Exciting Opportunity for Safety Scientist or Human Factors professional

We are looking for a safety scientist or human factors professional with experience of healthcare to undertake three months’ work with us. The aim of the project is to use Safety II/Resilience Engineering theories and frameworks to analyse a series of 39 Never Events. Traditional safety practices view adverse events as occurring when there are departures from protocols. Solutions therefore often involve training and protocol development, especially for nurses. However, these solutions are often ineffective, as indicated by the continuing occurrence of Never Events.

Resilience theory proposes that the complexity of the healthcare environment is the key to understanding how adverse events occur. Clinicians create safety by adapting to pressures and challenges, and adverse events happen when adaptive capacity is eroded. Understanding how to prevent never events, from this perspective, involves understanding the work system and its complexity.

We want to investigate what this Safety II perspective might add to our understanding of Never Events and how to prevent them. The work will involve desk based analysis of a series of Never Event reports to produce a framework for incorporating Safety II perspectives into Never Event analysis. We will gain stakeholder input into the framework and produce guidance for applying it.

The ideal person to undertake this work is someone with knowledge of safety problems in healthcare and understanding of theories of human error, accident causation and/or Safety II and Resilience Engineering. The work must take place over a three month period from May to July, 2018. All approvals and materials are in place for the project to start in May. Work can be carried out remotely if necessary, but some face to face meetings in London will be necessary. For further information, please contact:

Dr. Janet Anderson

Director, Centre for Applied Resilience in Healthcare

King’s College London

Janet.anderson@kcl.ac.uk

02078483788

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Paper: A systems approach using the functional resonance analysis method

Al Ross, Andrea Sherriff, Jamie Kidd, Wendy Gnich, Janet Anderson, Leigh Deas, Lorna Macpherson (2018). “A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice.” Applied Ergonomics 68: 294-303.

Open Access:  http://www.sciencedirect.com/science/article/pii/S0003687017302697

Our work found that the functional resonance analysis method (FRAM) allowed complexity to be mapped so that important factors are not missed when designing healthcare interventions.

Background
All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application.

Methods
The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a ‘world café’ workshop (n = 56).

Results
We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention.

Conclusions
Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.

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Masterclass 2017: Keynotes and Timetable

We are pleased to announce three guest keynote talks that will take place at our Resilience in Healthcare Masterclass 2017 – October 9th and 10th.

Prof. Jeffrey Braithwaite – A leading health services and systems researcher with an international reputation for his work investigating and contributing to systems improvement.

Dr. Duncan McNab – Associate advisor to NHS Education for Scotland, Practising GP Journey into complexity – From reductionism to resilience.

Dr. Adrian Plunkett – Consultant Paediatric Intensivist. Founder of: Learning from Excellence.

Our provisional timetable is now available at http://resiliencecentre.org.uk/masterclass/

Places are limited but online booking is still available at this time.

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Masterclass 2017: Registration open

Registration is now open for Masterclass 2017!

Click or tap to register now

Registration includes lunches, refreshments and dinner on the night of the 9th November, and all Masterclass sessions.

The Masterclass will start on October 9th at 10.00am and finish on the 10th October at 4.30pm.

The venue is De Vere Colmore Gate – Birmingham. This masterclass is supported by the West Midlands Patient Safety Collaborative.

A two day course for researchers and health professionals who want to learn how to apply resilience engineering concepts to improve care quality and safety. Organised by the Centre for Applied Resilience in Healthcare (CARe) – a clinically embedded research centre.

This interactive masterclass will include:

• A comprehensive overview of resilience and Safety II principles and how they can be applied to improve quality and safety
• Keynote address from Professor Jeffrey Braithwaite from the Australian Institute of Healthcare Innovation
• The latest learning from our resilience work in emergency care, care of older people and safety and risk management
• Interactive sessions with experts to learn how to apply a resilience approach
• Discussion about the benefits and challenges of applying Safety II in practice

Click or tap to register now

 

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Resilience Challenge Wins First Prize in International Competition

Resilience Challenge, an online video game raising awareness about safety and the difficult pressures on healthcare providers, has been awarded first prize in the ‘Second Resilient Health Care Net International Prize in Resilient Health Care’. This was a global competition, which awarded prizes to projects that translate innovative safety ideas into clinical practice. Contributions were judged based on their feasibility, and ability to strengthen resilience in healthcare systems.

As the top award in healthcare resilience engineering, RHCN recognises Resilience Challenge for its unique contribution to promoting patient safety.

A collaboration between King’s College London’s Centre for Applied Resilience in Healthcare and Karman Interactive, and supported by the Cultural Institute at King’s, the game takes the player through various scenarios which require difficult decision-making. CARe also hopes to start wider conversations about what can be done at an organisational level to support successful decision-making on the ground.

Jennifer Jackson, a PhD student at King’s who led the project, said ‘We are thrilled to have Resilience Challenge recognised by the Resilient Health Care Network. It has been an exciting challenge to take very technical, complex theory and turn it into something fun and engaging. We are exploring how the game can be used in staff education at an NHS Foundation Trust, and hope to continue conversations about improving safety in healthcare. We are grateful for the funders of this project, the Cultural Institute, and our industry partner, Karman Interactive.’

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Masterclass 2017 – 9th and 10th October – Save the date

We are pleased to announce that our Resilience in Healthcare Masterclass 2017 will be held on October 9th and 10th in Birmingham (UK), with Prof. Jeffrey Braithwaite as guest keynote speaker. More details will follow shortly.

  • Two days’ intensive learning about applying a resilience approach to improving the quality of care
  • The latest learning from our resilience work in emergency care and the care of older people
  • Interactive sessions with experts to learn how to apply a resilience approach
  • Reflections on the benefits and challenges of applying resilience engineering

To keep updated you can subscribe to our site from the CARe homepage (see box, bottom left).

Proceedings from our previous Masterclass events can be found here (includes presentations and videos)

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Paper: Understanding emergency department escalation

Please read our open access paper here: Understanding ED escalation

Back J, Ross AJ, Duncan MD, Jaye P, Henderson K, Anderson JE. (2017). Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience. Annals of Emergency Medicine.

What keeps your emergency department (A&E) safe?

This paper, published in the Annals of Emergency Medicine, outlines how escalation policies are used by emergency departments when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying “normal” processes. The study objective is to examine escalation policies in theory and practice.

What is already known on this topic

Care delivery organizations commonly develop “escalation policies” for managing crowding and surges in emergency department demand. The effectiveness of these policies has seldom been studied.

What questions this study addressed

This study used mixed methods to identify common patterns in escalation policies in UK EDs and to evaluate how well they performed in practice.

What this study adds to our knowledge

Formal escalation policies often presumed the availability of resources that were missing or degraded when escalation was needed. Consequently, the actual practice of managing crowding deviated from that inscribed in policy.

How this is relevant to clinical practice

Recognizing and monitoring the gap between formal policies and actual practice should help in the development of more realistic and useful escalation policies.

Please read our open access paper here: Understanding ED escalation

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Take the Resilience Challenge!

Click or Tap to Take the Resilience Challenge!

Resilience Challenge is part of CARe’s wider work to inform policy about healthcare safety. The game is designed to raise awareness of the different pressures that healthcare providers have to cope with, and to start conversations about what can be done at an organisational level to support successful decision-making. Our goal is to make healthcare systems work safely for everyone involved.

Innovative Technology and Organisational Resilience in Healthcare is a collaboration between King’s College London’s Centre for Applied Resilience in Healthcare and Karman Interactive, brokered and supported by the Cultural Institute at King’s.

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Last chance to book your place: Resilience in Healthcare Masterclass 2016

The Second Resilience in Healthcare Masterclass at the Mercure Bristol Holland House Hotel and Spa on November 10th and 11th.

The last Booking Date for this event is 7th November 2016.

– Interactive sessions with experts to learn how to apply a resilience approach

– Discussion about the benefits and challenges of applying Safety II in practice

– The Masterclass is accredited by the Chartered Institute of Ergonomics and Human Factors


Click here to register
(via King’s College London eStore)

If you require an invoice please email: masterclass@resiliencecentre.org.uk

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Updated: Resilience Masterclass Programme

The Second Resilience in Healthcare Masterclass at the Mercure Bristol Holland House Hotel and Spa on November 10th and 11th.

Announcing Our Programme Sessions

  1. Concepts and underpinnings. Using the Concepts for Applying Resilience Engineering (CARE) model. A comprehensive overview of resilience and Safety II principles and how they can be applied to improve quality and safety.
  2. Incident Analysis. Including a keynote talk by Dr. Mark Sujan from the University of Warwick. His talk is on “Reporting and learning – A Safety-II perspective”.
  3. Quality Improvement. Including the latest learning from our resilience work in emergency care, care of older people and safety and risk management.
  4. Tools and Methods. Including a workshop led by Dr. Al Ross from the University of Glasgow. Learn how to use FRAM to analyse system safety and strengthen safety.

– Interactive sessions with experts to learn how to apply a resilience approach

– Discussion about the benefits and challenges of applying Safety II in practice

– The Masterclass is accredited by the Chartered Institute of Ergonomics and Human Factors


Click here to register
(via King’s College London eStore)

If you require an invoice please email: masterclass@resiliencecentre.org.uk

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