We are delighted to respond to the consultation on the National Patient Safety Syllabus. Please find a copy of our response below.
This response was prepared by the Clinical Human Factors Group using representatives from healthcare, human factors and ergonomics, quality improvement science and aviation.
We are pleased to see this remarkable document, that would not have been possible ten years ago without the efforts of groups such as NHS England, NHS Improvement, the National Quality Board, The Health Foundation, The Royal Colleges and the Clinical Human Factors Group. We recognise this important step and we strongly support the Patient Safety Syllabus. In particular, the:
1. emphasis on systems thinking and proactive approaches to patient safety
2. the recognition of Human Factors and the breadth and balance of the Syllabus
3. recognition and commitment to the ongoing development of the syllabus.
We would be pleased to provide expertise and support for ongoing development of the Syllabus and detailed curricula that will support this Syllabus.
Our feedback below, focuses on parts of the Syllabus that we believe would strengthen its impact:
1. making the Syllabus easily applicable to all staff groups
2. emphasising human factors design and controlling risks at source
3. recognising Non-Technical Skills as a human factors intervention that everyone can do
4. teaching Non-Technical Skills and underpinning behaviours as an enabler of culture change
5. observing behaviour to assess and measure outcomes.
1. Making the Syllabus applicable to non-clinical staff groups and easier to understand
We believe the Syllabus would benefit from developing its relevance to non-clinical workers, such as, porters, cleaners, procurement, property managers, whose activities have a critical impact on patient safety, who need different skills to patient-facing clinicians.
The Syllabus may evolve to address the needs of non-clinical workers – however – in its current form, it may be a challenge for them to develop curricula and potentially a missed opportunity if non-clinical workers do not engage with training.
We recommend input from non-clinical staff, as well as staff working in primary and tertiary care, to determine how they can apply this Syllabus. The Chartered Institute of Ergonomics and Human Factors’ learning pathway, in development, could be an option for some staff groups. In addition, we recommend that the Syllabus would benefit from a more concise structure with tangible Domains, less overlap, and clear measurable or identifiable behavioural outcomes to make it easier to understand and to translate into curricula for all groups.
2. Emphasising Human Factors design and controlling risks at source
To ensure the best opportunity of proactive risk control, that is, preventing the introduction of the risk, in the first instance, the Syllabus should emphasise the importance of the safe design of equipment, the use environment, medical device design, IT Systems and the physical workplace in patient safety.
The syllabus needs to cover design and managing human error by providing an understanding of the use of human factors and ergonomics to specify, select and test for ease of use, safety, efficiency, and effectiveness.
The lack of emphasis on design is particularly notable in Domain 3: Human Factors. Moreover, 2.1.5 Investigating incidents does not mention the need to consider ergonomic factors (for example, design of equipment, work environment) in relation to ‘human performance problems’.
The Syllabus emphasises the use of advanced assessment tools to identify patient safety issues. But if the Human Factors Specification (that is users, tasks, use environment and contextual requirements) is not understood, then staff will not have the information required, in order to improve the issues they find, or specify, select, design and build, or design services that meet the needs of the people that use them.
Going forward there needs to be consultation with NHS representatives that have some of the greatest impact on controlling risks at sources, such as, Procurement, Estates, Property & Facilities, designers,builders and architects of new spaces. Moreover, those NHS staff that design, commission and install the IT systems, which can have a major impact on patient safety, should also be consulted regarding their patient safety training needs.
3. Recognising non-technical skills as a human factors intervention that everyone can do
Human Factors training is the first Human Factors introduction for many healthcare workers and should be used as a building block for further training.
Non-Technical Skills are a set of social (communication, leadership, teamwork), cognitive (situation awareness, decision making) and personal resource (e.g. managing stress and fatigue) skills that support high quality, safe, effective, and efficient inter-professional care within the complex healthcare system.
Non-Technical Skills Training could be the unifying feature of the Syllabus that everyone in the NHS can apply (with training) – no matter where they work. From that foundation, the more specialised safety management skills in the syllabus relating to incident investigation, system analysis, culture change could be introduced.
We recommend that the Syllabus should re-frame Non-Technical Skills as ‘core NHS employee skills/behaviours’, provide measurable learning outcomes (already available from existing evidence bases) and ensure that, like all other Syllabus areas, it attracts the use of evidence-based training techniques and application of methods.
4. Teaching Non-Technical Skills and underpinning behaviours as an enabler of culture change
Bringing about a safety culture, developing a learning culture, and avoiding blame are complex challenges and we feel that the Syllabus has dealt with these too simplistically. These issues are key in healthcare right now and are a core part of every patient safety disaster that we see, local or national.
Following the Just Culture Guide is not enough. References to patient involvement in investigations have been around for the last twenty years, yet little has changed.
We recommend that the Syllabus should focus on measurable learning outcomes or identifiable behavioural outcomes that are known to facilitate a Just Culture. These skills can be emphasised in relation to speaking up, understanding hierarchy, overcoming bullying and undermining behaviour and improving listening to patients and colleagues.
Identifiable behavioural outcomes, for example, to determine patient involvement and a learning culture might include: asks open questions; listens actively; focuses on what’s right not who is right, expresses sorrow. These are examples of behaviours that underpin other just cultures.
There also needs to be recognition that sustainable culture change is as an indirect effect of transformation of other things, such as jobs, tasks, equipment, skills and capabilities, and the physical and organisational working environment including leadership attitudes and behaviour. The Syllabus needs to reference the wider organisational context and other relevant change programmes.
5. Observing behaviour to assess and measure outcomes
Whilst the document identifies how learning outcomes might be assessed, we believe observing behaviour against agreed frameworks is a valuable tool for assessing learning outcomes as it reflects ‘work as done, not work as imagined’ and provides an observable measure of cultural norms and what drives the culture.
Many of these already exist, for example, the NOTSS and ANTS and SPLINTS frameworks for assessing Non-Technical Skills for Surgeons, Anaesthetists and Scrub Practitioners and similar observable measures have been found useful in other safety-critical industries.
6. Additional points for consideration:
2.3 ‘Preventing human error’ would be better labelled as ‘Reducing (or Minimising or Managing) human error’.
It would also be useful to introduce the principle of ‘use error.’ These are unintended outcomes caused by poor design of equipment, devices, work environments, IT systems.
3.3.2 Decision making is a key non-technical skill for many roles and should be mentioned.
3.3 Phrasing should be corrected – ‘Is aware of non-technical personal non-technical skills and their
effect‘.
If you would like to view the syllabus please go to the Academy of Medical Royal Colleges website
