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The presentation covered: What is Human Factors and ergonomics (HFE) and what it’s not The basic principles Complexity Why things go wrong (and right) Systems approachesH Human-centred design Medical error’ What’s happening in Scotland? Practical human factors thinking How to get involved

The toolkit explores the three phases of how we normally respond to a crisis; Emergency – at the beginning of a crisis there is high energy. A sense of urgency and a common goal brings teams together and things get done. Regression – our sense of purpose becomes less clear, energy levels drop, people get frustrated and are less productive. Recovery – new goals emerge, and we begin to focus on rebuilding rather than simply surviving. An end, or at least a new sense of normality, is in sight. The aim of this framework is to help people begin to think about how they might move to Recovery. The workshop consists of a 90 minute session that can be delivered online or in person. The toolkit, along with some guidance on how to run it: How to guide Proposal Framework for learning Lesson plan Presentation Action plan For more information or support on using the toolkit please contact paul.gimson@wales.nhs.uk social media @improvementcymru

The toolkit focuses on patient safety and incident management; it touches on ideas and resources for exploring the broader aspects of quality improvement and risk management. There are three sections to the toolkit: Incident management—the actions that follow patient safety incidents (including near misses) Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources).

In March 2020, the pandemic hit. They needed to take the approach online and find an engaging way to keep the conversations going, whilst maintaining the quality and integrity of the Whose Shoes? approach which is known for promoting energy and action, tapping into passion for quality improvement. How could the best ideas emerging during the pandemic, be nurtured and grown? This report Keeping the conversations alive during the pandemic to build the future of health and social care looks at how they have managed to maintain the momentum of their work at such an important but challenging time.

The purpose of this review from Hutchinson et al. was to systematically examine published and grey research reports in order to assess the state of the science regarding the validity and reliability of the RAI-MDS 2.0 Quality Indicators (QIs). The authors found that evidence for the reliability and validity of the RAI-MDS QIs remains inconclusive. The QIs provide a useful tool for quality monitoring and to inform quality improvement programs and initiatives. However, caution should be exercised when interpreting the QI results and other sources of evidence of the quality of care processes should be considered in conjunction with QI results.

What is root cause analysis? Root cause analysis (RCA) is a structured method used to analyse serious adverse events. Initially developed to analyse industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. The RCA approach is the current methodology to investigate why and how serious incidents have happened in healthcare and to assure the Trust, Clinical Commissioning Group (CCG) and the patient/family that lessons have been learned and that the incident will not happen again. This methodology is soon to change next year as set out in the new Patient Safety Incident Response Framework. What happens to the report? Once written, the RCA report will be sent to the CCG, other outside bodies and the patient/family, alongside an action plan on how practices will change. What type of incident is RCA used for? Many Trusts will perform an RCA on incidents which are deemed to have greater learning for the Trust despite the degree of harm, moderate harm and above, and never events. Most Trusts use a modified RCA for ‘local’ investigations – these incidents may include pressure damage, falls and medication errors. What is the process? The current process of undertaking and processing a serious incident is laid out below. This is taken from the NHS Serious Incident Framework. Many Trusts will provide RCA training to anyone undertaking the lead role in an investigation – this could be a patient safety lead or a clinician. How long does it take to complete an RCA? This can depend on the experience of the investigator, the capacity of the department involved to collect statements, a timeline and information. If the incident has been declared to the CCG, the report will need to be completed within 60 days. A local RCA should take no longer than 4 weeks. How many RCAs are completed each year in the UK? During 2018 there were nearly 62,500 incidents that were reported as moderate harm or above. The majority of these would require an RCA. This figure does not include incidents that were not reported on to the Strategic Executive Information System (StEIS) but were investigated using the root cause analysis locally. Currently, patient safety teams up and down the country are drowning in writing RCA reports. We are caught up in a process of investigating harm that has already happened. Hours, days, months are spent having meetings mulling over the RCA. Looking at timelines, thinking of why the incident happened and whether there was any way for it to have been prevented. The cost of undertaking an RCA must be in the thousands of pounds. The team often includes the patient’s consultant, head of nursing, governance leads, patient safety managers and clinical staff. This group may meet up at several different occasions to make sure that all facts are correct and that the RCA is written well and meet a standard that the CCG will accept. Multiple drafts are written before submitting the final report. Action plans are found at the bottom of the RCA – once the root causes have been found, that is when the actions can be formulated. These actions will need to be carried out in the department/area where the incident took place or across the Trust if it was a system failure. Once written and signed off by the Trust and the CCG – the RCA is complete. What happens next? The end of the RCA should be the beginning of either a quality improvement initiative, a new policy, a change in practice or change in process. This part of the process is often poor – ‘reminding staff’, ‘education’ and ‘reflection’, assuming it must be human error and must be ‘fixed’ by telling people how to do it better. There is little training in setting appropriate actions or a centralised place to evidence that the action is now imbedded. The Care Quality Commission (CQC) can call on these actions and the evidence of these actions at any time. At present there is not a robust, standardised approach across the NHS to gather evidence that actions have been put in place post incident. One of the reasons for this is a lack of capacity and capability due to the industry we have made of writing the RCA and lack of quality improvement training or time provided to all staff throughout the NHS. Final words Have we forgotten the purpose of our role within patient safety? Figuring out what went wrong systemically is only one part of our role; however, assuring the family and patient that we have put new systems in place and that we are striving for this incident to never happen again is equally, if not more, important – so why is there not a standard process/industry for this? If we focussed more on the prevention we could get off the hamster wheel of investigating recurrent harm. It is hoped that the new serious incident framework will address this issue and allow us the time and the capability to put in measures to stop recurrent harm happening to patients and the public. What are your solutions to action plans and gathering the evidence for these plans? Have you a system that is easy to keep track of RCA reports and follow up? I would also be interested in the patient/public view of investigation reports and whether this type of approach is what they want?