critical mass introduced to the concepts Monthly team training days Multi-disciplinary group on LIPS course

5. Process – Introducing behaviours One behaviour, one area One individual, one day Multi-disciplinary champions Monthly meetings Sharing good practice Learning from one another Asking of each other

6. Spread of Behaviours AreaBriefingDebriefingClosing the loop SBARCritical Language Ward 32 Ward 33 ANC Delivery suite Elective Theatre Emergency Theatre NICU Community MLBU

7. Developing Behaviours Realising potential Novice to expert Requires practice Coaching Reflection

8. Developing Behaviours Briefing RedAmber NOVICE GreenSilverGold EXPERT Not being used Done by minority of people Every one takes part Done using a structured checklist Outstanding jobs are allocated to a named individual Leader invites people to speak up if they perceive a problem with patient care

9. Developing Behaviours Debriefing RedAmber NOVICE GreenSilverGold EXPERT Not being used Done by minority of people Occurring at target frequency What did we do well What could we have done better What can we learn Teamwork Equipment System change required Leadership Task Management Situation awareness Communication Patient’s feedback is fed into the debrief OR If a team member has spoken up they are thanked for having done so

10. Process – Communications

12. Evaluation Clinical Outcomes Cultural Survey Anecdotal

13. What have we gained? Day starts when it’s supposed to start We all know the game plan Handover time cut by 20 minutes, Ward 32 ODPs want to come and work in maternity Communication has improved across and within disciplines It feels safer in theatre

14. Success Factors Support at all levels Built in-house capability An appreciation that we are the culture…