Pilot of a Multi-disciplinary Human Factors Course in a Rural Setting in Australia. Adjunct Professor John Fraser School of Health, University of New England, Australia Director, Hunter New England Area Rural Training Unit Senior Medical Educator, New England Area Training Services Adjunct Associate Professor Christian Alexander School of Health, University of New England Senior Research Fellow, Hunter New England Area Rural Training Unit 0
Background 840,000 population (175,000 in northern sector) Geographic area larger than England Excessive adult mortality & morbidity from preventable diseases (CVS & injury) Many small towns with declining rural economies and aging populations Indigenous Population (20% of state s Aboriginal population ) Workforce Shortage in northern sector, procedural generalists staff many rural hospitals 1
2 Objective: To teach skills in advanced communication and human factors as part of a procedural skills training program conducted for to a group of GP registrars, nurses and other health professionals working in a rural setting during 2006/07. This project supports RHSET objectives and priority areas to support, educate and train the rural and remote health multidisciplinary workforce utilising an innovative method from aviation and applying it to rural health.
3 Shel Model of Human Factors Software (procedures, manuals, checklists) Hardware (Equipment) Liveware (Team of health professionals and patient) Environment Elwyn Edwards, 1972
4 How does error occur in health care? (Reason Model) Error (unintentional actions) Vs violations (deliberate actions) Latent failures factors in a system which remain dormant until activated. Active failures errors in which consequences are immediate.
5 Stages of Project Stage 1 Establish a multi-disciplinary advisory group of senior nurses and doctors with experience in medical education who will advise on this project. National reference group RACGP, ACRRM Literature review and Project officer attends Eastern CRM training course, consultation with ACRRM, RACGP, NEATS and RDN Discourse of rural root cause analysis. Theme and content analysis Develop a curriculum with face validity.
6 Subsequent Stages Quasi experimental design Develop instrument to assess competence in human factors in a rural setting Develop a number of standardised scenarios testing this human factors and emergency medicine. Two day course emergency medicine training and human factors. Scenarios pre and post human factors training in small groups. Order of scenarios rotated at different sites. Structured feedback and video taping of scenarios, coding for themes Evaluation of workshop Three month followup evaluation
7 Background Australian rural health services deliver high quality services despite high workloads. (1) In a rural setting, all members of the team need to be optimally utilised to maximise outcomes. (2) ARTS framework Assessment Resources Transport Support 1Tracy S, Sullivan E, Dahlen H, Black D, Wang Y, Tracy M. Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women. British Journal of Obstetrics and Gynaecology 2006;113:86 96. 2 McConnel F, Barraclough B, Nichols A, Schweizer Y. Quality and Safety in Rural and Remote Medicine: The management of risk. 2004 Scientific Forum Proceedings 2004, Alice Springs. 2 EMERGENCY DEPARTMENT EQUIPMENT CHECKLIST Equipment After hours Drug Cupboard and Fridge Ambulance Equipment Auroscopes Bag Valve Mask Device Blood Alcohol Kits & Dispenser Blood Warming Device Blood Fridge Blood Gas Analyser Broselow (Paediatric) Tape Brown Paper Bags Cardiac Monitor Catheters Suprapubic Catheters Urinary Cervical Collars (semi-rigid) Chest Drain & Ambulatory Chest Drainage System Collar & Cuff CPAP/BiPAP Device Crash Cart Crycothyroidotomy Set Defibrillator (manual/saed) Disaster Staff Role in Emergency Department Disposable Nappies Dressing Trolleys Drug Cupboard Ear Syringe Tray ECG Machine Emergency Buzzers Emergency Delivery Kit (Obstetrics) End Tidal CO2 Monitor Enemas ENT Tray Entonox Cylinder Epistaxis Catheters Extensions Sets with T Eye Tray FOR GP REGISTRARS Available? Yes No Location? ACN 099 568 939
Stage 1 Methods: Discourse Analysis of regional root cause analyses Patient safety guidelines mandate that all SAC 1 incidents (fatal or potentially life threatening) are reported to Health Minister and investigated. SAC 2 potential to cause serious injury may be investigated. A multidisciplinary root case analysis makes recommendation to reduce error. Theme and content analysis of 21 RCAs from 2004 March 2006. 19 SAC 1, 2 SAC 2 Validation of results with independent researcher 8
9 RCA Themes Communication Role Planning Culture
Results: Communication Between doctors Between teams Between hospitals and NGO Between sites (hospitals) (Related issues of distance, time, preempting complications covered in planning theme) Doctor- patient Doctor nurse Between wards Poor medical records and documentation Hand overs and transfers Followup and discharge. 10
11 Results: Role Defining lines of responsibility Overlaps and gaps between teams Not recognizing serious signs and symptoms Experience of staff(supervision, junior vs senior) Not acting on seriousness of signs and symptoms Not following up patient results etc
12 Results Planning Based upon patient characteristics, workloads, skills of health team Being systematic rather than adhoc Updating protocols, policies and procedures) Systematic responses to emergencies (preempting complications and higher risk cases) (Related issues of distance, time, lower threshold to refer on)
13 Results Culture Becoming a safer learning culture Importance of education and training Importance of closed loop communication and documentation Versus Normalising behaviours when could increase risk of error Not questioning variation in clinical behaviour Behaviours condoned Accepting workloads, increased workloads lead to omissions and shortcuts No escaluation of response even if patient worsens Presumptions in staff, continuing diagnosis and treatment even if patient is not responding, i.e. no reassessment, no peer review of others in team
14 Stage 1 Development of a curriculum Steering Committee has met twice to date. Includes nurses, doctors and quality assurance staff. Clinical governance, quality assurance, education background Group developed theme for inclusion in course by nominal group process.
15 Recommendations Multiple delivery methods, role play, vignettes, games etc
Recommendations Content to include: Orientation Role delineation Situational awareness Teams Vs Groups Assertiveness training & power gradients Active listening and skills in providing feedback Closed loop communication, checking if message is received Group Think (emperor s new clothes) Transfers & handovers Near Miss Analysis Open disclosure - Express regret, describe what has happened and what will be done. 16
17 Future Directions in Stage 2 Standardised scenarios Instruments to access competency in human factors in health care.
18 Emperor s new clothes or Group Think Shirley, 42, is well known at the emergency department, presenting often with minor complaints and diagnosed by a psychiatrist with panic disorder. Her mother died last week and she attended the funeral interstate. She represent today with sweating and tremor and myalgia, P 100, BP 130/80, RR 25. She is triaged as having another panic attack by the senior nurse and doctor in the unit. You are the junior doctor in the unit. An ECG shows tachycardia only, with equivocal S wave an Q wave changes?? You disagree with the senior doctor, could this be pulmonary embolism, but don t want to rock the boat as your assessments to date have been borderline and another is due this week. What do you do? A scenario then follows, as Shirley gradually but distinctly deteriorates, the group is assessed on it s ability to monitor situational awareness and to monitor peer performance and give feedback where a power gradient exists.