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Here we share some thoughts, insights and ideas related to Human Factors Training

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Enhancing Trainer Skills

Intro by David O'Regan

I invited Trevor to write a blog about the airline industry. Aviation, safety, human factors and crew resource management have taken centre stage in health care. My discussions with Trevor unveiled a dimension that I do not believe has been considered or given enough airtime – no pun intended. Trevor attributes the culture change in the aviation down to the realisation that training people by instruction was no longer appropriate and that the industry had to facilitate people to able to fly – the new terms are coaching, mentoring, reflection and self-actualisation. He closes his blog with a particularly important point.

Consider the 'person-specification' of your raw recruit. Airlines no longer look for pilots to fly their aircraft. They seek team players and teach them to fly.

I believe this applies to surgical training. We should no longer be looking for people who can operate but we should be seeking team players, teach them to operate and to adhere to standard operating protocols. We will start functioning as teams and engender respect. I believe we will then achieve a level of quality that to date has eluded us because many believe their way is the best way - at present we are herding cats.

Blog by Trevor Dale

It has long been the case, in many situations, that students and trainees need something of the chameleon in the genes. One trainer wants it done this way and another has an opposing view. This was certainly the way I progressed through basic flight training and the first 15 years of commercial flying.

It is worth spelling out that commercial aviation has a high penalty element for failure. It can of course terminate in death of self and others. Thankfully not all professions involve the first of those.

There is something frankly ironic, and for many quite stressful, about passing through a 'terminal' building at the airport. However, data suggests that flying is far the safest form of transport and so far, I have managed to obey the simple maxim of flight safety. Keep the numbers of landings exactly matching the take-offs.

When it comes to pretty much any profession, consider what the client, the ultimate employer, desires. A standard product in terms of skills but retaining their own individual personality. No one, outside of HR departments, wants identical clones with robotic reactions simply because people are all different. Passengers and crew colleagues vary as do medical colleagues and patients. In aviation, experience tells us that standardised procedures are essential to underpin the everyday variation in location, weather conditions and technical details. It rather helps if you're hurling 400 tons of metal full of passengers and fuel into the sky if you have a fairly firm idea what your colleague is doing now and hopefully, going to do next. The same thing seems reasonable to expect in health and social care, especially surgery. This is why briefings or 'huddles' are so crucial. A sharing of situational awareness to all present and potentially involved in the ensuing action. Surprises don't work out well in safety-critical professions. Although many believe that airline flying is all about pushing a couple of buttons and the automatics do the rest, it is in reality anything but. As we all know, weather can change significantly and little things like how long the runway is can make a huge difference.

There are three useless things in flying. Fuel in the tanker, sky above you and runway behind you. Believe it or not, but even sophisticated aircraft stuffed full of fancy computers still fly according to the laws of physics, not the software developer.

My early experiences of receiving training to fly varied little in fact, but then it is pretty basic. Pull back on the stick and the houses get smaller, push forward and they get bigger. Push the stick to either side and the houses go upside down. However, keep pulling back on the stick and suddenly the houses can start getting dramatically bigger. Once one progresses through to more advanced flying, such as on instruments, in cloud or at night there is more room for interpretation. But we all had to achieve very strict parameters in flying precise accurate standard procedures in order to graduate and be let loose on an unsuspecting public. Nowadays this encompasses professional behaviour as well.

At flying college, I had the misfortune to have one particular instructor who had a laid-back attitude to calculating the approach and landing speed, which is weight-dependent in normal conditions. His was a 'that's near enough for what we need' approach. I came unstuck when taking my flight check from another examiner. I had an instructor change, fortunately, after that. I could have been chopped (removed from the course) but must somehow have had enough else in my favour, proving that you can, occasionally fool some of the people. Almost all the instructors had a military background. Some were great, some more stand-offish. Friendliness and professionalism are a terrific blend, especially in professions where skill and judgement in keeping self and others safe are called for. Confidence without arrogance is the ultimate aim and role-modelling is essential. What I now recognise as authenticity, integrity and empathy.

In the 1980's the realisation that attributing accidents to 'pilot error' was simply not enough. Airliners full of people were crashing at the rate of 1 per month on average. Crew Resource Management became the hot topic on the back of NASA-funded research into behaviour on the flight deck. From this came the initial training concept of raising flight crew awareness of effective and ineffective safety behaviour. What had been accepted as reasonable authoritarian hierarchy was now recognised as unhelpful and unsafe.

Analysis of the flight data and cockpit voice recorders revealed that most accidents occurred when the Captain was the pilot flying and the junior pilot was monitoring and supporting. Clearly change was essential. However, this had to be handled delicately without taking away the Command authority and responsibility. And so, it morphed into entirely new crew roles. In many airlines the standard procedure when in an emergency situation, became for the Captain to hand the flying of the aircraft to the co-pilot, thus freeing up the captain to think, manage, communicate and moreover exercise his or her judgement and experience. What was suddenly recognised was that if the co-pilot controlled the flight path, the Captain had spare capacity to think logically and monitor the evolving situation. The concept is known as Situation Control. In essence it is a coping strategy to trap and avoid the potential for stress overload in a crisis – fight, flight or freeze.

Enhancing awareness in break-out discussions of aircraft accident case studies is one thing. How does that translate into a real-World performance? What was needed was a thorough transformation of training and regular checks. Every year flight crew undergo six-monthly refresher training and checks in a simulator and another check on a regular passenger-carrying flight, known as a Route Check. Failure on any of these means instant grounding until a satisfactory performance on another day or ultimately dismissal if the pilot fails to meet the required standard. Aviation simulators have evolved into very hi-fidelity replications of reality. To some extent 'G' forces can be experienced though not totally, but the pilot can be fooled into thinking they are really flying and more to the point, about to die if or when they make some mistakes. The argument that "I wouldn't have done that in the Real World" simply doesn't stack up.

But to make the most of this training involves transforming the trainers from their previous stereotype of Instructors to facilitators. The time for instruction is when someone simply doesn't know. It is an input of new knowledge. But when one is building on existing knowledge and experience, as is the case with behaviour, then a drawing out of ideas, building on one's own experience is more successful. The fundamental issue is that nobody reacts well to being told how to behave. For it to be a sustainable change it needs to be coaxed out on a voyage of self-reflection, self-awareness and self-actualisation.2 That changes the Instructor to a mentor and coaching role. In the current world the trainer now has to embody Evidence-Based Training3 into every session. Observing, analysing and designing personal challenges for each individual trainee. Then offering and accepting feedback in a calm, factual method. This now has broadened into including cognitive and behavioural skills alongside the obvious technical skills. This was an enormous challenge for many even experienced instructors who struggled to comprehend the additions. But it became apparent that many instructors could not adapt and had to be removed from their roles. Many had arrived in their exalted position without having demonstrated and talent and now were found wanting.
We designed, developed and delivered an entirely new course which focused on the true role of the trainer and adult learning methodologies. The course was 5 days initially of theory and practice, modelling everything we were training. It was continuously assessable and not everyone graduated successfully. It is known as the Core Course and is mandated in over 43 countries. The impetus was from the Civil Aviation Authority, the single safety regulator in the UK, mandating Human Factors training and assessment alongside the technical skills from 1995. Other countries were doing the same or similar and it resulted in a Pan-European research program1 to define those essential Non-Technical Skills. The further development of ANTS4(Anaesthetic Non-Technical Skills) and subsequent NOTSS and SPLINTS for surgeons and scrub teams all evolved out of this original work.
The graduate of the Core Course would understand the key concepts of safe flight deck performance, be able to brief crew before they embarked on a real or simulated training session, be able to observe both technical and non-technical skills throughout the subsequent session, analyse them and lead a facilitated discussion post-hoc. A key part would also be the training report as written up afterwards which had of course, to be truthful, accurate and agreed, ideally with the trainees. We developed a simple format of Commentary - what happened; Appraisal – did it meet the required standard; Pointers – what could the trainee do differently and also what could they continue to do, in future.

The final piece in the jigsaw is, of course, standardisation of the trainers and this is regularly achieved by 'Training Standardisation Captains' who check the trainers every 24 months. They in turn are standardised regularly by external examiners from the regulator.

However, there is one other basic change that resulted from the whole movement into human factors in aviation. Certain other professions where safety performance is a crucial aspect could benefit. Consider the 'person-specification' of your raw recruit. Airlines no longer look for pilots to fly their aircraft. They seek team players and teach them to fly.

References
1. https://cordis.europa.eu/project/id/AI-95-SC.0307/results
2. https://www.researchgate.net/publication/23669522_The_Role_of_Debriefing_in_Simulation-Based_Learning
3. https://www.skybrary.aero/index.php/Evidence_based_training_(EBT)
4. https://www.abdn.ac.uk/iprc/documents/ANTS%20Handbook%202012.pdf

About the author:

Trevor Dale FRAeS, MRCPS(Glas)(Honorary) MCIEHF
Trevor Dale was an airline pilot from 1971 to 2005 and became a Training Captain flying Boeing 747's. Trevor began introducing human factors training to healthcare professionals in 2002 with paediatric cardiac surgery and now continues to do so across the entire spectrum including surgery, ICU, anaesthesia, maternity, mental health and community teams.
Trevor has been active in development of research and training initiatives in healthcare, aviation and other safety-related industries including nuclear power generation.
His passion is to help professionals develop and maintain their full range of skills, both technical and non-technical. He is working to introduce human factors implementation into child protection social work.
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We are in charge more than we believe

Dr Alka Patel is a lifestyle medicine physician and health coach.

She has been a medical doctor for over 20 years and she began her professional career on a high, driven to build her career and find success. 

But this drive in her professional life meant Alka put her health on the backburner. The result, a collision course with burnout.

Despite working hard as a doctor to help people become healthy, Alka realised that medicine was headed in the wrong direction, she wasn't being the doctor she wanted to be. 

An over-reliance on medication as a cure for every illness and a dependence on doctors to wipe away symptoms was detracting from what really mattered.

Alka firmly believes that many illnesses can be prevented and reversed with a shift in lifestyle habits. 

She talks with Trevor about her Lifestyle First Method ®, coping with stress and grief and how you can live your longest, healthiest and happiest life by putting your lifestyle first especially now at this difficult time.

Here's my conversation with Dr Alka Patel, in episode 11 of Atrainability Radio.

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@dralkapateluk

https://dralkapatel.com/

https://www.practitionerhealth.nhs.uk/


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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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Safety is never about behaviour alone

Dr Ken Catchpole is a cognitive scientist and human factors practitioner who seeks to understand and improve human performance in complex systems. 

Ken currently works at the Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.

His research has been primarily conducted in the UK and USA, exploring trauma, cardiac, orthopaedic, vascular, gastrointestinal, spinal, and urological surgery. He has also contributed to accident analysis and quality improvement across the world.

Through popular media, over 70 peer-reviewed publications, and at least 150 invited lectures, Ken has engaged thousands of people in the improvement of healthcare from a human-centered perspective.

In this episode of Atrainability Radio, we reminisce and challenge each other on how human factors in healthcare have moved on in the UK and in the US.

Here's my conversation with Ken Catchpole, in episode 11 of Atrainability Radio.

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@KenCatchpole

@HFTHNetwork

Human Factors transforming healthcare https://www.hfthnetwork.org/

@AHRQNews

Agency for Healthcare Research and Quality - https://www.ahrq.gov

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.


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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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Everything you do is worth a review

Roy Lilley has been in and around the NHS since 1974. 

He is an independent health policy analyst, writer, broadcaster and commentator on the National Health Service and social issues.

An excoriating critic of the NHS and its institutions but a fan of the patient facing front-line of healthcare and the anonymous people who manage the services.

He has been a policy advisor, a visiting fellow at Imperial College London, helped start the Health services Management school at Nottingham University and was a founder of the Federation of NHS Trusts… that became the Confed. Roy is the author of over twenty books on health and health service management, and is the Founder of the Academy of Fabulous NHS Stuff, and runs the nhsManagers.network.

Roy talks candidly to Trevor Dale on Atrainability Radio about trying to change attitudes to human error and fallibility across healthcare.

Here's my conversation with Roy Lilley, in episode 10 of Atrainability Radio.

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@FabNHSStuff

The Academy of fabulous stuff https://fabnhsstuff.net/

Roy mentions

Matthew Syed @matthewsyed

Dr. Marlies P.Schijven http://www.googleglasssurgeon.com/team

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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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The staff are on a stage and the patients are watching

In 2017, Jen Gilroy-Cheetham's life changed forever. 

Just six months after having her second child, she was diagnosed with a rare neuroendocrine tumour and was advised that she would need to undergo keyhole surgery to have half of her stomach removed. 

Complications led to one of the darkest and scariest times of Jen's life, as she was put into a hospital ward feeling unwell, vulnerable and extremely unsafe.

Jen, previously a programme manager at the Innovation Agency, shares her experience with Trevor Dale in this episode of Atrainability Radio. 

She talks from experience as a patient and as a healthcare professional and relives her journey to recovery. 

Jen highlights what's needed within a healthcare setting to make patients feel safe and explains what needs to change and hopes that by talking about her experience may help others in the future.

Here's my conversation with Jen Gilroy-Cheetham, in episode 09 of Atrainability Radio.

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Useful links


Watch Jen's TEDxNHS 2019 live https://www.youtube.com/watch?v=ZSjfuKnYlTg

Twitter @gilroy19 @innovationnwc

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.


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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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You don’t need to be an expert to get it right

Jacob Bayliss currently manages Pride in Practice for the LGBT Foundation - a quality assurance and social prescribing award focusing on the health needs of the LGBT community.

He has a long history of training, consulting and developing community-led initiatives to tackle health inequalities and to create meaningful change.

In this episode of Atrainability Radio, Jacob talks openly to Trevor about how society is changing and his commitment to supporting healthcare professionals to embrace the discomfort, to talk openly and feel confident when working with LGBT communities. His vision is to create services where LGBT people can be seen.

Here's my conversation with Jacob Bayliss, in episode 08 of Atrainability Radio.

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Watch Jacob's TEDxNHS 2019 live talk https://www.youtube.com/watch?v=0IzKfa1fBns

Twitter @jacobb_91 or @LGBTfdn

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.


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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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Communities are not short of dreams, ideas and hopes

Dr Andy Knox is a General Practitioner based in North West England. 

Andy trained as a doctor in Manchester, England and worked in various hospitals across the city before training as a GP. He is now an executive GP for Lancashire North Clinical Commissioning Group and works with the Better Care Together Team for Morecambe Bay.

Andy talks to Trevor Dale on Atrainability Radio about the impact of massive health inequalities across the UK and developing a culture together, in order to create real wellness within our communities. 

Re-imagining cities and regions as healthy places, challenging the status quo and re-imaging the future.

Here's my conversation with Dr Andy Knox, in episode 07 of Atrainability Radio.


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Watch Andy's TEDxNHS 2019 live talk https://www.youtube.com/watch?v=ZfIyXle2y1k

http://www.bettercaretogether.co.uk/

@wellbeingandy

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.


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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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There is still kindness out there

Alexandra Adams a 4th year medical student, registered blind and hearing impaired, making her the first deafblind person in the UK to be trained towards becoming a doctor. 

Having faced discrimination and inequality in the workplace, she advocates for better diversity, inclusivity and representation for those with disabilities.

Alexandra shares with Trevor in this episode of Atrainability Radio, her very own personal stories and frustrations as a patient and also a doctor in palliative medicine and how empathy is vital.

Here's my conversation with Alexandra Adams, in episode 06 of Atrainability Radio.


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Useful links

Watch Alexandra's TEDxNHS 2019 live talk https://www.youtube.com/watch?v=s8eAaxl0pTw

Follow Alexandra on Twitter @alexandra_DBmed or @facesoftheNHS

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.


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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

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15 seconds to make a difference

Rachel Pilling, a consultant ophthalmologist, co-founded 15s30m, a quality improvement tool, to enable all NHS staff and patients to reduce frustration and increase joy.

Rachel talks to Trevor in this episode of Atrainability Radio about how she empowers her team to have equal standing and an equal voice.

Here's my conversation with Rachel Piling in episode 005 of Atrainability Radio.

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Useful links

Watch Rachel and her Co-Founder Dan Wadsworth's TEDxNHS 2019 live talk - https://www.youtube.com/watch?v=wDqNHlKavVE

For more information on 15s30m visit: http://15s30m.co.uk/ - An internationally recognised tool for spreading quality and improvement in health and social care

Follow Rachel on Twitter: @miss_pilling or @15s30m

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.

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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

Still to come in the first season of Atrainability Radio:

Alexandra Adams is a 4th year medical student and the first deafblind person in the UK to be trained towards becoming a doctor

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The top is still very male heavy

Sarah Hillman, clinician and academic researcher, and self confessed medical feminist, talks candidly to discuss her main research interests in women's health and genetics in primary care.

Sarah highlights in this episode of Atrainability Radio how key life changes for women such as becoming a mother or hitting the menopause, are today, still causing barriers when working in a predominantly male dominated environment.

Here's my conversation with Sarah Hillman in episode 004 of Atrainability Radio.


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For more information about Athena Swan visit www.ecu.ac.uk/equality-charters/athena-swan/

Watch Sarah's TEDxNHS 2019 live talk https://www.youtube.com/watch?v=RMWDG5S9eQo

Follow Sarah on Twitter: @sarahhillman26

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.

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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

Still to come in the first season of Atrainability Radio:

Rachel Pilling is a consultant ophthalmologist and co-founder of 15s30m

Alexandra Adams is a 4th year medical student and the first deafblind person in the UK to be trained towards becoming a doctor

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How just one smile made me feel safe

Sports presenter and campaigner Charlie Webster shares the story of the moment she was told she was going to die. 

She still suffers flashbacks and PTSD three years after contracting Malaria in Rio de Janeiro at the Olympic games. 

Charlie talks so openly in this episode of Atrainability Radio about how we can learn from her physical and mental aftercare and how it is important to recognise in others when they are not okay but it is even more important to recognise in ourselves when we are not okay.

Here's my conversation with Charlie Webster in episode 003 of Atrainability Radio.

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Follow Charlie on Twitter: @charlieCW

Watch Charlie's TEDxNHS 2019 live talk here: https://www.youtube.com/watch?v=ryLZ6HLlZmE

#ptsd #ptsdawareness

More information about Charlie is on her website: charliewebster.com

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.

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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

Coming up in the first season of Atrainability Radio:

Sarah Hillman is a clinician and academic researcher

Rachel Pilling is a consultant ophthalmologist and co-founder of 15s30m

Alexandra Adams is a 4th year medical student and the first deafblind person in the UK to be trained towards becoming a doctor

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NHS faces huge clinical negligence legal fees bill - are there solutions?

According to the BBC today, the NHS in England could face legal fees totalling £4.3bn to settle its outstanding clinical negligence claims.

The figure was discovered by the BBC through a Freedom of Information request and included all current unsettled claims, along with projected estimates of future claims.

Atrainability is currently helping several entirely different healthcare organisations deal with this problem.

Human Factors Ergonomics is at the heart of everyone. Some problems are at the organisational level; some are individual issues.

The organisations we work with represent a complete cross-section of healthcare.

One is a small public hospital that we have helped to identify the deep problems which can be fixed. The front line teams have stated that there is no effective senior-level leadership.

Senior leaders are not present when they should be. This absence of senior leadership is frequently a factor in failing organisations.

Along with this, they do not deal with staff complaints and evidence is there of 'encouraging' staff to change complaint statements. Clear guidelines are not there.

Staff have nothing to refer to settle differences of opinion about care pathways.

Bullying and inappropriate behaviour are rife. There is a suspicion that this abusive behaviour is implicated in a reluctance to escalate concerns about a rapidly deteriorating patient which may have resulted in a death, and consequent legal costs of course.

There are doubts about clinical competence. Unsocial hours working is not equitably shared out. There are conflicts of interest between public care and lucrative private work.

There is considerably more.

In this case, we suggest that the managers get on and manage. Stop ducking the difficult conversations with other managers, clinicians and staff. Patient safety must come first.

They also do not understand the human condition. They are ignoring work conditions that provoke increased unnecessary stress. They do not learn from failure and certainly not from success.

They have wonderful dedicated front line staff who are worn out. Some of that stress comes out in unprofessional behaviour. It needs managing.

Another organisation we are helping is not within the NHS. It has used Lean methodology as a core concept.

Lean is excellent for car production lines. Some of the concepts are laudable. Stop the line. Continuous improvement. Just in time. But with that comes 'efficiencies' in manpower. They do not have enough frontline staff.

Six Sigma is a better model. It is about doing the right thing, not the outwardly most efficient.

A defect is anything which doesn't meet customer expectations. I think that covers patient safety. They have state of the art equipment and again, dedicated front line staff whose concern is for their patients.

Here we believe a lack of standardised procedures and guidelines are again a problem. Plus lack of recognition of overwork and stress again.

Another of our current clients is rather strange and a delight.

We have an NHS Trust that has decided to be proactive. Their head of Quality Improvement (QI) has realised that building human factors ergonomics principles into their QI programme and spreading it across the entire Trust staff could have a very beneficial effect.

I say they are strange because most of our clients come to us having harmed or killed someone through 'negligence'. This one has spotted that using Six Sigma and other concepts can maybe intercept the threat vector.

The avowed intent is to empower staff to think and share their ideas; to encourage staff to take a proactive stance.

Of course, the management must be listening – actively, but this is a delight to work with.

When you look at the recent GMC publication 'Caring for doctors, caring for patients' this fits the bill superbly. Except it is not confined simply to doctors but everyone.

To ensure wellbeing and motivation at work, and to minimise workplace stress, people have three core needs, and all three must be met.

A Autonomy/control – the need to have control over our work lives, and to act consistently with our work and life values.

B Belonging – the need to be connected to, cared for, and caring of others around us in the workplace and to feel valued, respected and supported.

C Competence – the need to experience effectiveness and deliver valued outcomes, such as high-quality care.

As simple as ABC and of course it applies to everyone.

It isn't rocket science - JFDI.

We will help you!

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The essence of patient centred-care

Yusuf Yousuf is a healthcare support worker in Older Person's Services, a role he transitioned to after more than 10 years as a hospital porter.

Yusuf shares his very personal and emotional stories and experiences, finding inspiration in the NHS if you know where to look.

Here's my conversation with Yusuf Yousuf, in episode 02 of Atrainability Radio.

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Useful links

Follow Yusuf on Twitter at @yusuf_yousuf


Watch Yusuf's TEDxNHS live talk here
https://www.youtube.com/watch?v=NGhXX8cxs0g


Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.

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Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

Coming up in the first season of Atrainability Radio:

Charlie Webster, is a Sports presenter and campaigner

Sarah Hillman is a clinician and academic researcher

Rachel Pilling is a consultant ophthalmologist and co-founder of 15s30m

Alexandra Adams is a 4th year medical student and the first deafblind person in the UK to be trained towards becoming a doctor

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The years I have known I was dying, have been the best years of my life

I'm delighted to share the first episode of our new podcast series, Atrainability Radio.

Lucy Watts is a 26-year-old prominent disability and health advocate, activist and consultant.

She's a committed individual who dedicates her time to making a difference for others.

As a disabled young woman, Lucy has to overcome a wide variety of barriers, not least the low expectations of disabled people by others and the lack of accessibility, as well as living with a complex, life-limiting illness, causing complex medical needs.

In this episode of Atrainability Radio, we get to know Lucy the person not just Lucy the patient.

Here's my conversation with Lucy Watts, in episode 01 of Atrainability Radio.

Subscribe in Apple Podcasts

Subscribe in Pocket Casts

Listen in Overcast

Listen in Stitcher Radio


Useful links

More information about Lucy is on her website - http://www.lucy-watts.co.uk

Follow Lucy on Twitter: @LucyAlexandria

Watch Lucy's TEDxNHS live talk here:
https://www.youtube.com/watch?v=Y_j_zmZBvsI

Be sure to subscribe to never miss an episode. Click the 'Subscribe to podcast' button on the podcast player above or subscribe via your preferred podcast player.

---

Trevor Dale and his team at Atrainability work extensively with NHS Trusts and healthcare professionals to train thousands of staff to create safe and effective teams.

In this podcast series, Trevor interviews a wide range of everyday NHS staff and patients, as well as his colleagues. Each conversation shares a unique story, spreading their learning far and wide.

Many of Trevor's guests in Season One of Atrainability Radio spoke at TEDxNHS 2019, where Atrainability were a sponsor. This is the first time these insightful conversations have been shared for the public to hear.

Coming up in the first season of Atrainability Radio:

Yusuf Yousuf is a healthcare support worker in Older Person's Services

Charlie Webster, is a Sports presenter and campaigner

Sarah Hillman is a clinician and academic researcher

Rachel Pilling is a consultant ophthalmologist and co-founder of 15s30m

Alexandra Adams is a 4th year medical student and the first deafblind person in the UK to be trained towards becoming a doctor

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Honesty is the best policy?

Trending today in the news is the story of a transplant gone wrong.

The Oxford University NHS Foundation Trust agreed £215,000 of damage for one of the resulting cases, where a 36-year-old patient died of an aneurysm caused directly by infection from a donated liver.

Two other patients who received transplanted organs from the same donor also became ill.

The story relates to an incident in 2015, where the surgeon harvested several organs, but nicked the stomach during the retrieval process, spilling contents over the other organs, resulting in infection.

As much as we don't like to speculate, we have to question what was happening in the mind of the clinician who must have been aware they had perforated the stomach.

There is serious learning from this incident, for all involved. We must now ask how the experience can be best disseminated, in an effort for this to never happen again.

What I would hope to see from the surgeon involved is humility. One assumes they would be embarrassed and, in the spur of the moment, elected not to report the incident. Which of us hasn't made a comment or decision in a single moment, we haven't subsequently regretted?

One would hope that a professional, in whatever field, would be able to swallow their pride, overcome their embarrassment, and do the right thing, for the right reasons; the essence of professionalism.

We can't afford everyone to go through learning by trial and error. People often throw out the line, "lessons should be learned", but let's consider first what those lessons should be.

There's an opportunity for someone who has been through this experience to share their learning with colleagues, turning a severe negative into a positive.

I know from my time as a training captain in aviation that, to make a mistake as an expert, we must share that experience with others. We are held to a higher standard.

Where mistakes happen as a professional, you must swallow your pride. You must try to find a positive out of what is a devastating incident.

I can understand why the patients and their families would seek to apportion blame in an incident like this. But I would hope that the event was unintentional, and failure to admit their mistake (and be honest) at the time, a failure they have subsequently lived to regret.

What would striking off a clinician achieve? As long as they accepted their role in the mistake, that is. Assuming this is the case, they possibly become the best person to teach others.

If they demonstrate reflective learning and the appropriate attitude, and of course the duty of candour, with support from colleagues and management share what they have been through, hopefully that could produce some benefit for others in a tragic situation.

We do, however, meet people who won't accept their part in such incidents. These people are a real worry. When the attitude is, "well, it's just one of those things!", that approach isn't good enough.

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Communication and Perspective

I always try to build in one to one time at the end of our training courses, knowing that this may well fit certain people's preference type better.

Recently one of the theatre staff took me up on this offer. I wasn't sure quite what was coming next; they had appeared quite harassed at the start of the course, looking tired and stressed, not that this is unusual in the NHS.

They stated that they had enjoyed the course but wasn't so sure at the outset when I had introduced myself as being ex-Ambulance Service. They proceeded to tell me a sad story of how they witnessed a close family member collapse and die in front of them.

They took all the correct initial chain of survival steps until the ambulance crew arrived (quickly thankfully!). However, two things stuck in their mind and have caused a great deal of angst.

Firstly, before emergency help arriving, our client delivered CPR at a ratio of 15:2, not the currently recommended 30:2 ratio.

They stated that they ought to have known better!

I gave reassurance about this, we both agreed it is compression rates over a minute etc. that matters, plus this is not a work context, you are dealing with a loved one unexpectedly collapsing.

We do need to give ourselves a break at times, but we are the 100 percenters' that exist throughout our NHS. In retrospect, investigations showed sadly that the outcome was never going to be a positive one in this case.

The other more interesting fact is how much anger they felt towards the ambulance crew.

The male crew member appeared very efficient, but our client had a real issue with the female crew member as she had asked if the patient had "taken anything?" prior to collapse. The answer was "No".

However, the female crew member asked the same question twice more during the resuscitation attempt.

From our client's view, there was an insinuation that perhaps medication/drugs misuse could be a factor.

They have been unable to stop thinking about the offence the crew caused, to the point that they have been looking out for the crew, the female one particularly. They felt the need to put her straight about what a good, decent person their relative was.

I chatted generally about emergencies in a pre-hospital setting, also about competence and confidence levels amongst ambulance crews. I asked if they had considered the situation from the crew's perspective?

Often there is one experienced crew member and one less so (or even under training), this is quite normal in most Trusts.

I explained that we are all desperate to add to the effort of resuscitation and are continually running protocols/possibilities (CABCDE's, 4H's & 4T's BM's, SAT's, BP's, rhythms, ETC02….) through our minds, trying to rule out causes of collapse and unconsciousness.

Asking about drugs/meds is one of the correct enquiries.

I also explained that we often think out loud, and when we have run out of things to ask (usually due to stress), we sometimes end up repeating ourselves. This is especially true when we are inexperienced and have run out of options more quickly, despite our desperation to help.

This verbalised thinking is widespread; it can also be the crew communicating to one another about the point they are at in their thought process.

It may also be a way of asking for a colleague's prompt, rather than saying in front of the family "I don't know what to do next!"

It is also a method of maintaining the professional facade to preserve confidence with the patient's family.

Frustration quickly builds when there is no apparent cause, and therefore no clear treatment plan.

Our client was quite understandably upset and had been crying at points in our discussion. There was though a point of realisation when they acknowledged the crews' possible perspective. They agreed that this was something they had never considered.

There was a physiological change to their expression, akin to a weight being lifted. They had never considered anything other than the crew being judgemental about their loved one.

What a privilege to be able to help someone move forward with such an emotive issue. We also laughed that there was now no need to keep stalking the ambulance bays!

I concluded by giving the reassurance that they had done everything possible in terrible circumstances and to focus on that.

I believe my explanation is valid, I could be wrong, but I have been there on the ground, desperate to help and sometimes unable to.

Stress affects us all, and nobody has all the answers. Taking another's perspective, view or position can often be of great value in so many situations and relationships.
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Ageing dogs – new tricks?

Listening to the footballer Michael Owen on breakfast TV recently was fascinating.

He's always been highly competitive not least with himself. He spoke of his struggles to deal with the psychology of getting older and not being the man he once was.

As a footballer, this was due to his body no longer being able to do what it could and consequent injuries. He had to admit he couldn't outsprint the younger guys. His stamina was not what it was, and his joints and muscles were letting him down.

He told of the reaction from one of his famous senior colleagues accusing him of being idle, overpaid and lazy. The guy used to be a friend but when the going got tough…perhaps not so much a friend.

How do we deal with the passing of years? Can we accept our ageing?

A few years ago, the realisation that my once perfect vision was deteriorating hit me hard. I hid the fact for a while because I thought it would stop my flying career. I needed glasses! The point I was having double vision when tired was a requirement for a prism and not that unusual! Then along came the heart condition – turned out to be a wiring problem solved by a pacemaker! Even retained my private pilots' licence through all this.

But underpinning it was a fundamental undermining of my self-confidence. A denial that I was mortal. You see, I'd barely been ill in my charmed life. Case of flu, bitten by an African tick one time in the Kruger Park in South Africa (moral – don't walk through long grass with shorts on!), chickenpox as a kid, but nothing serious.

You see, both my parents died comparatively young by today's standards. Father at 66 from a heart attack having had a stroke a couple of years before. Mother the next year from a recurrence of cancer aged but 61. I'm well beyond those years already. Suddenly I didn't feel like superman.

I've just been to the fabulous English Lake District again. Managed plenty of good walking and climbing and I'm reasonably fit for my age. But probably time to admit I won't scale Scafell Pike again. I could do it I'm sure, but don't kid myself. Coming to terms with that can be a struggle for some of us to accept. Michael Owen has had to face it at a much younger age – he isn't even 40 yet!

Generally, as we age, we gain more experience and knowledge and, to some extent, skills improve. However, there comes the point when our dexterity begins to wane. Also, perhaps some of those riskier things we used to enjoy are replaced by a more considered approach. I have become a slower (fractionally), more considerate driver, albeit still way above average of course!

With passing years, sometimes the air of authority grows, although of course, we are highly approachable. But in colleagues' minds, there may be a tendency to trust, possibly too much? "Don't worry about Trev, he's been doing this for years, he knows what he's doing …"!

Life is competitive. We need that balance of confidence without arrogance that I've mentioned before. "I'm not difficult to approach, I'm just damn good at my job, the best in fact."

Where is this going? Well, it's made me wonder about some of the problematic behaviours I see and hear about – in healthcare. Three times recently, I've been asked to come and help organisations where they are experiencing uncivil behaviour. In particular, in each case, with tutors of junior doctors.

Just because we experienced abuse when we were young ourselves does, in no way, excuse us doing the same. Although that is exactly what I heard from a foreign female doctor tutor last week.

I will return to this theme in a future blog. But in the short term, perhaps look in the mirror.

How do senior medics cope with getting older? What's the famous old saying? Physician heal thyself!

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Safety 2 to the core

Often we get commissioned to train front-line teams because an error has been made.

After all, they were probably the ones involved at the 'sharp end'. How, though do the managers behave? In fact, what defines effective management culture?

To become even more specific, what is the relationship between managers and staff at all levels?

I've written before about organisation culture and who sets it. The Board will think they do, but in reality, it is the middle and senior management, and even team leaders, who deliver the actual version.

Erik Hollnagel refers to Safety 1 and Safety 2.

Safety 1, as I'm sure you're aware, is essentially backwards-looking. In effect, waiting for the next problem and dealing with the fallout.

Safety 2 is forward-looking, as in proactively looking for future issues and trying to head them off.

To achieve this, you need an empathic approach, one that seeks to understand, not what someone has done, so much as why it seemed like the correct action when hindsight might have proved it in error.

I argue that to behave in this manner, managers up to the top need to comprehend what these Human Factors are; how they affect good people trying to do a complex job under frequently very challenging conditions.

Any organisation I work with, I ask the staff if they know or have met their Chief Executive and Board. Guess what? In struggling organisations, the answer is normally along the lines of "well I've seen their picture" or "I've been at a meeting where we've been lectured at and told off".

An interesting example was a little while ago where I asked a roomful of senior leaders, in front of their Chief Exec, whether they worked in a learning or blame culture. Quick as a flash, the CEO said, "This is not a blame culture!"

However, one of the clinical leads was waving their hand and when prompted said, "This is absolutely a blame culture, and I and all my colleagues are practising defensive medicine because we don't feel safe!"

So let's look forward in Safety 2 fashion. What does it take?

One of our long term clients that have long since implemented a turnaround in culture, and saved thousands of pounds in the process, started by getting us along to talk to the Board. We were given just 30 minutes to enlighten them! Oh boy.

The words Human Factors came up at every subsequent Board meeting, and suddenly they fell in that they didn't know enough.

We were invited back to give them a short training course on what affects peoples' abilities to work safely and effectively. Things like:

  • Allow them to be human – give them adequate breaks and resources.
  • Examine processes – do they work? Or do you get workarounds because they are not fit for purpose?
  • Are equipment and training given so that it is easier to get it right than get it wrong?
  • Have they and their managers had some form of training in understanding these issues and the effect on performance?
  • Are they treated with empathy and understanding or needless, useless blame?

Sadly many of our clients come to us with the problems.

Often the CQC have told them off because of failings in performance or harm.

This is not difficult. It is no big secret that the way to get high performance is to look after and respect your workforce. Again a part of Hollnagel's Safety 2.

I ask people do they feel like a resource or a liability, a risk?

None of us is immune from error. We don't do it on purpose.

To paraphrase Sidney Dekker from his book 'Just Culture', don't resort to blame but try to understand why somebody thought the action they took was the correct thing to do. Ask why it made sense to them at the time.

Do this, and you will see…

  • a reduction in staff absence through sickness
  • better staff retention
  • more people applying for jobs
  • fewer incidents
  • reduced spend on compensation

You know it makes sense!

Contact us for a chat about how we can help move your organisation to Safety 2.

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Never events and the 10,000ft rule

Widely reported in the news recently was the story of a gentleman who went into the hospital for a routine bladder procedure and left having received a circumcision.

70-year-old Terry Brazier was awarded £20,000 in compensation following the "never event" at Leicester Royal Infirmary last summer. The hospital said it was "deeply and genuinely sorry".

The news story shows that never events continue to happen. In my experience, there are as many of these incidents occurring today as there were before the focus on never events started within the healthcare sector.

Receiving a circumcision instead of a Botox injection into your bladder is, I suppose, unfortunate and distressing. But think of what else could have happened.

We know of one case where a young patient was supposed to have scar tissue removal on his scrotum but received a vasectomy instead. This mistake was truly devastating for the young man, and impossible to reverse in this instance. The surgical team also suffered immense distress when they realized and that is a subject for another day.

It makes you wonder how these never events come about. Surgeons don't purposely set out to operate on the wrong side or to carry out the incorrect procedure. But these never events are not diminishing statistically, despite apparent safeguards put in place to protect against them. And I find that extremely alarming.

One of the things we find, when asked to go into a hospital and try to help prevent further incidents and rebuild morale, in the wake of an avoidance harm incident, is that interruptions and distractions often feature.

Last year, I was training and coaching in a surgical unit, when I was called into the neighbouring theatre which had just experienced their own never event. It was a wrong side nerve block, thankfully resulting in no devastating harm, but certainly with the potential to cause real damage to the patient. Distraction was a factor there. The anaesthetist and assistant had been chatting about their respective weekend social life. That was just after they had completed the mandatory 'Stop before you Block' check.

A good friend of mine, a senior Emergency Department Consultant told me the biggest safety threat of all is managing your environment, both externally (interruptions) and internally (self distractions). Just not thinking or concentrating.

In the aviation profession, we follow the 10,000ft rule. When flying commercial airliners, anytime you're operating below 10,000ft above the ground, you enter a social lockdown mode. There's no discussing your next round of golf, or your plans for the weekend. We call it the 'sterile flight-deck'. It equates roughly to the first and last 10 minutes of the average commercial flight but as you descend below 10,000 feet altitude is a mandatory safety check so we combine the two at that convenient moment.

There are times and places for social chit-chat. There are times and places for focusing on the task at hand.

When pilots aren't concentrating on flying the plane, that's when things tend to go wrong. It could be something relatively harmless like a bit of speeding (!), or it could be more severe like flying too close to another aircraft, or a hill, or radio mast.

It's positive to see some hospitals now introducing their own 10,000ft rule. The team are advised of the threats to safety at the briefing stage and reminded to make the safety call. Someone in the team says "10,000ft", and everyone goes silent. There are no interruptions, no distractions, focus. They could also be briefed to announce any concerns that they might notice and ensure a response – think of the 'Gorilla' video! Attention mechanism etc.

When you reach the crucial part of the procedure, the part where things have the potential to go wrong, that's when the 10,000ft rule is activated. You don't allow anyone else to enter the room and phones are switched to silent.

In the case of the gentleman receiving the circumcision, the compensation payout and negative PR can help focus attention on the causes and prevent them from happening again. A lot depends on how embarrassing the never event is for the hospital in question.

There are never any winners when there is avoidable harm. But I'm still not sure that everyone in healthcare takes never events as seriously as they should.

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Complacency at play in healthcare

How many of us consider ourselves to be better than average drivers? 78% of people on the roads think they are better than average. If you've got a mathematical bent, work that one out!

But what's the biggest killer on the roads? Probably complacency.

There's a great quote by Captain E J Smith, the captain of RMS Titanic. "I never saw a wreck and never have been wrecked nor was I in any predicament that threatened to end in disaster of any sort." Now does that ring any bells?

The number of times we meet people - and I've been doing this job for 30 years - and they tell me they don't need a checklist, or they don't need to change their approach. That's complacency at work.

It's almost like famous last words. We witness this a lot, where people kick back and say, "Why do I need a checklist? Why do I need to do briefings?" But when you look back at the root cause analysis of incidents, did everyone involved know what was going on?

That leads us to consider the whole idea about naturalistic decision making and pattern matching, with most decisions made during the day taking place without really thinking. We make decisions about what to wear or what to eat, without much thought at all. The same goes for walking, breathing, eating; doing the vast majority of things everyday. OK I accept the more stylish of you do think about what you're going to wear, but look around you. Plenty don't!

There's a bit of a danger in healthcare, where people have been told they should be so good at their job, that they can do it without thinking. In that respect, human factors concepts become heresy. Because what we're suggesting is that, you should always engage your brain and not make assumptions.

May I suggest that the high-performing professional is always thinking, "Is there something here which tells me I could be wrong?" Is there a contrary indication?

In over words, we need to look to overcome confirmation bias; the belief that, once we've made a subconscious decision, we're right. Humans tend to disregard anything that doesn't fit that initial pattern matching, our naturalistic decision making. It goes a long way to explain why complacency is such a factor because we're all sure that we're right.

I recently experienced complacency at work in an operating theatre. There was a change in the order of the list, with a patient elevated to the front of the queue because they were in greater need of surgery.

But instead of rubbing out the names on the whiteboard, the theatre team just reversed the order of the numbers listed alongside the names. It was worse than that, in fact; rather than erasing and rewriting the numbers, they added the revised order of numbers in a different colour.

As I watched this take place, I thought, "Why wouldn't you just rub out the numbers so there is no chance the order can be confused?"

Next time you come across someone who seems unduly pedantic and almost obsessive on checking everything. I almost guarantee that they'll be someone who found out the hard way and they really don't want to go there again.

Where does complacency play a role in your professional life, and what steps can you take to stamp it out?

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