Patient Safety, Simulation and Human Factors …Part II …the applications of simulation

Out of all my blogs the one that seems to have stimulated most interest was the one I wrote on how simulation should be seen as part of patient safety activity (click here for that blog) rather than the typical thought that it is just a form of training and often just resuscitation training at that.

Spurred on following some Twitter (@NWSEN) and face to face interactions I wanted to write a blog which built on this work and in particularly looking at the art of the possible and how simulation can, and in fact is, being used to support some of the emerging patient safety concepts. 

Remember we are describing simulation as a spectrum of activity (blog on this is here) with a variety of underpinning educational theories aligned to the learning outcomes, these learning outcomes can be ones for the individual, team or organisation. Additionally simulation should be a quality assured education event that can be delivered in a variety of ways including with real people (see blog on simulated persons here), manikins, augmented reality, virtual reality and in virtual worlds.  

This is not meant to be an in-depth description of the emerging patient safety themes, as the original authors through their publications can far better articulate that material. The focus here is on the application of simulation to support the areas. What I have done is to provide a link or two to some of that background source material for further reference. 

Supporting and developing culture 

Patient safety seems to be awash with references to culture, indeed it seems to have become the latest area to blame after people, and teams …. now we can blame organisational culture. 

Culture though, as a disseminated construct, becomes difficult to change as it exists in the organisation not the individuals, so there is some confusion on how to impact culture - indeed writing a strategy to improve culture is probably not a great start emphasised by Peter Drucker who said culture eats strategy for breakfast

What we can however do with simulation is to focus on behaviours (individual and team) as often these can not only be a product of local, organisational and professional culture but also serve to reinforce and amplify it. 

We all ready have some behavioural taxonomies for team and individual behaviours and we can develop scenarios to identify, challenge and discuss behavioural and social elements. The NHS Values, which underpin the organisational ones, can be included and supported. Simulation can also be a way to increase patient public engagement and understand what is important to the patient (see values based care)

Opening the door to change - CQC report 

Interprofessional Education (IPE)

It is recognised that current drivers call for IPE and it is often used as a method for delivering patient safety training, there are very real barriers for IPE and potentially a box ticking mentality exists that suggests all simulation should be inter-professional. There is nothing wrong with uni-professional simulation if the presence of other professional groups would actually not add value and a risk that potentially some professionals may feel like a prop in the scenario. 

Clearly there are however numerous benefits from delivering and developing IPE learning outcomes as part of a simulation scenario that has been developed appropriately. The opportunity for individuals to learn with and about other professionals cannot be underestimated and links to both culture and team working as well as learning how to perform in a more normal clinical context. 

Learning outcomes for interprofessional education (IPE): Literature review and synthesis 

A review of undergraduate interprofessional simulation-based education (IPSE) 

Values Based Education 

Values based practice has been sited as a complimentary element to that of evidence based practice but one that focusses on what is important to the patient. This is not only important as part of informed consent but also during any care encounter. 

It provides an opportunity to acknowledge the concerns of the patient and come to agreement as to treatment /  interventions and thus supports a patient focussed care agenda. 

Although this area is emerging it can be embedded into simulation, just as we would have expectations about the clinical decision making and process supported by Evidence Based Practice the same applies to supporting the process with values based practice.

Values Based Practice 

Incidents and learning from error (Safety I) 

Simulation has been discussed as a method to learn from errors, often as simulation is not fully understood by governance teams this is seen only as an opportunity to recreate a specific incident. There are two issues with this firstly often the event is very unique, and learning is very specific, and secondly there is a risk of psychological harm re-exposing those involved to the incident again and again - it feels punitive even if this isn’t the intent.

The potential of using simulation to identify the process / procedures in the complex clinical areas we work is a useful tool as part of incident investigation, with a focus on what normally happens rather than a focus on the incident specifics. This allows a greater understanding of Work as Done and an opportunity to see if this matches organisational policies or if they represent Work as Imagined. 

Additionally simulation can become proactive and support systems thinking i.e. identifying latent errors before they cause harm although pro active it is still a Safety I focus i.e. it looks at a simulated error / rare events. This is reliant though on the skills of the faculty as there is a risk that the focus is purely clinical or team focussed and hence blame shifted from individuals to the team.

There is an opportunity to learn from, and share simulated errors though there does need to be a vehicle to do this and ideally this should be across the NHS - typically the normal incident reporting structure does not support the reporting of simulated incidents (as they will only ever be near misses) and opportunity to learn in the organisation and share this learning is lost. Some organisations have agreed to investigate Serious Simulated Untoward Incidents with a ghost system that mirrors the actual incident reporting i.e. it is investigated by someone appropriate for that level of (potential) event to ensure organisational learning - this agreement however is not routine and there is no way to share across organisations other than social / simulation networks.

How simulation can support learning from harm events

Human Factors & Ergonomics in Practice 

Resilient Healthcare

FRAM - Functional resonance analysis method 

Learning from dynamic non events (Safety II)

There is a lot of interest and an increasing focus on what we do normally rather than waiting for things to go wrong and analysing a much smaller cohort. This is not instead of the Safety I work but this has potential for augmenting that work and reducing Safety I events - it also feels much more positive and has ability to challenge some of the negative organisational cultures around incidents and errors in that humans are seen as a benefit not a risk.

This is separate from excellence reporting (focussing on what we did very well) but rather has a focus on the normal, i.e. when things don’t go wrong in our complicated (dynamic) systems hence the dynamic non event term.

Simulation allows an opportunity to explore the process resonance (wobbles) that cause potential problems all the time in our jobs but that the staff manage to recognise or compensate for to ensure safe effective care. 

Understanding these wobbles through questioning in the debriefing can occur by asking questions like

• what makes doing this task / procedure more difficult in practice?
• what things make you struggle when doing this
• what is the most common barrier to completing the task

So is this just not near miss reporting? 

Safety II has the opportunity to be used both for understanding events as well as proactively as a risk mitigation process, but the focus is on what we normally do rather than the rare incident event. Near miss events are the rare event just with no serious outcomes. The real potential for the Safety II work is to identify these system wobbles and realise that a lot of these will not just affect one specific discrete area but rather cause resonance in a lot of systems - thus a piece of work in one area can have multiple impacts. 

There needs to be a way to organisationally capture and process the information with a safety II focus so it can be shared and processed by the organisation and actioned. Ideally this would be a way to triangulate data from Safety I incident reporting (reactive), Safety I Simulated Incident reporting (proactive) and Safety II analysis including data from debriefing. This data could then be thematically analysed to work out key areas and to focus activities.  

User focussed design

Simulation can be used to really understand the needs of the user to test the development of new systems, processes, building designs, pathways, roles indeed anything. Although this is now the norm for a lot of our medical equipment design it is less routine for processes designed within the NHS either at an organisational, regional or national level be that pathways, algorithms, job roles, IT or building design. Working with individuals who understand how humans work and the limitation of the human machine (physical and cognitive) can allow these processes to be developed appropriately from day one (pro-active design) and this can and does involve simulation. 

This can be large scale i.e. the development of new processes for a new hospital site and testing of clinical areas before patients are moved in (as described here) or smaller scale i.e. design of a specific clinical process. 

Simulation is often a way to understand staff and patient interactions but also sometimes as a prop to just work out the easiest and safest way to do a task (ergonomics) - making the mistakes on a lump of plastic rather than a patient. An example of this was around working out the logistics of how to move a ventilated patient into a new angio suite - the angio table could be positioned in three different places, anaesthetic machine in two places and the trolley could be brought into the room head or foot first - by far the easiest way to develop a safe process was to test each permutation with a manikin. 

Moving things forward.

The examples discussed are all things that have been done to an extent - what is missing is the ability to share and develop a larger community to facilitate this and to link this into organisational learning and patient safety. 

• Identify best practice for individual uses of simulation i.e. models for organisational learning from simulation rather than individual learning 
• Clarify who would deliver the elements (local / regional resources)
• Support faculty development in different ways of delivering simulation
• Robust academic involvement to support evaluation and validation  
• Work with ergonomists / behavioural psychologists as part of the simulation / safety team
• National guidance on tools to monitor and encourage Safety II analysis 

Hopefully the time is right for NHS national organisations to clearly articulate the potential of simulation as a tool for organisational learning and patient safety so the activities become mainstream and available across all organisations.