An HF approach to Qi

2013-2016 Theatre safety project

Neal Jones

Assistant Director of Patient Safety

The problem!

• 12/13 The organisation had multiple surgical never events.

• There were significant parallels in the error causation factors.

• Human Factors elements were identified as prime error causation components

The drivers of error

• Healthcare should be a high-reliability industry

• Unfortunately literature shows that it is fraught with error, can be unsafe, and at times is not effective

• The potential for error and system failure is always there

• Things happen on a daily basis: staff go off sick, equipment doesn’t work, people forget to do something - we are all human no matter how diligent

• This is a normal part of a complex healthcare system

Human Factors design philosophy

Safe patients

Safe Staff

Just/open and learning Culture

Resilient workforce Cognisant of self and

team performance limitations

Environment, equipment and

process designed to support workforce

(Person centred design)

Our approach

A. Creating a culture in which staff can make timely interventions and compensate for system failures is a key pre-requisite to developing high reliability.

B. Designing out system failures to reduce the stressors placed upon the workforce and enhance clinical performance.

The project plan

• A human factors based re-design of the identified failing safe

systems • Improve culture and confidence of workforce – improve staff

retention and staff satisfaction

• Targeted intra-professional human factors team training for every member of the Theatre clinical workforce to:- – Increase error reporting through cultural change – Create a resilient workforce that can identify and mitigate risks in real

time. – 342 theatre staff trained in HF since October 2013

• Safety focused quality improvement methodology

• NHS traditional approach to error reduction =

– Add more boxes to be ticked irrespective of the frequency of the error type.

• Additional complexity = reduced compliance and increased risk.

• Goal- remove wasteful steps create space for safety

The answers can be found in…..

The people that physically do the job

The Project team

• Medical Director • Assistant Director of Patient Safety • Directorate Manager Theatres • 2 x Surgeons • 2 x Anaesthetists • 2 x Scrub nurses • 2x ODP’s • 2 x Dual roles • 2 x Theatre managers

• + regular listening exercises across teams

(DORR- methodology)

– Deconstruct RCA’s to identify the system drivers of unwanted behaviour/error causation.

– Observe normal practice to differentiate

between the exception and the norm

– Refine/Redesign the systems to mitigate the unwanted behaviours

– Re-train the teams in the new systems

• Design new fit for purpose solutions

The new tools

H - Have you noticed this?

A - Ask did you hear my concern/suggestion?

L - Let them know this is a patient safety issue

T - Tell them to STOP until it is agreed that it is safe to continue

Human factors trained student ODP utilised HALT to prevent a surgical never event

The HALT tool has been utilised over 150 times to protect patients since its introduction

The course

• Full team training model

• Discussion based program to explore the teams current practice and behaviours, and form contextual learning that can be implemented to enhance the teams safety performance with immediate effect.

The content

• 08:30 Registration & Coffee • 09:00 Welcome & Housekeeping • 09:15 Human factors in Health Care • 10:30 Coffee • 10:45 Human performance effectors • 11:45 Situational awareness • 12:45 Lunch • 13:30 Decision making • 14:30 Team dynamics • 15:30 Coffee • 15:45 How to use/Checklists/Halt tool • 16:30 Video based theatre error case discussion • 17:00 Close

• The Results!

Long term performance 2012-2015

0

50

100

150

200

250

300

350

400

450

2012/2013 2013/2014 2014/2015Total Errors reported 189 414 429

Axi

s Ti

tle

Total Errors reported

126% Increase in error reporting of since project implementation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2012/2013 2013/2014 2014/2015No harm 68% 85% 87%

% o

f e

rro

rs N

o h

arm

Annualised % of total errors that resulted in No harm

27% increase in episodes of No harm since project implementation

0%

5%

10%

15%

20%

25%

30%

2012/2013 2013/2014 2014/2015Low harm 27% 12.50% 11%

% o

f e

rro

rs l

ow

har

m

Annualised % of total errors that resulted in Low harm

59% Decrease in episodes of Low harm since project implementation

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

2012/2013 2013/2014 2014/2015Moderate Harm 3.70% 2.17% 1.10%

% o

f e

rro

rs m

od

era

te h

arm

Annualised % of total errors that resulted in moderate harm

70% Decrease in episodes of Moderate harm since project implementation

Episodes of patient harm 12/13 V’s 15/16

Year No harm Low harm Moderate Severe Death Never event

12/13 213 49 12 1 0 3

15/16 395 27 3 0 0 0

% variance

85% 44% 75% 100% N/A

52% increase in overall error reporting

Year 13/14 14/15 15/16

UK Never events

338 306 340+

StHK 0 0 0

Fiscal Year Theatre activity % increase from start

date

2012/13 27,636 ↔

2013/14 30,851 ↑ 11%

2014/15 31,305 ↑ 13%

2015/16 31,842 ↑15%

Probability of Harm

Year Low harm

probability Moderate harm probability

Never event probability

All harm probability

2012/13 1:558 1:2,303 1:9,212 1:431

2015/16 1:1,179 1:10,614 0 1:1,061