Storyboard submission Follow the detailed instructions in this template for writing a description of your storyboard. Type your information in each section below and save this completed storyboard document as a Microsoft Word file. Please spell check your storyboard before submission as it will be published on the NHS Wales Awards website. Please note: The storyboard should be between 500 1000 words maximum (including references but excluding headings, images or graphs) Submit your storyboard using the online submission system at www.nhswalesawards.org.uk by Friday 25 January 2013. Storyboard submission 1. Storyboard Title Human Factors and Non-technical Skills: An education programme to improve patient safety on the Intensive Care Unit 2. Brief Outline of Context (Where this improvement work was done; what sort of unit/department; what staff/client groups were involved) This work was carried out on the Adult Critical Care Unit at the University Hospital of Wales, Cardiff. It is a large, general Intensive Care Unit (ICU), also responsible for providing a number of regional tertiary referral services, to around 1400 patients per annum. The project developed and delivered an education programme, supplemented with simulation sessions, to the majority of the
Critical Care multidisciplinary team, training close to 200 members of staff. 3. Brief Outline of Problem (Statement of problem; how they set out to tackle it; how it affected patient/client care) High-risk industries, such as aviation, have long recognised that human error makes a significant contribution to safety related incidents. Healthcare is no exception, with some studies suggesting that up to 90% of safety related incidents are attributable to human factors [1]. ICU patients are particularly vulnerable to the consequences of error, having very little physiological reserve. By necessity, the critically ill require multiple drug therapies and medical interventions. Care is frequently provided by countless healthcare professionals. This provides numerous opportunities for error and consequent patient harm. Adverse events increase length of stay, but also cause significant morbidity and mortality [2]. This has both a human and financial cost. A range of non-technical skills have been identified over several decades by industrial psychologists working in partnership with high-risk organisations. These skills include, amongst others, situational awareness, team working, task management, decision making and communication. Awareness and use of these soft skills has been shown to mitigate some of the risks of human factors in error. Integration of these skills into practice has been advocated by many national agencies including, the Department of Health, the NHS Institute for Innovation and Leadership, and the 1000 lives plus campaign. Review of our own critical incidents identified a clear need to educate all staff on the importance and relevance of human factors to the safety and outcomes of our patients. We aimed to actively develop non-technical skills in the team and improve organisational safety culture. 4. Assessment of Problem and Analysis of its Causes (Quantified problem; staff involvement; assessment of the cause of problem; solutions/changes needed to make improvements) Research has shown that 10% of all patients admitted to hospital will suffer some kind of adverse incident; half of these are preventable; a third lead to significant disability or death [2].
Human error is implicated in the majority of these adverse events [1,2]. 5. Strategy for Change (How the proposed change was implemented; clear client or staff group described; explain how they disseminated the results of the analysis and plans for change to the groups involved with/affected by the planned change; include a timetable for change) It was recognised early on that delivery of an ambitious education programme for a large ICU staffing contingent would require considerable resources. A multi-disciplinary human factors and simulation teaching faculty was formed. This comprised individuals with existing expertise, two experienced psychologists, and members of the education team. Together, a 1-day teaching programme was developed. The morning comprised an interactive classroom based session, followed by a practical simulation session, focusing on non-technical rather than traditional technical skills. This approach allowed consolidation of theoretical knowledge gained earlier in the day. A handbook was provided to each participant for later reference. The teaching was delivered between June and September 2012. 6. Measurement of Improvement (Details of how the effects of the planned changes were measured) It has been notoriously difficult to obtain and demonstrate quantitative improvement in this field and literature evidence is scare. However, qualitative participant feedback was considered important. A biannual organisational health survey, conducted by the ICU Consultant Psychologist was considered to be a further method of capturing the possible benefits of this intervention. Implementing training of this nature is recommended by a number of national bodies responsible for patient safety. This has not occurred widely to date and to our knowledge we are the first ICU in Wales to undertake a programme on such a scale 7. Effects of Changes (Statement of the effects of the change; how far these changes resolve the problem that triggered the work; how this improved patient/client care; the problems encountered with the process of changes or with the changes) The concepts were new to all but 4 of the 198 staff members that attended. Participant ratings for the theory session were favourable,
scoring 9.1 out of a possible 10 for relevance and 8.9 for influencing future practice. This improved further with the afternoon session, to 9.5 and 9.4 respectively, as participants were able to further appreciate the clinical application. Qualitative feedback, utilising the methods described, have strongly supported the value of the training. Nursing staff have particularly shown that they recognise the importance of voicing concerns. Using the taught graded assertiveness techniques they feel more confident to do this, even within traditional healthcare hierarchies. There have been several reported incidences where this has occurred. Knowledge of these concepts has also enabled the introduction of an intubation protocol, based on human factors principles, which has been shown to improve the safety of ICU airway management [3]. Debriefing after critical incidents is now actively sought by staff, enabling lessons to be learnt for the future. 8. Lessons Learnt (Statement of lessons learnt from the work; what would be done differently next time) Management team commitment for a project such as this is crucial, as it requires a substantial investment of staff time. We provided virtually all staff with the education package, but nursing study day allocation constraints meant that the sessions could not always be truly multidisciplinary. Participants recognised the importance of this and highlighted it in the feedback. We will strive to achieve this in future sessions. It must be recognised that non-technical skills and organisational cultural change cannot be delivered in a single day. This programme has provided a common language to discuss human factors and error, but will require an on going commitment. We are fortunate that the ICU Directorate Management Team have clearly acknowledged the safety benefits of this programme and have committed future staff time to developing the training further. 9. Message for Others (Statement of the main message they would like to convey to others, based on the experience described) There are few novel and revolutionary medical interventions on the horizon that will radically alter patient outcomes. The only clear way to improve patient care is to reduce the harm that we as healthcare professionals and organisations unwittingly cause. Weaving human
factors into the very fabric of all healthcare systems is paramount. This can be achieved by educating every member of the organisation, without exception, of the importance and relevance of human factors. Understanding and enacting these principles will enable every member of the organisation to play their part in improving patient safety and saving lives. References 1. Walsh T, Beatty PC. Human factors error and patient monitoring. Physiol Meas 2002;23(3):R111-32. 2. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-519. 3. Jaber S, Jung B, Corne P et al. An intervention to decrease complications related to endotracheal intubation on the intensive care unit. Intensive Care Med 2010;36:248-255. Photographs can be provided should this application be successful.