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Experts’ Top Tips

Interview with
Welcome to Airway Matters. I’m Kevin Fong. I am a consultant anaesthetist with an interest in patient safety, risk management, and human factors. And I am joined by a panel of human factors experts today. Fiona, I’m going to start with you. But I want to ask you all this. How did you first get interested in human factors? Well, it was when I was a registrar in a paediatric intensive care unit. It was just after a Elaine Bromiley died. Martin Bromiley had released the report into her death. And two of the consultants on PICU said, we should be doing simulation training regularly on the intensive care unit. And I was the guinea pig.
It was my shifts and they brought in a little baby mannequin and said, right. We called neonatal collapsed, off you go. And it was from then on really that I really became interested in simulation and human factors and how it’s relevant to our day-to-day work. OK. I guess I wanted to pick all of your brains about what things you do in your everyday practise that are examples of human factors. Let’s start with you Chris. Every day in theatres, I use the tools that I’ve learned about in non-technical skills– so leadership, and followership, communication.
And we encourage our team leaders to stand back from complex events and take an overview of what’s going on rather than getting involved so they can retain what’s known as situational awareness. They can see the big picture, rather than getting involved in the minutiae to the detriment of an overall plan. So that’s the day-to-day stuff, which is where I think a lot of people come into human factors in health. But increasingly now, I’m looking at the tools that can help us do our jobs better. So physical tools such as the equipment that we use being well-designed enables us to perform better.
And the systematic tools or processes that we have in hospitals that can make it easier to do our jobs well or more difficult. So I’m trying to work with those so that the systems that we have support us to look after patients as safely as we can. Fiona, you are leading the current Difficult Airway Society Human Factors Group. What is– give me a brief description of what human factors means. So I think human factors are making it easier to do the right thing and making it difficult, or I suppose ideally, impossible to do the wrong thing.
It’s all about accepting that human beings are human and we’re going to make mistakes and trying to design safe systems and safe ways of working so that it’s ideally impossible to do the wrong thing. And it’s all about using sort of the speciality of human factors and ergonomics as it has been done in other safety critical industries. It’s all about using that expertise to try and make our practise as safe as possible, I suppose. And Clinton, what about you? You are– I mean– you’re really on the other side of the partnership. You’re there looking after us, keeping us honest. What is human factors to you? What are your top tips for its practise from your perspective as an ODP?
I think there’s something to be said about routine and having the same routine time and time again, which then doesn’t sort of lend itself to variability and ambiguity. The single best thing that I’ve found infinitely helpful is where anaesthetists talk out loud. We can hear what they’re going through. We start to understand what they’re going through. And that gives me a bit of a heads up in terms of what’s coming downwind. What do I need to start thinking about to anticipate to make your life a bit easier?
And that then has the effect that you’ve got a bit more capacity to think about something else if I’m already off down the road trying to anticipate what it is you’re going through. And that’s something I think that’s talked about a lot in the human factor, isn’t it, that shared mental model– you know, not just being inside your own head space without sharing that with anyone else. I mean, that’s kind of what you’re talking about there. How about you Fiona? What’s your top tip? I think it’s really good to know your team’s first names. For me, that’s really– I’m not very good at remembering names. It’s really hard for me.
But I think it means then in a crisis you can say, Clint can you get me the defib from the recovery, or– I think it improves communication. I think it’s good for morale. I think it flattens the hierarchy, or you always say, the authority gradient, don’t you Chris? I think it enables people to speak up if they feel something’s not quite right. So for me, that’s what I really try to work on. I think learning people’s names is one of the most underrated human factors tools that you have in a crisis. Because you think, well there’s no time to learn people’s names. But actually, if you do that, it kind of tends to calm things down. I think so.
Yeah, I think– you know– there are lots of ways you can do that. I think the who– you know, pre-safety brief at the beginning of the day really helps, doesn’t it, having everyone introduce themselves. But again, I’m not very good at remembering if I hear things. But I think if having name badges on. Or I know in our office, we started to have a whiteboard and everyone writes their names down on there. That’s really good for me. So I can just have a look at halfway through the case, oh yes, what’s the name of that HCA? A lot of people have been putting their names on hats, aren’t they.
I think having a name badge on your shoulder rather than the lanyard is good. I’m sure– I don’t know. Have you got any other top tips for learning names? No. And I think one of the things is, we do all forget names. And teams are quite mobile in healthcare now. So we’re often changing teams during– During the day, yeah. And having techniques for communicating to individuals when you don’t know their name is also important. So some of those tools are ones that I would use and I’ll teach so that you can identify people by eye. So when you’re actually looking them in the eye, you can get feedback that they’ve received your message.
By touch as well– if you don’t know their name, just a hand on the shoulder so that you are identifying the person that you are speaking to. But also, getting some read back so that people know that if it’s an important message that you’re passing, that they’ve received that message. So those are things that I would use routinely in theatres. You’re in an interesting position because fair enough, you’re the most experienced clinical practitioner in the room in a crisis– and particularly very often with some of our more junior trainees. Or even some of our more junior consults, you are the most experienced person.
How do you deal with the problems that sometimes can arise about, I guess, authority gradients and that sort of thing. What are your tips for that as you know, that ODP anaesthetist partnersip, which is usually pretty harmonious but not always. No, no. I’ve had my fair share of testing relationships. [LAUGHTER] But what I would say is that there’s something around it’s not what you say, it’s how you say it. And I’ve found myself in certain situations whereby I can see something isn’t quite going the way it should be. And I– for whatever reason or whatever frame of mind the anaesthetist is in, they might not be aware of where we’re heading. So I pose it as a question.
And I find that that gives an opportunity to stop and think about what is they’re doing and maybe change what it is they’re doing. But again, it depends. It’s never sort of binary. The job will change depending on what’s going on. It’s the old ODP Jedi mind trick, isn’t it? That’s not the piece of equipment you’re looking for. [LAUGHTER] It’s all about parameters as well and saying, actually after my third attempt or the second attempt, it just reminds me to do something. I think what you’re doing is giving us permission to speak up. And again, that starts to flatten that sort of authority gradients. But it opens dialogue. And ultimately, that’s what you want amongst the team.
Have you seen a change in your time as a clinician? With the human factors, I think the biggest change I’ve seen– certainly in my time serving at UCLH– is the inter-professional education. It’s the opportunity away from the clinical environment where you’ve got protected time to have a discussion, but ultimately to understand what’s going on for the other individual and they can hear your frame. I don’t think you always have that luxury within the clinical environment due to the sort of competing pressures. Chris, you’ve been away and actually had some professional training in human factors and ergonomics. Was there anything that particularly surprised you or anything that you thought, gosh, we really should be doing this or we’re not doing this?
I think after my introduction with non-technical skills, the thing that struck me most was the way in health care that we investigate when things don’t go quite as well as they should. There’s very much a blame culture that was persisting. So an individual is held responsible for something that didn’t go well rather than looking at all the contributory factors. And that was one of the main things I started to learn about human factors and ergonomics was the huge range of influences that there are on individual and team behaviours. And that we need to examine all of those to determine how we can improve the work that we do. Excellent.
So I’m going to sort of bring it to a close here and finally ask you, really, you know finally for your last take home message top tip that you would tell any of our learners today, you know, this one thing I think would improve your human factors practise and your daily practise, what would it be? I’m going to steal Fiona’s one. I am but to say learning names because I do think it’s important. And I do think it’s important even in a crisis. And it is essential from day-to-day, but even in a crisis. So for me, it is about learning everybody’s names no matter how bad the situation looks. Who wants to go next? I’ll go.
Even if you’re feeling embarrassed about asking a question, practise speaking up.
I’m going to say, I think if you have good technical skills, that makes room in your head for good non-technical skills. So I think practicing all the workshops and practicing all the various highway techniques to get us out of difficulty are worth doing over and over again regularly so that in a crisis, we’ve got them to hand. Perfect. And Clint? I think I’ll stick with the shared mental model. Now whether that’s for parameters or in terms of your thought process, I think shared mental model for the team between anaesthetist and ODP is absolutely paramount. OK. So we have learn everybody’s name, have a shared mental model, tell everybody what’s on your mind and what’s happening so everybody knows.
We have put in practise the things that you going to rely upon in an emergency wherever you can, whenever you can. And practise– whoever you are on the team– speaking up and making your voice heard so that you can make your voice heard when it really counts. That’s a pretty good set. Thank you very much. My thanks to Chris, and Fiona, and Clinton. And so that’s the end of our panel on Airway Matters. I hope you’ve enjoyed it. I’m Kevin Fong. And join us for more on the module.

In this video, Prof Kevin Fong, Consultant Anaesthetist at UCLH is joined in a panel discussion by four other experts in Human Factors and Ergonomics (HFE): Dr Fiona Kelly, Consultant Anaesthetist and Intensivist at Royal United Hospitals Bath and lead of the Difficult Airway Society (DAS) group on HFE, Prof Chris Frerk, Consultant Anaesthetist at Northampton General Hospital and CHFG Trustee, and Mr Clinton John, Operating Department Practitioner and Head for Clinical Education at UCLH. They will discuss and share their top tips about HFE in the context of airway management.

This video concludes the HFE activity in Airway Matters. Throughout the course we will come back to several of the concepts presented so far. We will meet Prof Chris Frerk again in Week 2, discussing the importance of cognitive tools, such as guidelines and algorithms and in Week 5 where he will outline how to learn from airways events and create a just culture – as things unfortunately can go wrong despite clinician’s best intention and efforts.

In the context of the COVID-19 crisis, the CHFG has created a series of resources freely available on their website, including a document on key human factors messages when working under pressure and a podcast with Prof Chris Frerk and Martin Bromiley.

The next activity will focus on airway management in patients with COVID-19.

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