Our history

//Our history
Our history 2018-03-28T16:26:38+00:00

The Clinical Human Factors Group is a broad coalition of healthcare professionals, managers and service-users who have partnered with experts in Human Factors from healthcare and other high-risk industries to campaign for change in the NHS.

Our Vision

Our vision is of a healthcare system that places an understanding of Human Factors at the heart of improving clinical, managerial and organisational practice, leading to significant improvements in safety and efficiency.

Learn more about how, together, we can achieve this vision.

Read Our Manifesto

Our History

Martin Bromiley, Founder and current Chair of CHFG, explains how CHFG came about

In 2005 my late wife died as a direct result of medical errors during an attempted routine operation.  A subsequent independent review identified that a well equipped operating theatre and a team of clinicians all technically skilled had failed to respond appropriately to an unanticipated emergency.

They had failed to follow protocols, use equipment properly, maintain situational awareness, prioritise and make decisions appropriately.  Leadership was confused, communication problems arose despite attempts to speak up by the team and any benefit of the team skills and awareness present was lost.

In short, human factors not technical inability led to my late wife’s death.

Martin Bromiley
Founder and current Chair of the CHFG, June 2011

Systems Failed not Clinicians

Healthcare culture often inadvertently conceals systemic problems and in the past has laid the “blame” on certain individuals.  But to me this is fundamentally flawed thinking.

It wasn’t the clinicians that failed; it was the system and training that failed them.

The protocol was not clear, rehearsed and briefed, the use of equipment not well rehearsed and understood, techniques for maintaining situational awareness were not explicitly understood or encouraged, leadership skills required and the dangers of fixation were not experienced or understood by the team; and at no stage was more open communication explicitly encouraged in the organisation or by the clinical leaders at the moment of the emergency.

It wasn’t the clinicians that failed; it was the system and training that failed them.

To me as an airline pilot this was obvious because of the culture I work in and the training I have received; but to those on the 29th March 2005 this was learning on the job.

Building a Culture of Learning

I decided to do some research. I had no plan, I had to bring up two young children and keep a roof over our head.  But I felt that others should be able to learn from what had happened.  I assumed Elaine’s death was a one off, but clearly it wasn’t.  I assumed maybe healthcare was in good shape, it was just this team in this location, but it wasn’t.  All the learning about ergonomics/human factors in aviation and other industries seemed to have reached the hospital gate and gone no further.

As I started to talk to people, I found examples of excellence in healthcare, clinicians who really understood human factors, but they were in very small isolated pockets.  Someone somewhere needed to help coordinate their work and publicise it.  I spoke to people I thought might be able to do that, but no one seemed to be willing or able, or maybe they just didn’t understand.  By 2007 it was clear; if no one else would do it then I would have to do it myself.

Since 2007 the Clinical Human Factors Group, originally inspired by the Royal Aeronautical Society Human Factors Group has developed aiming to promote understanding of human factors in healthcare from Board to Ward and beyond.

Focusing on the Patient

I assumed we would face similar problems to those in aviation, but I realised very quickly that healthcare is a very complex set of disparate tribes, centralised regulation is very weak, centralised policy actively challenged or ignored, and political power and tribal loyalty confused.  The state of healthcare isn’t the result of carefully planned and focussed efforts driven by a need to maintain or improve safety; it’s the result of hundreds, even thousands of years of inertia, denial and vested interest which have created an organisation more akin to the teaching professions of old or the church.  Of course where is the patient, and 21st Century clinician in all this?

Learning and Understanding

Now healthcare seems to understand that it should have more in common with other safety critical industries.  Human Factors is a developing science in healthcare, and is intrinsic to a myriad of different processes.

Change will inevitably move at a different pace within different processes and healthcare organisations.  We are all part of this learning process and I’m really encouraged, and humbled that so many significant people are prepared to part of us to make a difference.

Making a Difference

The CHFG has one significant advantage over other healthcare organisations –we are not held back by the inflexibility of bureaucracy or organisation.  Please don’t think of traditional healthcare organisational structures, think more campaign and activist with the power of respected world class experts in our group who are trusted for their independent, considered and thoughtful support and guidance.  We have the ability to push where others can’t and it is vital that as we grow and develop we retain these vital capabilities.