Improving Patient Safety

Focussing on non-clinical skills

Close analysis of aircraft crashes let NASA conclude in the late 1970s that many of these were caused, or significantly influenced, by poor non-technical skills.¹ In other words, they were not caused by technical failure of the aircraft or the pilot not being sufficiently trained to fly it. The type of non-technical skills referred to included communication, fixation on one thing so that other important details were missed and confusion. Then training commenced for these skills—this was initially referred to as cockpit resource management but later this became crew resource management with the realisation that the whole crew (including ground staff) were involved in avoiding accidents. The issue of the hierarchy of the flight team in particular and resulting inability of crew to speak up when concerned (empowerment) are now addressed. This type of training is now mandatory on an annual basis in the aviation industry and assessments take place regularly and are as important in allowing crew to continue flying as assessments in technical skills.

The healthcare industry lags many years behind aviation industry in this aspect of safety, despite many similarities between the two, especially in acute hospital medicine – such as working within (often unfamiliar) teams in an environment in which emergency management of the situation is crucial. The situations are commonly stressful and fatigue is also an issue. At the beginning of the 21st century awareness of the role of non-technical skills in healthcare and specifically their role in patient safety increased as a result of a number of publications and events. A report, To Err is Human, published in 1999² in the US drew attention to vast numbers of adverse events (i.e. those caused by the teams looking after these patients) occurring within the healthcare environment. Many studies since have confirmed this—approximately 10% of patients in hospitals will suffer such an event.

The “Swiss cheese” model³ demonstrated that most adverse events do not happen in isolation but as a result of many barriers and defences being breached. A number of high profile cases occurred in the UK (e.g. the wrong kidney being taken out during surgery, the wrong chemotherapy drug being injected into the spine). As a result of the above, the profile of patient safety has considerably increased and the comparison with the aviation industry has led to awareness of the role of non-technical skills in healthcare.

Non-technical skills in healthcare are similar to ones in aviation—those skills which are neither based on knowledge nor technical skills. They have been usefully divided into two groups—those which are individual and those which are social or interactive skills required within a team set up.⁴ Individual skills include planning, prioritising, decision making and individual situation awareness. Interactive skills include leadership, team working, empowerment issues and team situation awareness. Communication skills feature heavily within both groups.

A major challenge is how to improve these skills both in an individual and within a team.

The following issues arise:

• Can these skills be taught? – The evidence is that they can, although some people naturally possess more than others<
• When should they be taught? – As early as possible in training, so that the idea of patient safety and management is ingrained into staff
• Should they be taught separately from technical skills? – Whilst problems with non-technical skills should be addressed within technical skills training, they probably need separate teaching as well. It has been acknowledged that they need to be taught specifically within a problem-based learning undergraduate curriculum.⁵
• Should they be taught to a multidisciplinary group? – Whilst the individual skills could be taught to a specific group of staff the social skills appear to require multidisciplinary training—something which does not commonly occur within the healthcare environment.
• What teaching methods should be used? – As with all teaching methods, there are lots of appropriate different approaches. The use of simulators has been widely advocated and certainly communication, leadership and teamwork are well demonstrated in a simulated setting. Though there is an increasing number of simulators available for healthcare teaching, access is still limited. Small group workshop-based teaching allows in-depth discussion of subjects and a number of places, including the hospital I work with, are developing such courses. In the UK the National Patient Safety Agency have developed a course in association with the Royal College of Physicians which can be downloaded from the internet and taught to small groups. It is aimed at newly qualified doctors.
• Should non-technical skills be assessed? – Some form of assessment should follow all training, both of the trainees and the trainers. The difficulty here is how to assess the skills. Patient safety, including competency in non-technical skills, is a core component of the training programme for newly qualified doctors in the UK. An assessment system for anaesthetists has been developed⁶ but we need to assess teams as well as individuals. However, these assessments take place in the simulated settings and not in real workplace settings. The real test is whether the number of adverse events occurring to patients is reduced. This is a long term project because of the difficulty in measuring such events—there is widespread underreporting of such events. Increased awareness of the staff about patient safety issues results in an increased number of adverse events reported.

At Burton on Trent, a District General Hospital in the Midlands in England, we have set up such a course. The course idea originated following an incident in the intensive care unit in which it was clear from retrospective analysis that the problem was due the to failure of non-technical skills and the difficulty nursing staff had in questioning the actions of a doctor, given the traditional hierarchical structure within the unit. Discussions about this with a non-clinician who had experience of the aviation industry highlighted the differing approaches of the two industries.

The aim of the course is to give the staff tools to recognise a risky situation and act as required. The tools are termed “beacons” in recognition of their role as “warnings”. As increasing beacons are noted, the situation is likely to be more risky and extra attention is required. The beacons are: communication, confusion, policies and procedures, fixation, trepidation, leadership and team working and humanity. Problems relating to these can be seen as non-technical skills.

There are repeated references to car driving where similar non-technical skills are required and the concept of recognising and acting on risk is understood by the participants. We also have developed a video about a fictional character called Mildred, who is followed on a patient journey through hospital, encountering many different areas in hospital and teams involved in her care. Each scene portrays a different problem relating to non-technical skills—situational awareness, communication, leadership and team work and empowerment. These form the base for the workshops. We run a follow up half day session following the course. We ask the participants to go back to their workplace and observe (and act on if required) situations from a safety perspective, particularly with regard to non-technical skills and the beacons.

In conclusion, whilst as stated above, the healthcare industry lags considerably behind aviation, general awareness of and training in safety and specifically in the subject of non-technical skills, recognition of the value of these in healthcare is increasing. There would appear to be acceptance of the fact that these skills can be learnt and many differing ways are being used for the same.

References

1. Helmrich R, Merritt A, Wilhelm J. The Evolution of Crew Resource Management Training in Commercial Aviation International Journal of Aviation Psychology 1999; 9 (1): 19-32

2. Kohn K, Corrigan J, Donaldson M. To err is Human: Building a safer health system. Washington, DC: National Academy Press:1999

3. Reason J Human error: models and management British Medical Journal 2000 320: 768-770

4. Fletcher G, McGeorge P, Flin R, Glavin R, The role of non -technical skills in anaesthesia: a review of the current literature. British Journal of Anaesthesia 2002; 88 (3): 418-429

5. Wass V. Patient safety education symposium AMEE 2006, Genoa

6. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-technical Skills (ANTS): evaluation of a behavioural marker system. British Journal of Anaesthesia 2003 90 (5): 580-8