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Quality of care before the pandemic The care that people received in 2019/20 was mostly of good quality However, while quality was largely maintained compared with the previous year, there was no improvement overall Before the arrival of the coronavirus pandemic, we remained concerned about a number of issues: the poorer quality of care that is harder to plan for the need for care to be delivered in a more joined-up way the continued fragility of adult social care provision the struggles of the poorest services to make any improvement significant gaps in access to good quality care, especially mental health care persistent inequalities in some aspects of care The impact of the coronavirus pandemic As the pandemic gathered pace, health and care staff across all roles and services showed resilience under unprecedented pressures and adapted quickly to work in different ways to keep people safe. In hospitals and care homes, staff worked long hours in difficult circumstances to care for people who were very sick with COVID-19 and, despite their efforts to protect people, tragically they saw many of those they cared for die. Some staff also had to deal with the loss of colleagues to COVID. A key challenge for providers has been maintaining a safe environment – managing the need to socially distance or isolate people due to COVID-19. Good infection prevention and control practice has been vital. The crisis has accelerated innovation that had previously proved difficult to mainstream, such as GP practices moving rapidly to remote consultations. The changes have proved beneficial to, and popular with, many. But many of these innovations exclude people who do not have good digital access, and some have been rushed into place during the pandemic. The pandemic has had a major impact on elective care and urgent services such as cancer and cardiac services, and there is huge pent-up demand for care and treatment that has been postponed. The pandemic is having a disproportionate effect on some groups of people, and is shining a light on existing inequality in the health and social care system. It is vital that we understand how we can use this knowledge to move towards fairer and more equitable care, where nobody’s needs go unmet. It is important that the learning and innovation that has been seen during the pandemic is used to develop health and social care for the future. New approaches to care, developed in response to the pandemic and shown to have potential, must be fully evaluated before they become established practice.

A significant backlog of elective surgical cases has built up during the COVID-19 crisis. The freeze on elective surgery has produced a waiting list that may take years to clear. In the US, the CDC has issued guidelines that "facilities should establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership to develop a prioritization strategy appropriate to the immediate patient needs". According to the CDC, this committee should work around 'objective priority scoring'. The MeNTS (Medically-Necessary, Time-Sensitive Procedures) instrument is a clever attempt to deliver this scoring, responding to availability of resources and the situation around COVID-19. However, the key challenge is that that the list needs to be prioritised in a way that reflects patient needs and ensures their safety. This is not something that MeNTS can deliver. It also is built around COVID-19 related limitations on resources and this will vary in significance depending on the hospital location and where it is in the journey out of lockdown. The risks of mortality and complications for a patient are a complex combination of the severity of the procedure and the physiological variables of the patient. As an example, a 55-year-old undergoing a radical laproscopic prostatectomy has a risk of mortality of 1.6%. However, if the patient has low blood pressure, that risk triples. If the patient also has low sodium then the risk is 10 times higher [C2-Ai insights]. The spectrum of different operations and key physiological variables creates at least 40 million potential combinations and hence risk. This is hard to manage with one patient but trying to prioritse a group of 5, 10, 100, 1,000 or even 10,000 becomes unmanageable. New patients will be joining the list while others leave following their procedures and so triage of the list will not be a one-off event. The list will need to be populated and triaged intelligently and in a consistent way repeatedly at least until there is a return to ‘normality’. There is evidence that some trusts are attempting to build their own systems for prioritisation. This may be possible around matching operative type and resource availability but the efficiency of these systems overall should be a concern. Best intentions are fine but, when reviewed later, the ability to correctly prioritise patients to minimise harm and mortality is likely to be limited if not flawed. C2-Ai’s COMPASS Surgical List Triage system is an example of a system that can support evidence-based triage and individualised risk assessment of patients, while supporting the objectives of the CDC. It supports clinical decision making across all phases from crisis back to steady state. It has been developed by the creator of the POSSUM system and is built around the world’s largest patient data set (140 million records from 46 countries) through the support of NHS Digital. The underlying algorithms are constantly refined against new and existing data sets to ensure relevance and accuracy. The Surgical List Triage tool combines the mortality and complication risks from the different patients to derive the prioritisation. The system carries out bulk assessments using individualised risk assessments for each patient. These reflect the operative type and their physiology to calculate the risk of mortality and complications, as well as providing a detailed breakdown of potential complications with percentage probability with a simple click. This system also suggests patients that should be reviewed for potential optimisation before any procedure. The physician can click on the link to see the detailed risks for the patient to support their decision making. The system can be used regularly to maintain the logic and integrity of the elective surgical list. This is superior to the potentially fragmented approach where parts of the list are manually considered in isolation as this cannot support effective optimisation of the whole list and the absence of any supporting evidence means the triage will vary enormously. COMPASS SLT is an evidence-based approach that supports optimal ordering of the list and clinical decision making that reduces avoidable harm and mortality. This in turn reduces variation, and cost while freeing bed capacity and also allowing the list to be tackled more quickly. When a patient comes in for the operation, an individual risk-assessment can be done using the COMPASS Pre-Operative Risk Assessment app. This provides a final check on whether the patient’s condition would justify optimising their condition before their procedure. However, it also details the most likely post-procedural complications individualised for the patient and their condition. That allows the treatment pathway to be tailored to that patient as well as recruiting the patient into their own recovery. For example, knowing that chest infection is the highest risk for a patient supports a conversation with them to stress the need for them to get up and about on the day of the operation. As an aside, the risk of mortality and complications can also be used as a strong element in showing informed consent has been obtained from the patient. In combination, these tools can provide a platform to support effective and ongoing triage of the list while reducing harm and unnecessary costs. The systems are currently in use in 12 trusts in the NHS. How are you prioritising waiting lists? We'd be interested to hear and share how you and your trust are dealing with the backlog.

The WorkSafeMed study combined the assessment of the four topics psychosocial working conditions, leadership, patient safety climate, and occupational safety climate in hospitals. Looking at the four topics provides an overview of where improvements in hospitals may be needed for nurses and physicians. Based on these results, improvements in working conditions, patient safety climate, and occupational safety climate are required for health care professionals in German university hospitals – especially for nurses.

Consuming tea and cake as I write this also means I can break my ‘in healthcare rule’. This rule says never say to a medical type, “well in other industries it’s done like this”. Healthcare is very different to anything else and outsiders like me should not point at other industries and say there is a panacea of methods that healthcare should use. But, placing the cup down, deep breath – what I discuss here is based on my training in incident investigation in the police (UK, US, and EU), military operations, rail, marine, aviation and security failure. Overall, I’m starting with how I was trained in road death investigation methods and the senior investigating officer (SIO) murder investigation system. Two reasons for this – one, there are online manuals, two, they kind of work and are a good starting point. There is a very big ‘however’ as medicine is different (in fact all industries are different to policing). This, however, is big and came to me as a conclusion while interviewing potential applications for those applying to be investigators in rail. I did not notice, but the rest of the panel noted with some extreme words, that all the police trained investigators were there to try and convict someone rather than stop it occurring again. These blogs are not about criminal and civil liability – just prevention. Super, all police colleagues alienated! Given the ‘Who’ might be one person, let’s think about them and see if we can think about getting a little help to get a team together. Yes, it’s true one nurse will have many investigations to do, but in part two of this series I described that ‘making facts’ is better with two. When I arrive at a crash scene or an investigation, I always ask one question: “Am I the right person to do this?” It’s a bit of a chicken and egg question as you have very little detail. Most of my callouts start with the phrase “you would not believe this but”. The first phase is to take a blank sheet of paper – never a proforma as that will get you only collecting data you expect to find and be a traditional scientist. Start by looking at the scene and thinking about all the possible reasons it could have occurred. Ideally (more in the ‘When’ section), its within 24 hours and nothing has moved or changed – but its healthcare so its weeks later, and the ward has changed from neonatal to geriatric, or the theatre has been moved to the next room. Before you decide who should be on the team, you should first ascertain the likely proximate (main) cause, these are: the ‘environment’, the ‘human’, the ‘equipment or system’. Of course, these factors interact but the proximate cause should decide where to start. Equipment Equipment failure – or the conclusion it’s not usable – is best done with an engineer and a human factors person. Medical equipment is often poorly designed. Why a piece of equipment ‘failed’ in terms of not diagnosing the patient’s condition or keeping them safe is a little complex. In the next post on human factors we shall explore the sub disciplines of human factors and as we shall see there are two groups who specialise in computers (screens etc) and machine design. Now four areas of failure need to be thought about. The machine failed and, for example, its electronics or pump stopped. An engineer is the best person to consult, but how the failure was signalled to the operator is of interest to the human factors person. The machine failed in the sense the operator did not understand how to use it or the output was confusing. The equipment failed in the sense that it looked similar to other equipment on the ward or the theatre but operates in a different way. Sometimes on the same ward machines that have the same function work in different ways. The machine worked well, but its outputs were not immediately comprehendible, or other machines provide outputs in a different way. An example of a simple bit of kit that fails in different ways: A hospital trolley with no locking mechanism on the wheels – it fails as the team chase it round the ward. A hospital trolley that has different drawers on each model so, in an emergency, drawers have to be searched through. A trolley in the north end of the ward which looks the same as other trolleys but is not stocked with the same drugs. A trolley with electronics of a similar appearance to others but where it has different user interfaces and graphical interfaces. I use these examples from my own research. One trust had 17(+) different types of trolley at one site, all with unique set ups and contents, yet all were labelled as having the same function. The experimental test was the question “In what drawer is the adrenalin?” A 100% failure rate was found. More when we talk about human factors. And thanks to Emma for pointing out this major issue – yay for reviewers! Environment People who know the environment best are those who work in it. Typically, the environmental issues to measure and understand relate to lighting, stressors like heat and cold, ergonomic physical space and, in my experience, noise levels. In many other industries a noise level of 120dB means closure of the site and ear defenders, in healthcare a noise level typically found in a factory is ignored. In the forthcoming human factors posts I’ll cover sound. Environmental factors are not as easy to correct. Telling the hospital that the anaesthetics room is so small it can’t be used will cause death threats from the facilities management team! Lighting changes – from fluorescent or incandescent to LED always causes issues. However, the issues of lighting – and by implication colour rendition – can all be simply measured by tools in the typical human factor types backpack (designer of course). Light meter, dB meter etc. Human factor people should be able to chat about the physical layout and how the fact us slowly evolving cave dwellers are physically weak should be discussed. Sometimes the physical design of an environment is very poor. I’ve heard the comment “With one hand the operator controls this, with the other these controls, and the other hand interacts with the screens”. Human 95% is the number you should be familiar with. That to say the most common factor – or contributory factor – is the human element. Research from the late Barbara Sabey’s seminal work points out that in 95% of cases it is the human that’s caused the problem. Irrespective of industry, location or activity that number (or very close to it) comes up. So, a human factors person should be part of the team. It takes a postgraduate qualification and lots of experience so hire one early on. They do drink lots of tea and although they are doing 95% of the work – they are only one of your team. Systems It’s true I should say it’s a human factors person that does this bit, but nurses are the best I’ve found. By the phrase ‘system’ we mean in terms of system theory, which 'Professor' Wikipedia says is “Systems theory is the interdisciplinary study of systems. A system is a cohesive conglomeration of interrelated and interdependent parts that is either natural or man-made. Every system is delineated by its spatial and temporal boundaries, surrounded and influenced by its environment, described by its structure and purpose or nature and expressed in its functioning. In terms of its effects, a system can be more than the sum of its parts if it expresses synergy or emergent behaviour.” I should describe psychology systems theory (part of human factors) – but the above is good enough for now and there are many sub fields. In essence, look at how information flows and how many stages people need to go through to achieve a task. Each stage or function adds another source of error. Walk through the process and critically examine how each stage can fail. My work in the military tells me every stage that can fail will. Remember humans are fallible and the system or method of working should fail-to-safe. Some within the NHS say fail to safe is a new concept. It’s part of the 1832 Railways act. If we mention a system it might be worth saying the phrase – task analysis. Task analysis is something human factors types are trained to do. It breaks down a task or system into each of its constitute part and looks at the order or dependencies that are needed to complete each main and sub task. The classic training is making a cup of tea, the victim, I mean student, lists all the stages and the master (teacher) points out that there are lots more stages. The student says fill cup with hot water. The master says – but where does the cup come from? Student and teacher hate each other for years after but a list of things to do to achieve the task is formalised. It’s a useful tool but often it’s the most junior member of an human factors team that does it and it’s a rite of passage to say you are a human factors person. The method should be used to help the investigation. Buy me a drink and I’ll explain why the doors of a tram – when its coupled to another tram, and that tram is in a certain station, and the third emergency button in carriage one is pressed while the driver is closing the doors in carriage two while another part of the tram the smoke detector is activated within 0.25 of a second of another alarm… well you get the picture. Four in a team then? With four headings this kind of implies four people in the team. The team should have those skills but what about the personal qualities and above all the relationship to the injured party. The investigation teams need to be independent and not be familiar with anyone involved. Humans are not rational data collecting machines and knowledge about others and the environment will cloud how you collect the facts – even if you try hard. The ideal lead investigator knows perhaps a little about the hospital or care place but does not know those involved. They should know a little about the equipment or machines, but not be so familiar that they know the ‘work arounds’ to get it to function. The lead investigator should handle discussions with outside organisations. Now if you are following carefully you note I’ve just added another team member – the senior investigator or lead investigator. This person organises the team of those with different skills and is responsible for the output and keeping the team from the pressures of the outside world, far enough away so the team can collect data. They should be cognisant of not just the investigation team but also those who were involved in the incident. This is where healthcare is very different to any other industry – the care of those involved. Care of those involved is, in my experience, very strange in healthcare. If you attend an incident you ensure that all those involved get home safely and have a contact point. In healthcare the fact that it’s highly unlikely that the action that led to a fatality was deliberate and the nurse, doctor, administration person was not trying their best appears to be overlooked. I attended an incident where the team were in tears and visibly shaking, they were told to drive home and come back tomorrow (next shift and list already given to them). It should not be the role of the investigator to organise a taxi and lend a phone so family can be called for support. Now the ‘Who’ may suddenly, radically change. The question first in your mind should be – is this an accident? You may recall in part one – ‘why investigate’ we defined an accident or incident. Essentially, we decided together that it’s a random rare unforeseen event with lots of variables coming together in one moment in time. Well at this point you should know if it’s ‘accidental’ or deliberate, and if its random or not. The who investigates or leads the investigation could change. If the test of accidental is not met, then it’s a criminal matter and the lead investigator or police senior investigating officer will take over and “Oh well done you are using a recognised method” should be heard. Investigations involve a small team. There is lots of data and the experience of just one person is not enough. A lead investigator can deal with the media, families and ensure the investigation team collects the facts. Those who investigate need to be able to collect the facts needed and be scientific in their approach. The person collecting evidence from, say, CCTV needs to have some experience of using it, and the person considering the medical records needs an understanding of how that particular ward uses the charts. Or, in my experience where they are, which is different to the ward on the floor below. No one has all the experience needed, and we all need to learn. My first recovery of CCTV images took two days. Strange the operator (now manager) and I are still friends many years later, but approach the matter with a smile and a look of “I’m lost”. Time off from the day job is vital. Investigations are hard work and mentally and physically exhausting. How long should the team be together? Well that depends and only comes apparent after a day. I’ve had a purchase order for 6 weeks investigation services and finished at lunchtime on day one. I’ve been asked to spend 6 weeks and then two years later still going. One of my team did the whole thing in 30 minutes… saving the 12 weeks of funding for something else. When I’m part of an investigation team I deal with humans and the systems, I’ve no (well little) knowledge of the engineering side or the other facets. Human factors is part of the story and the skill is for the lead investigator to bring all the views together. A human factors type should not lead the investigation. More colleagues alienated. Summary Investigations should be conducted with a small team. Small teams need a leader and that can be the person who is also charged with the welfare of those involved and the communication with those outside the team. The team should have time enough from their ‘day jobs’ to do it. How long do they need off? Well that’s down to the incident. The best bit of equipment to take is a blank sheet of paper, and there is a vital need to effectively communicate the findings. That’s three blog posts on the investigation method. Still lots to do. Read Martin's other blogs Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy) Human factors – the scientific study of man in her built environment. Part 4 When to investigate. Part 5 How or why. Part 6

Mummy – Where do facts come from? Well dear, when two investigators love each other very much (well can tolerate each other’s company for long periods of time) they do an investigation and the product is facts. Like a small child these facts bring great happiness, sadness and often inconvenient truths! These facts are messy – difficult to rationalise, have a life of their own, and will be tested by others in what appears to be out of context tests and exams. When the facts are older, both investigators will realise that they should not have been collected in the way they were. By then the investigators have made other facts that may be different from the first ones. We need facts in order to say what happened, write a report and stop the incident re-occurring – but what sources of facts and evidence is there that are relevant? In this section, I’ll discuss some sources outside the patient’s hospital records, test results, and the paperwork of the ward and theatre. The audience will know what all these records are and for brevity I will not go into detail. Moreover, is there a method or position in which facts are best collected that is rewarding and satisfying (to the regulator or other parties)? Perhaps that’s another blog? If we understand where facts come from this determines who (what sort of person) should collect them. Like many things, collecting facts by yourself is not as rewarding as doing it with others. I can already hear a deep sigh as a nurse is reading this thinking – others – did he say others? – well it’s just me and I’ve 40 to do by the time I go home. With emotions raised about the next piece, let’s think about the sources of facts an investigation will collect, then the method or structure to collect them. Ideally, we should talk about presentation of the facts and how they are displayed and shown off to others – look at my facts here, are they not clever? But let’s do that in the three E’s blog later. People – facts come from those present at the time Most of the evidence comes from those present or with some knowledge of the incident. Collection can be by interview, statement (oral and written), simulation... well loads of methods that try and recover a memory of an event, in the past, hiding in the mind. Noting here that humans are not video recorders and their memory is highly reconstructive and the worse creature on the planet to be a witness is a human. Humans also make terrible investigators, as they have biases and heuristics (more later when we chat about thinking and deciding in the human factors blogs). Interviewing witnesses is a skilled job but there are tools, techniques and methods that get ‘facts’ from inside someone’s head out onto your note pad – or recording device. There are three types of witness. Firstly, the person directly responsible (or who says they are responsible), there are those that directly observed the person who says they ‘did it’ and there are those who possibly noticed other useful facts – the security guard who noticed the arrival time, the HR person who interviewed the person the week before. Care needs to be taken if there is a chance of a criminal investigation, as the last thing the team needs is someone doing interviews that change the facts. Remember these posts are about prevention – not about criminal and civil liability matters. The tools and techniques tend to involve things like the Cognitive Interview. There are resources around that can help. There is an old NHS one – which hopefully has disappeared (by me ripping the leaflets up with my teeth) that says you ask the person to imagine the incident from another perspective. This of course we now know is the last thing to do. There are many blogs and posts I could write about the how to do an interview but look for a cognitive psychologist – PhD sort who does this area of memory research. From science and previous incidents – books and Professor Google The incident or one similar would have occurred before. This means there is a court record of it or a lovely science type has written a paper about it. Now hanging my head in shame, us science types don’t write in peer-reviewed journal articles in an easy to understand way. But all us science types love people asking about our work. Rather like the spotty kid at the school dance – we won’t make eye contact, but if you ask us about what we are interested in, well there is no shutting us up. Email saying I would like a copy of your paper to the spotty – I mean science type - is what you do. My team – who do the real work and have the titles of Professor and have lots of chartered words on their businesses cards – also stress that you need to, and I quote “and ask them to explain anything you don't understand" – they love that and it means you're not making any incorrect assumptions. Data and engineering logs Equipment when it fails tends to output data that is recoverable. The train I’m working on now records data every 1/25 of a second on every one of the driver inputs. In aviation, the flight recorder or black box (its orange by the way) measures the voice recording as well. One day healthcare will be there. But ask the question of its maker, what data is stored? Equipment operator manuals and testing Equipment sometimes, and in healthcare very occasionally, has been tested by a human factors type – ask the maker for the testing. This gives you an idea of how the medics dealt (or attempted to overcome) with its idiosyncratic ways. It sometimes seems that medical equipment is designed without much rigour. CCTV Spending two years of my life looking at CCTV images of a door in Paris means I think there is some value to CCTV ,and my work for HM Government on the subject does reveal its damn useful in finding the context of the event. Top tip is that data goes from a server after 28 days – so it’s one of the things to get quickly. There are CCTV experts, but a good dose of common sense means you will get lots of facts from it. Super, I’ve alienated another group of experts! Photos Photos are your friend. Photos are useful in your final report and show things clearly. Now you are about to hear spinning forensic photographers. Yes, there are specialist courses on how to take pictures and what camera to use. But, here we go, a phone camera is all you need. If I’m found dead in an alley with witnesses saying there were camera flashes – then those who taught me the subject have read this. Pictures tell a story and collect evidence in more detail than a note pad. Perhaps one day I’ll do a conference presentation on the topic. But the top tip at this point is to have a measuring tape in any close up and tell a story with your images. More experts alienated. Expert evaluations Experts are useful. A human factors person is a must, but a medic from a similar discipline or someone from the Royal college is a great asset. Although I lectured in neuropharmacology for 15 years, I still always get an expert in this field to explain the detail. I choose this area as everyone I’ve asked has been brilliant. I start with "help me understand…". Simulation and reconstruction These are major sources of data. But three questions: Why are you simulating the real world in a simulator – when it’s (the real world) out there? What’s the fidelity of the world the simulator generates? Who are your test victims - I mean participants? Healthcare is the weirdest place for simulation and exists in a world of its own. If you want to understand the issues, go to your local simulation suite and simulate nothing – aka a patient with nothing wrong with them – see what happens. A fiver says there will be hundreds of medical conditions found. It’s unlikely the correct conclusion that the person is well and asleep will be found. The problem is that aviation uses simulators (therefore they must be great), but these replicate the simple world of flying – aka stay in the blue, avoid green and land on the grey bits. Healthcare is not a simple world, its complex and we don’t know all the factors that you need to replicate or simulate. Simulation is a useful data collection method when you use people who were not involved in the original event. But those participating in the exercise know something is going to go wrong and have not worked the hours the team in the incident involved would most likely have done. I confess that in one of my published papers on fatigue the simulation was only 12 minutes long. But simulator time is expensive, and the pubs open at 16.00. Was the simulation good? Was there ecological validity in what I was doing? Well its published and other scientists thought it was ok. Oh, ecological validity – what you simulate or measure in a lab has something to do with the real world! Measuring things and testing them This is where my rail, road and aviation stuff comes in – I’m not sure why, but we always seem to throw one bit of metal at another and measure what happens. I’ve closed the centre of Croydon one night and threw black and white cars at each other all night. I’ve closed a motorway, caused chaos, and then the only thing the police remembered about the whole thing was driving along the closed motorway looking for badgers. Apparently, I do BF (Badger Factors). In the autumn I’ve learnt that badgers like the warm road and have a nap on the tarmac. Badgers are heavy things and if you hit them at speed you have another investigation to do. Testing to destruction gives loads of data, but the question before doing it is: what data do I get? – and are the badgers safe afterwards? Conclusion Data, facts, and evidence are vital to the investigation – that’s why you do it – to get facts. But a simple change in method or just the use of one word in an interview will change your outcome. Mummy may have explained about how two investigators love each other lots – but there is always a bigger picture. Is there a method or procedure that’s good? Yes, but that’s for another blog. But a quick search about the police methods (SIO) and the road death investigation manual might get you ready. Read Martin's other blogs Why investigate? Part 1 Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5 How or Why. Part 6

Key findings: Successive governments have pursued policies to improve the quality of care in the NHS, but the many and varied initiatives failed through a lack of consistency and the distraction of other reforms. Efforts to improve quality of care have been hampered by competing beliefs about how improvements are best achieved. More than ever, the NHS must focus on delivering better value to the public. This means tackling unwarranted variations in clinical care, reducing waste, becoming more patient- and carer-focused, and ensuring that quality and safety are at the top of the health policy agenda. This is best done by supporting clinical leaders through education and training in quality improvement methods, and developing organisational cultures where leaders and staff focus on better value as a primary goal. Clarity about the role of inspection in a quality improvement system is vital. Done well, inspection has a part to pay in quality assurance – but this should not be confused with quality improvement.

What can I learn? This web page gives you information on: the friends and family test patient insight group an animation on how the quality framework works.

The standards are: a description of what good public involvement in research looks like designed to encourage self reflection and learning, including where lessons have been learned when public involvement has failed to lead to expected outcomes. a tool to help people and organisations identify what they are doing well, and what needs improving intended to be used with any method or approach to public involvement in research adaptable to your own situation and can be used alongside other resources such as case studies, public involvement checklists, and toolkits.

About 6% of patients in healthcare settings internationally experience harm that could have been prevented. Around one in eight of these cases result in severe harm, causing permanent disability or death. Drug errors, therapeutic management incidents and incidents involving invasive clinical procedures are the most common causes of preventable patient harm. Higher rates of harm were seen in intensive care and surgical departments than in general hospital settings. This NIHR funded review pooled data from observational studies carried out around the world. It was not possible to identify completely accurate rates of incidents and harm, due to differences in healthcare systems, and the methods and time frames for reporting and analysing data. However, this well-conducted review provides the best evidence so far about the proportion of overall patient harm that could be prevented.

Here you can find patient safety resources including: Mortality reports Quality reports National Patient Safety Strategy Blogs.

Key findings: Most of the care that we see across England is good quality and, overall, the quality is improving slightly. But people do not always have good experiences of care and they have told the CQC about the difficulties they face in trying to get care and support. Sometimes people don’t get the care they need until it’s too late and things have seriously worsened for them. This struggle to access care can affect anyone. Too many people find it hard to even get appointments, but the lack of access is especially worrying when it affects people who are less able to speak up for themselves – such as children and young people with mental health problems or people with a learning disability. Too often, people must chase around different care services even to access basic support. In the worst cases, people end up in crisis or with the wrong kind of care.

Humans have not evolved to do medicine – or deal with complex machinery or systems. For the average (HF) scientist, it’s amazing how few errors occur and how a disinterested cave dweller (aka human) can work 12–18 hours, operate a machine (in many dimensions), and still get home safely at the end of the day. A short history of human factors HFs is a subdiscipline of both engineering and psychology. In respect of the psychology element, it is in the tradition of western performance measuring psychology. This measurement aims to aid productivity by identifying the best of the higher performing ‘cave dwellers’ for specific tasks. As we have all essentially evolved in the same ways and are not too far removed from our cave dweller ancestors, we should aim to design equipment that we can use now rather than waiting for evolution to enable us to use the kit. In this respect, HF is vital. In contrast to the western approach, the Soviet psychological tradition considers that all of us can be elevated to do any task. The background of this was that when the former Soviet Union industrialised rapidly in the 1920s they could not find the best of the higher performing ‘cave dwellers’ – as the majority were illiterate agrarian peasants. In the West, industrialisation was slow and there was time to find the best. A good example to illustrate this is the space programmes in the West compared to the Soviet Union. The United States tested people to find the best in the military whereas the Soviet Union advertised in the cotton mills “cosmonauts wanted”. Many say the Soviet tradition – also found in Scandinavian countries and in much of northern Europe – is a fair, humanitarian, way of thinking about humans, and the western method is there to divide the workers by exploiting them and getting them to produce more. This may explain my attachments to European medical establishments where I find everyone is happy! HFs is concerned with understanding how us ‘cave dwellers’ use our limited physiological skills and cognitive resources to achieve a task. The science is basic in that it attempts to understand, in principle, things like how our senses work, how our brain/mind filters the vast amount of information heading through those senses into the mind, and which bits are selectively attended to (or not). Humans tire easy, lose concentration, get distracted and are not exactly rational. Medication affects us in many ways, and aging and experience adds to the mix of human performance. That’s what HFs is about. If you ask in medicine, it’s about teamwork – or Crew Resource Management (CRM) – being nice to someone will stop any incident occurring. It’s non-technical skills – the idea that by watching someone’s behaviour (after expensive training) you can then understand their inner most cognitive processes and intentions. Or many different types of ‘psychobabble’, pet theories or simple weird ideas. HFs, being a science, relies on evidence and testing, and is interested in performance. HFs started not on the flight deck, or on the battlefield, but in medicine some 2000 years ago. The first HFs scholar was most likely a Greek doctor – him of the oath you all swear. He discusses how, for efficiency, tools and equipment are laid out in a way that is easy to use – that’s HFs or, as we have also borrowed from the Greek, ergonomics! Most likely one cave dweller preferred one rock over another. Of course, the one that preferred the apple as a communication tool was way ahead of their time! Subdisciplines of human factors There are subdivisions within HFs worthy of note as useful to medicine. These were hinted at in my last blog. These are human computer interation (HCI) and human machine interaction (HMI). Each group has its specialists. Often you don’t need a HFs generalist, you want an expert fully trained in one of these areas. An example of the difference in these subdisciplines can be illustrated in a crash involving a plane and a tug (thing that drags a plane around an airport). An HCI person looked at the screen bolted to the tug where information to the driver was displayed. Incidentally, HCI people are sometimes called UX (User Experience) designers. The theory was that the tug driver was distracted by the screen. It was fine. The HMI specialist said it must be the whole machine – the controls, the visibility from the driver’s seat – but all was fine. The HF person asked the tug driver, after doing the first two lots of tests again (HF people do things twice), when did you last see a medical professional? The answer was the day before; that he had ”some jabs ready for his holiday”. The HF person was shown the leaflet given to the driver after the jabs, telling him that he might feel dizzy or tired and not to operate heavy machines. The driver did not think an aircraft under tow was a heavy machine. HFs is, therefore, the study of the man, and the system, and the built environment which she is working. To relate this to the above about western psychology, HCI is often based on Soviet psychological testing. Rapid onset of computer and screen technology meant everyone was a naïve peasant again, with no clue how to operate the machine, or to get the Bluetooth to connect in the car! The answer of course is to use both traditions. The senses Let’s make a start about thinking about HFs. The history is important as it frames the study. Let’s think about the senses. Seeing hearing, feeling, tasting and smelling. If we start with the basics, then perhaps we can think a little about all those higher cognitive levels that the medical profession thinks HF is. Perhaps a bit on fatigue and attention as well. The senses tell us: What is out in the environment. How much is out there. Is there more or less of it than before. Where is it. Is it changing in time or place. Seeing We have evolved to operate in daylight, not at night; unlike almost all other animals we have detailed colour vision. But there is no zoom lens – we need to get closer to see the detail. Our vision is perhaps optimised to find ripe fruit in trees. Our field of view is extremely limited – or more precisely our ‘useful field of view’ is limited and in general we can only ‘see’ things we are directly looking at. Although our vison is very limited, it’s further reduced as the signal from each eye is split and sent off down different channels into the mind where it arrives as a blurred upside-down image, via the retina, and the brain has to interpret what’s going on. Vison is more about conception than perception. That’s to say the mind controls what we see to such an extent – and this control is based on experience and expectation – that vision is limited. The fact that there is something in the world that can be seen and could be identified is only a tiny bit of the picture (pun intended). The scary fact is that 95% of the information we use about the world is visual, yet we don’t have good vision. Well fruit picking is fine, but dealing with neurological conditions – no. A lot of medical packaging and its very poor labelling can’t be seen, let alone comprehended. Even in the test lab – let alone in the theatre with its weird lighting. Hearing The story gets worse – the good news is we don’t rely on hearing as much as vision. Humans find it difficult to discriminate sounds of voices from other voices and with noise in the background. Sound waves work in weird ways and you can have a negative (inverse) sound wave that cancels out the one you are trying to detect. Think noise cancelling headphones here! Taste, smell and touch These are minor senses when it comes to the overall picture of the world we need to form in our minds. Remember we are talking medicine rather than restaurant critique. They are useful. Warnings that use vibration (e.g. stick shake in a cockpit) work better than other audible warnings. I might do something on the psychology of warnings in a later blog. Investigators spend the majority of time trying to understand if the senses of the 'cave dweller' could have correctly detected and understood what was in the environment. Typically, the answer is no – that’s why it occurred. People rarely set out to have an accident, injure themselves or injure others for no apparent reason. Before the investigation team considers if higher cognitive factors like reasoning are to be thought about, you need to be sure the senses detected and correctly identified what was happening. Attention Psychologists since Greek times recognised the two types of attention mechanisms. One selective, the other sustained. Attention is the mechanism us cave dwellers use to filter out the overwhelming volume of information so we can attend to a bit of it over all the rest. The cat is reading this and also attending to the squirrel outside. If we were cats, I would not have had a job. Selective: Selective attention is where you rapidly need to selectively attend to one stimulus in the environment above all others. This is usually a product of visual search where we are looking for the thing to attend to – this can cause us to experience spatial uncertainly. The idea is that the ‘target’ will appear somewhere at some expected point (this relates to how our brain interpret things and based on expectations). Sustained: As the name suggests, this kind of attention investigates how long an operator can detect an event that is expected. Most of the research was conducted in the 1950s and investigated how reliably an American radar operator can watch the screen to detect a Russian aircraft. What we know about vigilance and monitoring tasks is that humans are very poor at it – we miss things very easily. Fatigue At the very first medical conference I went to, the A&E (ED) doctor who runs classes on HFs said he made errors due to not checking politely with his colleagues about his actions and then he spent 20 minutes talking about how pilots communicate. He then described his typical 18-hour day. At the question sessions, I asked if all his failures were not perhaps due to fatigue – and his answer was no. My second question was how often a pilot would do a shift of 18 hours and would you get on his plane if he said – “well I’m almost at 18 hours, I’ll give the landing a go”. Fatigue is time over 8 hours depending on the task. Times start from the moment you start for work – so a surgeon who drives 2.5 hours, does operations for 15, and then drives home for 3 hours has a long day. Fatigue is the hidden killer in medicine. Scheduling 12-hour days – well it keeps investigators in work. Fatigue is reduced by sleep and rest. Top tip – look at the quality of the sleep. “I’ve a young family”, “I was stationed at the end of the runway” is a good clue. Also look if the shift is ‘forward rolling’ or not. Fatigue is a very specialist area. I ask for help after the basics. Medicine is complex, tiring, difficult, challenging and us HF sleep specialists are few and far between and, in general, there has not been much done about understanding fatigue in the area of medicine (sorry). If you are an expert in this area – please, please, forgive the oversimplification. Summary HFs in the first sense is a study of basic processes. Investigations are always about these basic processes – seldom about how someone felt about someone else and about how these senses interacted with the environment, the equipment and the system or method of working. The downside of HF methods – more later in the 'how to do science' blog – is that many say it is eye wateringly expensive. Well, given the potential cost saving, it’s a bargain and research throughout Europe shows that it’s the most effective cost-saving intervention you can do. Research is done in situ and this takes time. The science types get involved to understand the human, the way of working, the equipment and the environment. Thinking of my recent projects concerning firearms deployment – well first get body armour, then training (pick up weapon – ask which end goes bang), then highly supervised patrols … then data collection – assuming your security clearances are all up to date. In respect of medicine, infection control training, theatre training, basic methods training in orthopaedics, come look how the saw has gone through the bone Martin… data collection. In heavy rail – well a lot more – apparently, I’m a great driver – stopping is my only problem! The point is to avoid anyone who says they can do it without the knowledge of the environment or say they developed this measurement tool in nuclear plant operations, and it will work here. The basic human processes described above are the same – but the environment is damned important. This is why a medically trained person is vital to keep the HFs person on a tight bit of rope. HFs is about understanding the limits of the cave dweller who dresses in scrubs and says trust me I’m an DPhil rather than trust me I’m an MD. Next time some slightly higher cognitive processes – memory, search, reasoning, biases heuristics. Thinking and deciding. The good news is that you will have concluded humans should not practice medicine – so how well humans’ reason or don’t will be of no surprise. Happy new year to our reader. Read Martin's other blogs Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 When to investigate? Part 5 How or why. Part 6

So, why do we investigate? In this part I’ll cover the philosophy of why we do it; later posts aim to provide an understanding of who might be the right person to do it. Having covered the why, I’ll do some posts about the when (always within 24 hours); the who (as in staff rather than the still-touring rock group); the what; and a few practical ‘top tips’ on the how. Why do we investigate? Well investigation gives jobs to us investigators and, well, that concludes my piece. Well let's at least think about the other reasons. Organisations investigate because their regulator or management team want it done. Sometimes investigations are done so the organisation feels good about itself. A report whose measure of impact and success is based on the weight of the printed pages, with a good report being 3–4 cms thick and the ultimate report keeping the door open in the summer, is not uncommon. It may be worth another post about communication of findings to achieve an action. A poster on the wall is not a good idea, or courses on non-technical skills (NTS) or team talks. Organisations often investigate in order to sack someone. Sack someone and the problem has gone. Well, while there is a feeling of action, this means very little learning is done, and from a human factors perspective it’s unlikely the human has done it deliberately. The organisation should really build a system that is tolerant of human error. In aviation, we (my company) were at the forefront of the no blame reporting systems. Protecting the organisations criminal and civil liability is often the reason for undertaking the investigation. Doing an investigation with only this in mind hampers the investigation team. Yes, liability is an issue, but in healthcare there is an overriding duty of honesty and candour. If you investigate knowing the Coroner will ask you awkward questions, this will affect what you investigate. The legal side and compensation are a matter for the lawyers. In my view, your duty is to report what you find. The only reason to investigate is to stop it happening again. In the words of the philosophers – Metallica – nothing else matters (hopefully the reader is cognisant of rock music). The investigation is only there to prevent another incident occurring, by providing evidence, obtained through careful data collection, that means it simply will not occur again. What’s an accident then? I’m now very conscious that we have got ahead of ourselves. We are talking about an investigation of an incident or accident or crash or oversight, but what do we mean by an incident or accidental death etc.? An accident is a typically defined as: ’"an unforeseen rare random event with multiple causes where in one moment in time something went wrong." Let’s take each of those words and consider why we investigate. Unforeseen – if it was expected – then it’s not accidental and most likely the subject of a criminal investigation. Rare – well how many car crashes have you seen? How many planes have crashed while you watched them? How many trains have you travelled on that hit the buffers? Crashes, incidents etc. are thankfully rare. Given what humans are designed to do – hangout and chill on the African Savannah lands – then its amazing how few incidents occur, especially with poor technology and the really badly built environment found in hospitals. I still recall watching an anaesthetist crawling under the patient’s bed as the room was too small to take a bed as well as the team. Random – you should not be able to predict precisely when they will happen. You may say there is an increased risk of an error in the operating theatre if the surgeons have loud rock music (Metallica) playing and the lamina flow is noisy, meaning no one hears the “I’m doing the left side here aren’t I?" But you can’t point at a patient and say they will die at 14:16pm, when we realise we have put the nerve block on the wrong side. Multiple causes – Human factors being a science means sad science types count the number of variables. In road transport back in 1972 (before mobile phones and Bluetooth that will not connect over 60mph – damn it – calm blue ocean) – where was I – oh yes over 1300 variables were identified. Importantly, an incident does not have a single cause but typically 2–4 or so variables come together in a moment in time. Top tip – if anyone says an incident has one cause then smile and walk away. Moment in time – A split second later the train driver would have seen the red signal because the train spotter in the way would have leaned over a bit further. A millisecond earlier the scrub nurse would have noticed the tray was not on the trolley before her colleague distracted her with a question about the x-ray. Time is the essence. When investigating an incident, you have lots of time, the incident occurred in a millisecond. Investigation therefore looks at a rare random event with the potential to have been caused by a complex failure in systems, equipment, human and environmental factors. Later in the series I’ll explain these factors in more detail. How do I know that I have investigated an incident to allow prevention to occur? Revisit the scenario and see if it could occur again. In one investigation that we did we found that a patient reporting in the emergency department and requiring a chat with a neurologist took 70 steps or stages in the booking process. This included a message to a fax machine whose location was a mystery. Yes, deep breath, an error model means a near perfect failure rate and no fail-to-safe method (our investigation and remedy designed a system of just one stage – no possible error and even designed a leaflet about the patient not driving home afterwards). The simple test is to go into the Emergency Department in the role of a ‘patient’ who needs to speak to a neurologist and ask the team to walk you through their processes. True in this retest there were now two stages – but the system failed to safe, and the ED team remembered I like tea. If you do an investigation and a year later the incident could still occur, and nothing has changed, then you have wasted your time. Importantly – say this is so to whoever will listen. As an investigator you sometimes need to spell things phone-net-ic-ally, so people understand that you will not go away and that sacking someone was not the answer. Ok, it maybe you that’s then sacked for asking a question phone-net-ic-ally... We have covered why we investigate and what an incident is. There is a long way to go before we reach the nirvana of incident free hospitals – but we have made a start. Well not really, it’s time to conclude with a confession. There is another reason why I investigate crashes/incidents, have done all that training, wear scrubs, body armour, get cold wet and damp (not at the same time hopefully). The other and for me main reason to investigate a fatality is to tell the family why their loved one died. It’s a privilege to explain why we think it occurred and give some reassurance that it will not occur again. I do investigations where police officers have died. I never expect the family to agree with me, but only to listen to what I have found. Sometimes after an investigation the family may come with us as we do experiments and be part of the world of science. It’s true they may cry and get emotional – but they are only doing in public what we do ourselves in private. Read Martin's other blogs Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. 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