The CHFG and NHS LA wish to acknowledge organisations, networks and project teams who have embraced human factors/ergonomics principles to positively impact care delivery /improve patient safety.
During two patient safety events held in Liverpool and Canterbury awards were presented to two NHS Trusts who demonstrated projects which have significantly improved patient safety, the winners were Walsall Healthcare NHS Trust in Liverpool, University Hospitals Leicester in Canterbury and UCLH were highly commended. A summary of each scheme is detailed below.
Walsall Healthcare NHS Trust – Winner at Liverpool
Reducing missed fractures in Accident & Emergency
In 2014/15, we identified that a significant proportion of claims involved patients who attended A&E but a fracture was missed (undiagnosed prior to discharge).
We initiated a project aimed at reducing the number of patients suffering harm as a result of missed fractures when attending our A&E department. Having conducted a root cause analysis on a cluster of incidents, we identified human factor issues that were contributing to the risk of missing a patient having suffered a fracture:
• Insufficient training in imaging interpretation for staff in A&E
• Insufficient senior support/team working to sign off decision making
The project therefore concentrated on ensuring that these two issues were addressed, led by Miss Joshi, Clinical Director for A&E as Project Manager, supported by our Medical Director as Sponsor.
• Knowledge and training – we identified that there was significant scope for improved education around imaging interpretation and that nursing staff could develop advanced skills to add to the skill mix. We have introduced a programme of training for nurses and junior medical staff that is mandatory and ‘refresher’ based.
• Team working – we recognised that support for junior staff could be improved –
– Support in terms of additional senior presence is now established
– we have introduced daily review of A&E cards by a T&O Doctor in order to identify any missed fractures and appropriately refer patients to our Fracture Clinic
We have achieved a significant reduction in clinical negligence claims involving missed fractures – this improvement reflects positively on the patient experience and safety.
University Hospitals Leicester winner at Canterbury
Safety Huddles to improve patient safety in Leicester Children’s Hospital
Children in the UK experience higher morbidity and mortality than those in comparable healthcare systems. Although the reasons for this are complex they are partly explained by delays in adopting a culture of situational awareness. UHL recognises through SUI’s and a governance review that it needs to respond and react to this.
The aim of the project is to reduce paediatric harm and improve communication and patient flow through the use of ‘Huddles’ to develop situational awareness.
Huddles are multidisciplinary briefings of key individuals who have information on team working and patient flow. Huddles provide frontline staff with a mechanism to stay informed, review events, make and share plans to enable optimally coordinated care. The exchange is rapid and structured to exchange only essential information.
Huddles can improve patient safety by increasing situational awareness i.e. understanding what is going on with each patient, anticipating and planning for future risks.
A number of ergonomic principles underpin the Huddles and are being used to evaluate their impact:
Safety Culture & Psychological Safety
• Safety culture survey pre- and post- Huddle intervention
Healthcare practitioner attitude to Huddles
• Adopted from S.A.F.E. evaluation
Perceptions of ward pre and post Huddles
• Interviews with staff
Team Situational Awareness
Four questions for each patient
• What is the likelihood of being discharged in the next 24 hours?
• What is the likelihood of moving to a less acute ward in the next 24 hours?
• What is the likelihood of requiring an unexpected intervention (e.g. escalation of care) in next 24 hours?
• What is the likelihood of requiring critical care (e.g. arrest, intubation or transfer to PICU) in next 24 hours?
The qualitative and quantitative evaluation framework is outlined above, measuring pre and post safety culture and psychological safety, staff attitudes and situational awareness in particular being able to anticipate what’s going to happen to the patients on the ward.
Huddles are due to be rolled out across UHL. A number of educational interventions are being developed, an internal video, tools such as checklists, scripts to support staff carrying out the huddles. These will be available to all staff via the safety portal on the internal intranet.
University College London Hospitals NHS Foundation Trust – Highly commended
Reducing Surgical Harm
UCLH have set out to improve the use of the 5 Steps to Safer Surgery (5SSS) trust-wide; improving teamwork and communication to reduce incidents of harm. To create a culture of openness where staff speak up when they have a concern and teams self-regulate; where we collectively learn when things go wrong.
In order to do this project activity fits into two workstreams: education and measurement. We are training staff to become surgical safety coaches and undertaking in-situ coaching with theatre teams trust-wide. Coaching provides teams with constructive feedback on their approach to the 5SSS using quick debrief conversations, including what went well and what could be improved. A policy was developed to state what good looks like and support staff in encouraging good practice. An interactive e-learning module for all relevant staff is also underway. Learning points from the measurement workstream’s observational audits, survey results and incident reports are shared through training and presentations at audit days by the central team, and via a monthly bulletin to all staff called ‘At the Sharp End’.
Key principles include learning from experience and sharing learning to try to prevent incidents reoccurring. Understanding that in complex surgical environments the root causes of incidents are multi-factorial. The 5SSS need to confront these factors using collaborative, ergonomic design of checklists and processes to improve area-specific usability and ownership. Team understanding of these potential factors and how to recognise and manage them helps to stop them becoming direct causes of patient harm. Celebrating good practice reinforces positive safety behaviours. Our coaching approach embodies this; working with teams to improve shared understanding and ownership. The move to qualitative observational measurement of the 5SSS (rather than simply measuring compliance) emphasises the importance of good practice to staff and more effectively informs improvement.
Qualitative snapshot observational audits measure the quality of leadership, teamwork and engagement throughout the 5SSS, replacing traditional paper compliance with the WHO Checklist (now captured electronically). Safety culture surveys regularly gauge staff views. The number of incidents reported and incidents of harm over time are measured using SPC.
A reduction in incidents of harm (14%), despite increased incident reporting (10%) reflects increased awareness of the 5SSS, their importance in reduction of harm and improved knowledge of what good looks like. More comprehensive measurement, fed back to staff at all levels, enables learning to be acted on quickly.
Surgical Safety Leads have been appointed to lead activity locally. Their network will facilitate rapid shared learning and provide clear points of contact. Clinical Education are supporting ongoing coaching and training needs and observational audits will be run monthly using our existing model of the successful Improving Care Walkrounds.