NES Patient Safety Programme Human Factors in Healthcare NES Educational Developments and Resources
Introduction The three Quality Ambitions articulated in the Healthcare Quality Strategy include a focus on ensuring that there is no avoidable injury or harm to people from healthcare received and that an appropriate, clean and safe environment is provided for the delivery of healthcare services. The Patient Safety Programme within NES contributes to the Safety Ambition through a range of training interventions, educational resources, development programmes and partnership working. As part of the NES Patient Safety initiative, work is being supported to scope and develop Human Factors educational resources. Human Factors is a multidisciplinary field which has a growing influence in the area of patient safety and the reduction of adverse events. Investigations into adverse events have shown that 80% are a result of human factors such as communication, situational awareness and decision making. A widely accepted definition from the World Health Organisation and Health and Safety Executive describes human factors as the environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety. One of the outputs in this first phase of work is identification of educational resources which include human factor elements, developed by NES, or where NES has contributed funding. This summary provides information on existing resources, examples of how they contribute to patient safety, and details of where further information can be obtained.
Educational Resources which include Human Factors content Training events Description The NES Patient Safety Multi-disciplinary group (PSMG) has commissioned design and delivery of a programme of short courses by NES Training Development Support Unit (TDSU) to support capability and capacity building across NHSScotland. Human factors in healthcare is one of a range of topics offered by TDSU as part of a menu of course options designed to raise awareness of patient safety across NHSScotland. Developing a Patient Safety Culture within the NHS, a short course designed by TDSU for doctors in training, includes a focus on elements of human factors and impact on patient safety. Scottish clinicians with expertise in human factors contribute to delivery of the sessions. How Do I find out more? John McKinlay 0131 650 8160 john.mckinlay@nes.scot.nhs.uk Mark Johnston 0131 650 9740 mark.johnston@nes.scot.nhs.uk Tools Target audience: doctors in training; clinical education facilitators NES supports the Scottish Patient Safety Programme (SPSP) Safety Improvement in Primary Care pilot. Human Factors awareness training has been included in core topic content of the sessions. Target audience: primary care healthcare staff Scottish Multi-professional Maternity Development Programme includes a range of programmes that include some elements of human factors training. Effective communication is one of a number of human factors that determine how healthcare professionals interact with each other. The SBAR technique promotes patient safety by helping individuals to communicate with each other using a structured, standardised method. http://www.patientsafetyalliance.scot.nhs.uk/docs/sbarguid e.pdf NES Training Development Support Unit includes patient safety tools such as SBAR in the content of the Leadership and Management Programme. Helene Marshall 0131 220 8642 helene.marshall@nes.scot.nhs. uk John McKinlay 0131 650 8160 john.mckinlay@nes.scot.nhs.uk
Target audience: doctors in training Scottish Multi-professional Maternity Development Programme includes SBAR in the content of : Scottish Core Teaching and Training in Obstetrics Course Pre-transport Care Course Emergency Maternity Care Course for Non- Maternity Professionals Maternity REACTS (Recognition, Evaluation, Assessment, Critical Treatment and Stabilisation) Course Mark Johnston 0131 650 9740 mark.johnston@nes.scot.nhs.uk Helene Marshall 0131 220 8642 helene.marshall@nes.scot.nhs. uk These courses delivered locally also concentrate on clinical decision-making and effective team work. Target audience: maternity workforce including nurses/midwives/doctors/paramedics www.scottishmaternity.org
Online resources The NES Evidence into Practice portal provides a dedicated section on Patient Safety which includes tools and learning resources. Within this section, the information on managing human error is being developed further to enhance access to learning resources and the international evidence on human factors. Target audience: healthcare staff http://www.evidenceintopractice.scot.nhs.uk Derek Boyle 0141 352 2901 derek.boyle@nes.scot.nhs.uk An e-learning resource, Introduction to Patient Safety, has been developed to provide an awareness of patient safety and human factors in healthcare. An initial pilot has been undertaken with NES clinical training groups, educational supervisors and postgraduate tutors and is being extended to further groups. The e-learning resource is available to NHS staff who have access to the learning management system LearnPro and provides certificated evidence of completion for training and CPD purposes. The majority of respondents in a review of pilot feedback reported the module would have a positive impact on their work and indicated greater awareness of potential error and increased likelihood to report incidents Target audience: NES training groups - pharmacists; dentists; foundation year doctors; educational supervisors, postgraduate tutors. The Clinical Skills Managed Education Network have developed a range of online resource packs for use by healthcare staff in Scotland. The skill packs for Learning Safe Communication Skills and Clinical Decision Making include elements of human factors. http://www.csmen.scot.nhs.uk/projects/resources.htm A Framework for Observing and Rating Anaesthetists' Non-Technical Skills (ANTS) has been developed by University of Aberdeen Industrial Psychology Research Centre and the Scottish Clinical Simulation Centre. The first phase of the study was funded by NES. The handbook provides a condensed guide to the Anaesthetists Non- Technical Skills System. It describes a framework and common terminology that allows anaesthetists to communicate effectively with each other in this area of practice, helping trainees (and others) develop abilities in Paul Bowie 0141 223 1463 paul.bowie@nes.scot.nhs.uk Andrea Baker andrea.baker@nes.scot.nhs.uk
both the workplace or simulated work environment. http://www.abdn.ac.uk/iprc/documents/ants/ants_handbook_v1. 0_electronic_access_version.pdf Target audience: trainees; consultant anaesthetists NES Training Development Support Unit includes ANTS in the content of the Leadership and Management Programme for doctors in training. Educational Guides The Non-Technical Skills for Surgeons (NOTSS) System Handbook has been developed by the University of Aberdeen Industrial Psychology Research Centre. Development of the system was jointly funded (2003-2006) by NES and Royal College of Surgeons of Edinburgh. NOTSS is a behaviour rating system for surgeons which allows consultant surgeons to give feedback to colleagues and trainees based on structured observations of non-technical aspects of performance during surgery. Ratings and feedback are given on four categories of non-technical skills: Situation Awareness; Decision Making; Communication & Teamwork; Leadership Target audience: trainees; consultant surgeons NES Training Development Support Unit includes NOTTS in the content of the Leadership and Management Programme for doctors in training. The Scrub Practitioners' List of Intra-operative Non- Technical Skills (SPLINTS) handbook has been developed by the University of Aberdeen Industrial Psychology Research Centre, part-funded (2007-2009) by NES. SPLINTS aims to identify the non-technical skills necessary for safe and effective performance of scrub practitioners (nurses, technicians). NES Training Development Support Unit includes SPLI NTS in the content of the Leadership and Management Programme for doctors in training.
Educational Networks NES contributes to the educational infrastructure of the Scottish Patient Safety Programme (SPSP) Fellowship. SPSP fellows have opportunities to participate in educational forums and conferences delivered by internationally recognised experts which cover aspects of human factors. http://www.patientsafetyalliance.scot.nhs.uk/programme/fe llowship-programme
Glossary Clinical Skills Managed Education Network: as part of NES the Clinical Skills Managed Education Network (CSMEN) seeks to provide clinical leadership; common quality standards; increased training provision; educational resources; co-ordination of research and development priorities as part of the Scottish Clinical Skills Strategy. Evidence into Practice portal: The portal provides access to the evidence base for safe, effective and person-centred care. The range of tools and resources include targeted clinical evidence search, evidence summaries, guidelines and pathways to support clinical decision-making, and educating and learning. PSMG: The NES Patient Safety Multi-disciplinary group comprises representation from NES Directorates. The aim of the group is to develop a long-term sustainable educational framework to support patient safety through a range of activities in conjunction with internal and external partners. SBAR: SBAR is a communication technique which can help healthcare professionals to structure the information they are trying to communicate to a colleague. The acronym comprises: S = Situation; B = Background; A = Assessment; R = Recommendation Scottish Patient Safety Fellowship Programme: The Scottish Patient Safety Fellowship Programme was introduced to develop and strengthen clinical leadership and improvement capability in NHSScotland in order to support the implementation of SPSP. The Fellowship Programme is lead by Healthcare Improvement Scotland, in partnership with NHS Education for Scotland (NES) and NHSScotland territorial health boards. Scottish Clinical Simulation Centre: The Scottish Clinical Simulation Centre (http://www.scsc.scot.nhs.uk), part-funded by NES, is a state-of the-art multi-professional training facility based in Forth Valley Royal Hospital. The Centre aims to develop and support a national network of experts in the delivery of simulation based education; maximize the utilisation and effectiveness of simulation for learning amongst frontline healthcare staff; and optimize the quality of simulation based education which will augment clinical performance and therefore achieve the ultimate goal of improved patient safety. SPSP: The Scottish Patient Safety Programme (SPSS) is a five year patient safety initiative launched in Scotland in 2008. The aims are to reduce hospital care mortality by 15% and morbidity by 30%. Specific objectives are to reduce healthcare associated infections, adverse surgical and drug incidents, to improve critical care outcomes and build a safety and quality culture.