Those who know me well will know that I'm a pessimistic optimist – I know we'll eventually see human factors firmly embedded in health care across the world, but I know it won't happen without a great deal of thoughtful work by those at the front line and, importantly, those who hold the system reins.
As we launch into 2015 there is much to feel positive about. We're seeing more interest in human factors across the clinical community than ever before, and projects and ongoing work at various frontline locations continue to expand and move our understanding into new areas. Sometimes assumptions we make about human factors, based on their application in other industries, has proven wrong, but quite rightly this has encouraged people to explore further. The question ‘Why?’ is so important. Let me share with you some of the new things I learned last year…
In December I attended a Health Foundation conference on patient safety. The conference was attended by many key decision makers/influencers within the NHS and, with a few exceptions, people seemed genuinely interested to use the moment to take stock, listen and ask questions about ‘where does health care go from here?'
I was lucky to share a platform with Professor Mary Dixon-Woods who emphasised strongly that QI projects have an important role, but they cannot solve all patient safety problems – especially if they continue to take place in a largely uncoordinated way. She commented that health care has got to stop 'swotting the mosquitoes one by one, and start draining the swamp'. A recording of Mary’s presentation is available – I highly recommend that you watch it.
Mary and I agreed that local improvement projects are and always will be critical to making sure things are workable and effective at the front line, taking account of local systems and issues. But we need to make a considered effort to ensuring clinical systems (at scale) are safer. Mary was part of the Safer Clinical Systems project which has just reported back and is well worth digesting.
A few days before the Health Foundation’s conference, the Clinical Human Factors Group (CHFG) held its second major conference in London. Dr Kevin Fong, doctor and BBC Horizon presenter, challenged us all by saying that when we've learned from aviation, we've learned the wrong lessons. Kevin suggested that we obsess about heroic saves such as the Hudson River ditching, but in so doing we miss the bigger picture – which requires that we should first and foremost design systems that avoid the need for heroic saves.
Professor Jane Reid gave an example of drugs packaging, highlighting that instead of avoiding error-prone situations in the first place, we give clinicians two drugs, very different in purpose, put them in very similar packaging then say to clinicians ‘Be careful, pay attention, make sure you check, don't make a mistake’. We, ‘the system’, present them with an error-prone situation and expect them to do the heroics. We must be mad! When will the NHS use its purchasing power at scale to design out such flaws?
I was also delighted that, at the same conference, the CHFG recognised those who've shown that compassionate care is part of good 'human factors' embedded practice through the Francis Jaye awards.
Those selected for recognition and award were very different. It was clear to me that the team winners, Cambridgeshire and Peterborough Foundation Trust's Older Adults Liaison Psychiatry Team at Addenbrooke’s Hospital (part of Cambridge University Hospitals NHS FT) achieved what they do through a flattened and level hierarchy and a constantly shared situational awareness (SA) of what’s happening with patients. In fact, their SA is so high that often when the team are with patients, their thoughts are helped by what they know colleagues will question them about later.
In comparison, the individual recipient of the Frances Jaye award, Maria Davison, a staff nurse at Derbyshire Community Health Services NHS Foundation Trust, achieved what she did by ‘going against the system’ and speaking up to raise concerns for the sake of patient care. It was great to hear that her concerns were listened to and acted upon.
In 2015 I will continue to knock on the doors of those at the top. We've built a good ongoing relationship with a number of national and international leaders and I'll continue to help them identify how we can ‘make it easy to do the right thing’. To give one example, people in our network have helped bring about a UK Parliamentary inquiry into the potential value of independent investigation in health care.
I know 2015 will be a year in which we all learn more about human factors in health care. There’s still much to be done, and I’m looking forward to helping build on the work that took place in 2014.
Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group, www.twitter.com/MartinBromiley