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In this blog, David Fassam, Senior Safety Investigator at the Health Services Safety Investigation Body (HSSIB), looks at one of the methods used in patient safety investigations: the Functional Resonance Analysis Method (FRAM). FRAM is an analysis method that looks at tasks, known as functions, and their connectivity and dependence on each other which are called aspects. The aspects within FRAM that are used to connect the functions and demonstrate the dependencies are inputs, outputs, preconditions, controls, time and resources.

How can your team improve decision-making and performance in an unpredictable world? The field of Naturalistic Decision Making (NDM) supports organisations in understanding and leveraging expertise. Over the past 40 years, NDM researchers and practitioners have helped clients achieve higher ROI, improve safety, and increase efficiency. In this presentation series captured from our 2022 NDMA Open House, you'll hear directly from leaders in the NDM field. They'll share a variety of key concepts, case studies, tools, and insights that you can use to improve how your team makes decisions—especially when stakes are high and conditions are uncertain.

Robert Barker, author of the book, 'The Time Based Organisation: Recreating and Transforming Existing Organisations', highlights how time-based analysis can be used in the NHS to transform the patient journey. Huge amounts of untapped potential and waste exist in the NHS, yet all the equipment, assets and infrastructure are already in place. Overall patient journey throughput times are currently too long, but the combined strengths of time-based analysis, which looks at value adding processes through the lens of time and NHS staff who know these processes better than anyone else, can transform the NHS patient journey. In the example below, you will see large amounts of non-value adding time (wait and queue). The value adding time here is around 8%. The NHS patient journey typically reflects the management structure where specialists control the treatment islands of efficiency but nobody is responsible for the non-value adding time gaps. Hence long waits and queue times. Tracking a patient journey using the lens of time identifies a lot of non-value adding time and additional costs that impact both the patient’s health and costs. Analysing the flow of patients is undertaken by value adding staff, your best consultants. Transformation of the treatment process journey is needed now more than ever, since it will include “What stops staff doing the best days work they can”. Note – Time-based transformation is driven by value adding employees not management consultants, but it requires support from NHS leaders.

This commentary, published in the Journal of the American Medical Informatics Association (JAMIA), highlights the value of explicit inclusion of context in Electronic Health Records (EHRs). The author highlights how discussions of why decisions were made illustrate important relationships in elements of patient care than can often get lost in clinical notes.

Enhanced Significant Event Analysis (enhancedSEA) is a NHS Education for Scotland (NES) innovation which aims to guide healthcare teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.Follow the link below for:guidance on how to perform enhancedSEA the updated report format, new Guide Tools, a short e-learning module basic educational resources on human factors science and practice.Although enhancedSEA was developed and tested with primary care teams the approach is also highly suitable for any health and social care setting.

This case study, published in Safety Science, looks at aviation to illustrate the conflict, and double-binds, created as those in high-consequence industries negotiate the fluid lines of accountability relationship boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova Scotia, in 1998. The paper offers dialogue to aid in understanding the influence accountability relationships have on safety, and how employee behavioural expectations shift in accordance. McCall and Prunchnicki propose that this examination will help redefine accountability boundaries that support a just culture within dynamic high-consequence industries. Key highlights from the paper Accountability relationships, as both retrospective and prospective, support just culture. Lines are fluid in accountability relationships, forcing operators to adapt to changing goals. Viewing accountability lines as rigid, increases risk and creates double-binds for operators. Clinging to retrospective accountability reinforces blaming/shaming operators for errors.

Appropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study from Ede et al. were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process. What is already known The escalation of patients following deterioration remains problematic and improvements are required. Nationally adopted escalation protocols (NEWS2) do not entirely complement the way in which clinical staff escalate care successfully in variable work systems. There is a constant realignment between protocol-driven care (work-as-prescribed) and actual delivered care (work-as-done) as standardised processes are often theoretical in their nature and overestimate system stability. What this paper adds Experts identified stark differences between work-as-prescribed (NEWS2 protocols) and work-as-done (everyday escalation tasks) with 28 % (9/32) of escalation tasks described as cognitively difficult. Three out of the nine variable tasks (‘making the critical decision to escalate’, ‘synthesising all data points’, and ‘identifying interim actions’) were closely coupled within FRAM Model 2b indicating potential points of weakness in the escalation process. The ability to efficiently synthesise data is a central task during escalation, and when effective, allows staff to use creative strategies to manage deterioration.

Walkthrough analysis is a structured approach to collecting and analysing information about a task or process or a future development (for example, designing a new protocol). It is used to help understand how work is performed and aims to close the gap between work as imagined and work as done to better support human performance. Walkthrough analysis is one of the tools included in the Patient Safety Incident Response Framework (PSIRF). This guide by NHS England provides information on how to carry out walkthrough analysis. It covers: Getting started System considerations Task and tool matrix View further PSIRF content and resources on the hub.