Patient Safety, Simulation and Human Factors: should we all work together?

So up until now my blogs have focussed on the individual elements of patient safety, simulation and human factors but not really brought them together into a unified piece of work - so here we are - what does Patient, Safety and Human Factors have in common and how can they collaborate to improve patient safety?

This actually is very timely too, as it links to the recent Opening Doors (link) publication from the CQC recognising that we are not reducing Never Events and signalling the need for an improved safety culture and the fact that NHSI are currently developing a Patient Safety Strategy link that aims to half avoidable harm in the NHS.

What is clear is that there is some really good examples of good practice and activity going on within NHS organisations but there seems to be a lack of a way to scale up and share these.

I do also think this is not just an issue for or with NHS organisations as indeed the same culture exists, and to an extent is reinforced, by regulators and arms length bodies who appear to blame organisations or individuals within them and preclude the possibility that there are external environmental causes. The case in point has to be Never Events which have never decreased and continue to occur. NHSI states “Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.” Surely by default if the Never Events continue to always occur either we don’t fully understand the cause of the error or the national level resources do not work?

Lets start by looking at the three elements, and with the use of some sweeping generalisations, look at some of the problems that can and do exist in each area.

Patient Safety - It sometimes seems that although often stated that patient safety is included in everything we do - all too often this is very superficial. There is potentially a lack of training and understanding for individuals leading patient safety and work tends to be very focussed on clinical elements often as this is the back ground of the leaders. All to often patient safety with its reactive focus waits for things to go wrong, look at who did it wrong, tell them they should of followed prescribed process - and then wait again for it to go wrong. This is very negative and staff constantly are / and feel they are being blamed which only serves to reinforce the negative culture.

Patient Safety Issues Patient safety is presumed included in everything we do and so doesn’t require training  Senior staff are clinically focussed and may have variable patient safety knowledge Reactive Safety I focus  Culture that is defensive and feels that they are being blamed for failings Different organisational areas of patient safety are isolated and have a focus on process Confusion around terms i.e. the presumption in some places that Quality Improvement = Patient Safety

Simulation - Typically this is led by passionate individuals from a clinical background and with a clinical focus. Local development of simulation often happens almost under the radar of organisations and as such there is often gaps in provision and a lack of understanding of what is delivered.

There is no nationally defined part of the organisation that simulation should reside so we see a spread of locations that includes as a silo entity, isolated in departments, part of medical education, resuscitation training or organisational development. 

The HEE National Framework for Simulation Based Learning  – has five guiding principles and includes leadership and governance and the strategic approach and resource allocation. 

Unfortunately, this strategic approach is often missing, rarely there is an individual appointed as an organisational simulation lead and in the rare times the role does exist such a role is often seen as a simulation delivery role rather than a coordination and planning one. Senior leadership are often aware that simulation is good and needed but there is little direct engagement with boards who could support the wider application of simulation.

Without this simulation occurs often in the shadows often with little real awareness about what simulation is and what it has to offer i.e. the presumption is that simulation just delivers resuscitation scenarios 

There is so much positive work being delivered across the country using simulation to support workforce development, but also identify and mitigate risk, developing new processes and pathways and even testing hospitals systems - again this is not uniform within or across departments and is often focussed in certain specialities i.e. anaesthesia, emergency departments and obstetrics. 

Simulation Issues Variable location of simulation in the organisation Lack of awareness of the potential or actual applications of simulation Often lack of support for faculty Confusion around terms and presumption simulation is resuscitation training Lack of direct board engagement  Lack of equity of access to all staff

Human Factors - This is often also led by passionate individuals and in fact often these may be the same individuals that champion simulation. The risk is that this and the drive to replicate / focus on the plane cockpit has led to a fixation on non technical skills training (NTS). Whilst there is the need to develop NTS in individuals and teams, the risk is that the current focus reinforces that Human Factors is NTS - rather than NTS is a part of Human Factors, which in turn goes to support the view that errors come from failings of humans i.e. human error. 

Human factors is often delivered as part of incident analysis training but this can be superficial and result in the message that errors occur because of humans - so the common finding in root cause analysis is still the an individual failed to adhere to process rather than the question was the process fit for purpose or was their other contributors to the event, again reinforcing the culture of blame.

This in part is potentially due to the lack of understanding of how humans work and ensuring process that supports this. 

The need for non healthcare experts who understand how to develop a user focussed designed process that supports humans to do the right thing and to really understand the causes when things to not go well, has been set out in a recent white paper by the Chartered Institute of Human Factors and Ergonomics. 

So what is a potential solution? 

So actually these three separate areas have some quite similar problems maybe a strategic lead, with board level access, could support these three areas using expertise from the different elements to support patient safety? 

Perhaps coordinating and developing the activities of the following groups?

Public team – providing simulated patients to support the trust staff, increase public patient engagement and ensure that the public is represented in patient safety decisions and investigations

Simulation teams – providing reactive and proactive risk management and team training and opportunity to ensure elements of risk and lessons learnt from harm is included where relevant

RCA team – to investigate when things go wrong – but with support and expertise from the other groups

Human Factors team – which would include access to non-healthcare experts to proactively support transformational, incident analysis, QI and service design and redesign

Clearly the size of the team would be specific to the organisation and would need to work with all other existing functions particularly governance, learning and development and procurement.

Suggested Recommendations  That an organisational lead be appointed to lead simulation, patient safety and human factors  There is clear national support and direction There is a national process to share and harmonise activities That the lead is a full time post and only role That the role is supported by an ergonomist and other non healthcare experts  That this role is seen as being across the organisation - not just clinically focussed  The same needs to apply to arm’s length bodies and regulators etc so their culture aligns with that of the NHS