“the more teams “well organised, · 2019-09-30 · ppss combines expertise from high...
TRANSCRIPT
“THE MORE TEAMS UNDERSTAND THIS THE
SAFER DAILY WORK PRACTICES WILL BE”
“WELL ORGANISED, RELEVANT AND
INSPIRATIONAL - THANK YOU”
S A F E T Y • E X P E R T I S E • E D U C A T I O N
WE PROVIDE A SYSTEMATIC APPROACH TO MITIGATE POTENTIAL AVOIDABLE MEDICAL ERROR BY EMPOWERING STAFF TO ENGAGE
IN A CULTURE OF SAFETY THROUGH THE PRACTICAL APPLICATION OF HUMAN FACTORS TRAINING IN HEALTHCARE.
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WHAT WE DO
PPSS combines expertise from high reliability organisations (HRO’s) and the medical profession to deliver human factors and patient safety education to healthcare professionals.
This gives us the ability to apply principles learned from HRO’s to the healthcare sector, facilitated by clinicians who work, “on the front line”.
We do this through, “accident storytelling” a philosophy championed by HRO’s augmented with training in the practical application of human factors science.
Organisational psychologists have studied how safety improvement has been achieved in HRO’s. We believe many of their fi ndings are transferable to healthcare, with appropriate training.
S A F E T Y • E X P E R T I S E • E D U C A T I O N
WHAT’S THE ISSUE?Avoidable error remains common in healthcare*
It affects patients and their families, increases length of stay and is expensive. It can create second victims of healthcare professionals delivering care and damage institutional reputation.
Often the contribution of the “system error” is overlooked in incident analysis in the search to determine culpability.
Often the learning opportunities from Root cause analysis (RCA) are not being disseminated appropriately to those on the “shop fl oor”, making the system vulnerable to repetitive error.
There is much reference to the importance of this training but in reality a paucity of consistent and systematic training being delivered to those actually delivering healthcare.
The National Standards for Invasive Procedures recommends,
“Checklists must be conducted by teams of professionals who have trained together and who have received education in the human factors that underpin safe teamwork.”
Yet, how many theatre teams have human factors training as routine?
*Leape et al NEJM
THE SOLUTION!Consistent and systematic H-F training delivered by those involved in
patient care who understand the challenges faced by clinicians and organisations on a daily basis.
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S A F E T Y • E X P E R T I S E • E D U C A T I O N
OUR COURSES
Level 1
One day course - basics - empowers and educates. This is the basic level to which all healthcare workers should aspire to. Accredited by Chartered Institute of Ergonomics and Human Factors.
Course delegate manual provided. The foundation to our additional courses. Online training material in development.
Level 2
Safety Guardians 2 day course. Prerequisite is Level 1 course. Designed for those leaders to drive and embed principles within their organisation.
Serious Incident Analysis Course
This is aimed at safety/governance leads who are tasked with corporate responsibility of learning from adverse incidents.
Adverse incidents are widely reported and analysed but often appropriate learning points often don’t get disseminated to front-line staff. We aim to bridge this gap through empowering the practical application of human factors science in the learning outcomes from adverse incident investigation.
Resilience Training
This is led by Dr Kate Jenkins who has specifi c expertise in this fi eld. Compliments our courses and particularly helpful in supporting staff following their involvement in an incident.
Our training is designed to compliment existing governance structures within an organisation.
PLEASE CONTACT FOR PRICING OF COURSES.
Our systematic and practical approach enables an organisation to inoculate staff with human factors training and create resilience and the confi dence to promote and maintain a safety culture.
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WHAT OURDELEGATES SAYHealthcare Professionals:
“Every health care provider should have this and put processes in place to educate all
healthcare professionals”
“Essential for safe practice”
“All hospital staff should attend, should be part of training”
“Extremely well presented course with relevant teaching materials that underpinned
how important human factors is in health care”
“Helping health professionals realise how they can prevent incidents happening”
“The whole day was fascinating and informative the important thing for me was that the people leading the course
understand the situations we work in”
Legal Professionals:
“Fundamentally important to understand the whole picture in incidents. To prevent
harm we must move away from a focus on individuals and their actions. – All
excellent – a good mix of theory + examples + tests”
“I’m a senior clinical negligence lawyer – keep seeing the same things again and
again. Interesting ways of analysing the real issues in the cases I see, and which
might help the organisations we work with”
“The course will assist with inquest work when thinking about why things happened
and how/what improvements can be made.”
“Will now look at human factors and system factors, with reviews of SI reports and
understanding the causes of poor outcomes/incidents”
“Great talk. Really engaging”
S A F E T Y • E X P E R T I S E • E D U C A T I O N
Who should attend?
1. Any healthcare professional including hospital management. Our mission is to get human factors training part of routine training within organisations.
There is no place for elitism in who should receive this training. We have taught Healthcare Assistants alongside Consultants with equivalent excellent feedback.
2. Medical negligence lawyers and trust legal teams.
Why?
This will improve their understanding the role of human factors and error in healthcare and facilitate and improve their ability to provide learning from adverse event (see feedback).
3. Clinicians providing “Expert Witness” reports.
Why?
Professor Norman Williams* has recommended that an, “expert witness” should comprehend the role that human factors may play in contributing to medical error.
PPSS can provide training to this group through utilising John Reynards extensive experience in medical negligence work along side the teams HF expertise.
F.A.Q.
*Gross Negligence manslaughter in healthcare - The report of a rapid policy review June 2018
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A pilot doesn’t look after patients- you can’t compare flying a plane to the variability and unpredictability of clinical practice-so how can they understand healthcare?
Peter Stevenson has spent 25 years researching error from a range of safety critical industries not just aviation. He has been able to combine this with experience of advising on clinical error so has unique expertise in understanding techniques and principles which can be transferred to healthcare. Our courses embrace learning which has been adopted from a number of HRO’s.
Are your courses “one size fits all”?
Not at all. We have core material and principles which need to be delivered, but take great lengths to find exactly what our client wants and work with them to meet their expectations and requirements prior to delivering a course. We will not start a program for your organisation without this pre-course preparation.
Are you accredited?
Yes. External accreditation from the Chartered Institute of Human Factors with course certification.
What is the randomised controlled trial to show this training is of any benefit?
Simply put their isn’t one! There is evidence in healthcare to show that this type of training improves,”safety culture” within organisations and improves staff retention.* We believe that there is no reason why the improvements in the rate of avoidable error as seen in other industries (hro’s) through their widespread adoption of human factors training cannot be emulated in healthcare.
We already have a good governance structure – why is this training necessary?
Our courses are designed to complement existing governance structures within an organisation and augment what is already in place.
*M Leonard et al Qual Saf Health Care. 2004
S A F E T Y • E X P E R T I S E • E D U C A T I O N
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THE TEAMPeter Stevenson DIRECTOR/FACULTY
Peter has been an Airline Pilot and Human Factors Instructor for over 30 years. For the last 14 years he has lectured 4th year medical students at the University of Oxford. He has advised other NHS Trusts after adverse events and designed and presented Human Factors / Patient Safety courses. He joint-authored ‘Practical Patient Safety”published by Oxford University Press.
John Reynard DIRECTOR/FACULTY
John is a consultant urological surgeon and Honorary Senior Lecturer in the Nuffi eld Department of Surgical Sciences, Oxford. He holds a Masters degree in Medical Law and Ethics. He trains doctors and medical students in techniques that can be used to prevent and mitigate the effects of error in healthcare. He is a co-author of ‘Practical Patient Safety’, published by Oxford University Press. He acts regularly as an expert witness in the High Court, Coroner’s courts and at the GMC, for both Claimants and Defendants.
Tim Kane DIRECTOR/FACULTY
Tim has been a consultant since 2009 with a trauma and arthroplasty practice in a busy district general hospital. His interest in patient safety and how it can be infl uenced stems from experience in governance. He has a particular interest in staff induction. He has mentored trainee doctors undertaking safety projects which have been presented at the IHI/BMJ quality improvement and patient safety conference. He is a member of the chartered institute of ergonomics and human factors.
S A F E T Y • E X P E R T I S E • E D U C A T I O N
Peter Hambly FACULTY
Peter is a consultant anaesthetist at Oxford University Hospitals NHS Trust. He is a member of faculty of the human factors teaching programme at Oxford and provides simulation-based training for a range of healthcare workers. He has a particular interest in catastrophic incident analysis.
Tom Duncan FACULTY
Tom is a consultant anaesthetist at Oxford University Hospitals NHS Trust. In addition to human factors training, his interests are in healthcare management. He has a Masters Degree in Healthcare Policy and Management and worked for a year on a fellowship seconded to the National Institute of Health and Care Excellence (NICE). He has previously worked as a specialist advisor to the CQC on hospital inspection visits.
Judi Curtis FACULTY
Judi was Associate Professor within the Faculty of Health, Social Care and Education at Kingston University and St Georges University of London. Her teaching and research interests were within the fi elds of Breast Cancer Screening, Diagnosis and Treatment. She continues to support the University as a peripatetic lecturer and dissertation supervisor and is a Senior Fellow of the Higher Education Academy.
Michael Newman FACULTY
Michael Newman is a Trauma and Orthopaedic registrar. He has a masters in Medical Physics assessing algorithms to aid radiation dose reduction with a view to promoting patient safety in CT scanning. Since early 2016, he has been the clinical safety offi cer for a cloud based preoperative assessment platform.
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Kate Jenkins FACULTY
Kate is a Clinical Psychologist who specialises in working in acute hospitals. Since 2006 she has worked at Salisbury District Hospital, leading the psychological service for ITU, Trauma Orthopaedics and Oncology. She developed a teaching package on Psychological Assessment Skills which has been adopted as a national gold standard and also regularly runs Resilience training with frontline staff, reducing burnout and stress. She has recently been involved in the debriefi ng and resilience learning from the Novichok poisonings in Salisbury.
Rory Cunningham FACULTY
Rory is a commercial helicopter pilot having fl own numerous civil and military aircraft all over the world. A former Army Offi cer Rory left the military having served most of his career on operations and training detachments overseas. He began fl ying Air Ambulance missions shortly after leaving the MOD in the North of England. His deep interest in Human Factors training began whilst instructing aircrew in the military and he has continued to teach and consult on Crew Resource Management training for a range of HEMS and civil aviation companies ever since.
Tony Newton FACULTY
Tony is a Track Maintenance Engineer in Network Rail. He is responsible for two Section Managers and a technical team, leading around 80-90 staff in total.
His primary involvement in Human Factors is during incident investigation looking at immediate and underlying causes for operational incidents and injuries. Utilising control methods and incident analysis when investigating the successive risk controls that have succeeded / failed during the timeline pre/post event. He is looking forward to using his knowledge in healthcare.
S A F E T Y • E X P E R T I S E • E D U C A T I O N
CLIENTS & ASSOCIATES
InPractice
Solent Design
Medical Risk Services Ltd.
Chartered Institute of
Ergonomics & Human Factors
Presentations delivered to:
Associates
Spire healthcare
HCA healthcare
Browne Jacobson
Clyde and co.
NHS resolution
Johnson and Johnson
Various NHS trusts
HM Coroners
1515
0800 193 1912
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