Thursday, 7 September 2017

What's in your attic?

This blogpost weaves together 4 threads:
1) In Oscar Wilde's only novel, "The Picture of Dorian Gray", Dorian sells his soul to ensure that a portrait of him ages while he remains young. 

2) In his must-read book "Safe Patients, Smart Hospitals" Peter Pronovost argues that healthcare professionals are very good at hiding mistakes from themselves. They compartmentalise mistakes and explain them away because of a belief that "doctors don't make mistakes."

3) In a very good lecture, Scott Weingart argues that:

"The difference between bad doctors and good doctors is not that the bad ones make a bad decision every single shift or even every single week. The difference between a bad doctor and a good doctor may be one bad decision a month. And that's really hard to get self-realised feedback on. There are not enough occurrences of real, objective badness to learn from one's mistakes."

4) Lastly, if we take the numbers from the Instititute of Medicine's "To Err is Human" as correct then we can postulate the following: 
  • There are approximately 100,000 deaths due to medical error per year in the US (1)
  • There are approximately 500,000 doctors in the US (2)
  • Therefore a given doctor will be involved in a death due to medical error once every 5 years
  • Let us make the assumption that only 50% of these deaths are recognised as having been caused by medical error. Then a given doctor will be aware of a patient who died in part due to his/her medical error once every 10 years.  Or 4 deaths per career.

Now for the weaving. 

For a number of reasons healthcare professionals will not be able to have a good understanding of their actual performance. Partly this is because our involvement in errors leading to death is (thankfully) rare and partly because the feedback loop in healthcare is often very long or non-existent. 

We are also, because we are human, very good at rationalising our poor performance. Lastly many of our jobs require confidence, or at least an outward confidence, in order to believe that we can do the job and to put patients at ease. 

This means that, like Dorian Grey, we have a public persona which is confident, capable and error-free. But we also have our "true" selves hidden away, perhaps not as pretty as we might like to think. 

If this is a problem then what are the solutions? 

Unsurprisingly perhaps, given that this is a simulation & HF blog, one solution is immersive simulation. The simulation has to be realistic enough to trigger "natural" behaviour and actions. Realisation of the differences between one's imagined and actual performance  often emerge as the simulation progresses. The simulation can also create the conditions under which poor decisions are more likely to be made. This means rather than waiting a month for a sufficiently stressful real-life event to occur, twelve stressful scenarios can be created in a day.

However it is during the debrief that the two personas, the portrait and the person, can be compared. The use of video-based debriefing means that the participant can see their own performance from an outsider's perspective. The facilitator helps the participant see the metaphorical wrinkles and scars that have accumulated over time. The skilled facilitator provides help in taking ownership of the blemishes and advice on how to work on reducing them.

Simulation remains overwhelmingly the domain of the healthcare professional "in training". Consultants, staff grades, registered nurses, midwives and other fully qualified professionals rarely cross the threshold. Perhaps this is because in training the portrait of ones true self is constantly being exposed. It hangs, as it were, above the fireplace or in a prominent position where many people can and do comment on it. Upon completion of training it is with a sense of relief that the portrait is relocated to the attic. And the longer it stays up there, the greater the fear of the horror we will be faced with if we take it back down.

Face your fears, attend a simulation session and let's clear out that attic together. 

References:
1) DONALDSON, M. S., CORRIGAN, J. M. & KOHN, L. T. 2000. To err is human: building a safer health system, National Academies Press.
2) Number of active physicians in the U.S. in 2017, by specialty area (Accessed 7/9/17) https://www.statista.com/statistics/209424/us-number-of-active-physicians-by-specialty-area/

Monday, 17 April 2017

Translating simulation into clinical practice: Psychological safety

At our sim centre, safety is a key concern. When people mention safety in the context of simulation, the first thought is often the safety of the patient. Simulation is safe for patients because, in the majority of cases, lack of patient involvement means that no patient is harmed. Perhaps the second thought regarding patient safety is that this is one of the reasons we carry out simulation in the first place.

Safety is not just about the patient however, but also about the simulation participant. In terms of physical safety, at our sim centre we have had sharps injuries, slips and trips, as well as a defibrillation of a mannequin while CPR was in progress. So, physical safety is important.

However, we think that the psychological safety of the participants is as important as their physical safety. Psychological safety “describes perceptions of the consequences of taking interpersonal risks in a particular context such as a workplace” (Edmondson & Lei 2014).  When people feel psychologically safe they will be more willing to speak up, to share their thoughts, and to admit personal limitations. This means that psychological safety is important not just in simulations but also in clinical practice.

The psychologically safe simulation environment is not self-generating, it must be created and sustained by the facilitator and participants. Creating this environment is not a cryptic, mystical feat which is only achieved by the expert few, but rather a set of behaviours and actions which can be learned. This means that the lessons learnt from creating psychological safety in simulation can be translated into clinical practice. Key concepts are:
  • Flatten the hierarchy
  • Prime people that mistakes will be made
  • Set an expectation of challenging observable behaviours/actions
  • Stress confidentiality

Flatten the hierarchy


A hierarchy is evidenced by a power distance or authority gradient where certain people are placed “above” others usually as a result of additional training or skills. A hierarchy, with defined leadership, is essential for safe care. However when the authority gradient is very steep those lower down are less likely to challenge behaviour. In aviation this has contributed to a number of well-publicised crashes including the Tenerife disaster. In healthcare it results in leaders making fatal (for the patient) mistakes without members of their team speaking up to correct them.

Flatten the hierarchy:
            In the daily brief by:
            Ensuring everyone introduces themselves
Ensuring everyone introduces themeselves by their first name
Admitting to personal fallibility
Setting the tone of expected respect

During the day by:
Gently correcting colleagues who use your title to refer to you by first name
Protecting those at the bottom of the authority gradient from bullying, harassment or other demeaning behaviour by others.


Prime people that mistakes will be made

In the simulated environment mistakes are almost guaranteed due to the planned crisis nature of the experience. In clinical practice mistakes cannot be guaranteed but it is unlikely that no mistakes will happen during a typical day. (Where research has been carried out, in paediatric cardiac surgery, there were approximately 2 major compensated events and 9 minor compensated events per operation. (Galvan et al, 2005)) It is therefore essential to prime people at the beginning of the day that mistakes are likely, that this is “normal” and that they should be looking out for them.


Set an expectation of respectful challenge to observable behaviours/actions

You have made it clear that people will make mistakes. You can then therefore set an expectation that others will challenge any behaviour or action which they are unsure about, which they think is a mistake or which they think threatens patient safety. Warn people that when their behaviour or action is under scrutiny that they will feel uncomfortable and perhaps threatened. Reassure people that when they are having these feelings of discomfort that they are experiencing a "learning moment". Either the person raising the concern is correct and a mistake is being averted or they are correct and the person raising the concern can be thanked and the action clarified.

Stress confidentiality

In the simulation environment, with very few exceptions, we can guarantee that the experience will remain confidential with respect to the facilitator (i.e. we will not talk about participant performance after the simulated event is over) and that we expect the same from the participants. In clinical practice a similar promise can be made. Of course errors, particularly those which may recur in other situations, must be reported using the appropriate system in order to help the system learn. However this does not have to be on a naming and shaming basis but rather a collective effort to explain how an error happened, how it was dealt with and how it may be prevented in the future. In addition this is an opportunity to stress that you will not talk about any mistakes behind people's backs or use the reporting system as a weapon to punish people.

Psychological safety and mistakes

Staff psychological safety will improve patient health
One of the concerns that people may have is that the “psychologically safe” unit/team/department will be more tolerant of error and therefore make more mistakes.  In 1996, Amy Edmondson looked at eight hospital units and, with the help of a survey instrument and a blinded observer, rated their psychological safety with respect to medication errors. She found that the more psychologically safe the unit was, the greater the number of errors reported. However, she also found that the more psychologically safe the unit, the fewer medication errors the staff actually made. Units which were not psychologically safe not only reported fewer errors but made more.


Final thoughts

Words shape our thinking and we struggle to discuss a concept if we don't have a name for it. It is time that the term "psychological safety" escapes the confines of the simulation centre and enters clinical practice. We all deserve psychological safety at work and you can help make this a reality by using some of the above tips.


References

1)   EDMONDSON, A. C. & LEI, Z. 2014. Psychological safety: The history, renaissance, and future of an interpersonal construct. Annual Review of Organizational Psychology and Organizational Behavior, 1, 23-43.

2)   GALVAN, C., BACHA, E. A., MOHR, J. & BARACH, P. 2005. A human factors approach to understanding patient safety during pediatric cardiac surgery. Progress in Pediatric cardiology, 20, 13-20.

3) EDMONDSON, A. C. 1996. Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error. The Journal of Applied Behavioral Science, 32, 5-28.

Thursday, 15 September 2016

Book of the month: Bounce by Matthew Syed

About the author
Matthew Syed (@matthewsyed) is a journalist and was the English number one table tennis player for almost ten years


Who should read this book?

Anybody involved in education and training will find something useful in this book.  Although there are a few problems, they are more than outweighed by the readability of this book and the transferability of the acquired knowledge into practice. Syed talks about the myth of innate talent, deliberate practice, expertise, motivation, the benefits of standardisation, the training of radiologists and inattentional blindness.


In summary

The book is divided up into 3 Parts and 10 Chapters:

Part I: The Talent Myth. Here Syed effectively destroys the myth of innate talent. He tells us what you need is opportunity, deliberate practice with feedback and luck. 
  1. The Hidden Logic of Success
  2. Miraculous Children?
  3. The Path to Excellence
  4. Mysterious Sparks and Life-Changing Mindsets
Part II: Paradoxes of the Mind. In this part Syed look at how our beliefs can help (or hinder) us.
  1. The Placebo Effect
  2. The Curse of Choking and How to Avoid It
  3. Baseball Rituals, Pigeons, and Why Great Sportsmen Feel Miserable after Winning
Part III: Deep Reflections. This part is less obviously related to the preceding parts (see "What's bad about this book?" below)
  1. Optical Illusions and X-ray Vision
  2. Drugs in Sport, Schwarzenegger Mice, and the Future of Mankind
  3. Are Blacks Superior Runners?

What's good about this book?

This book is well-written and very easy to read. As someone who has "been there" Syed does a great job of debunking the talent myth (or the "myth of meritocracy" (p.7)) He references a few of the other writers in this field including Malcolm Gladwell (p.9) and Anders Ericsson (p.11)

Syed explains why the talent myth is bad, in part because it means we give up too quickly because "we're just not good at it". The talent myth also means that "talented" people are given jobs which they are not suited for, this may be a particular problem in government.

This book is relevant to the acquisition of skills (technical and non-technical): Syed refers to Ericsson when he says tasks need to be "outside the current realm of reliable performance, but which could be mastered within hours of practice by gradually refining performance through repetitions" (p.76) In addition, mastery of skills leads to automaticity and a decrease in mental workload.


As mentioned in previous blog posts, failure is an important element of improvement and in order to improve we need to push ourselves (and our learners). Are your sessions set up in order to make the best possible use of the learners' time? Syed also explains that it is not just time (cf 10,000 hours) but the quality of the practice that is important.

Syed extols the benefits of standardisation. He spent two months perfecting his stroke so that it would be identical "in every respect on each and every shot" (p.94). This meant that now he could introduce small changes and he would be able to tell if these were improvements or not as the rest of the stroke remained the same. There is a strong argument for similar standardisation or reduction in variation within healthcare. Currently it is extremely difficult to see whether a change is an improvement because of the variation in the system.

"Feedback is the rocket that propels the acquisition of knowledge (p.95-96). Syed again refers to Ericsson when he discusses how the training of radiologists and GPs could be improved by giving them access to a library of material where the diagnosis is already known (e.g. mammograms for radiologists, heart sounds for GPs). Because the participants are given immediate feedback on their diagnosis they can learn very quickly from their mistakes. Could your skills or simulation centre offer something similar?

Syed also deplores the lack of adoption of purposeful practice outwith the sports arena. He quotes one business expert: "There is very little mentoring or coaching... and objective feedback is virtually non-existent, often comprising little more than a half-hearted annual review" (p.103). How many of our workplaces can identify with this?

Syed's final chapter "Are Blacks Superior Runners?" is a very well-written argument that it is economic and social circumstances that result in more black people being motivated to take up sport and excel in it. The false belief that black people have sporting talent, but are intellectually inferior, is part of a wider culture of discrimination, where for example people with 'black'-sounding names are less likely to be invited to a job interview.

What's bad about this book?

Syed commits the same mistake as Gladwell (which is nicely refuted by Ericsson here) that "(w)hat is required is ten thousand hours of purposeful practice" (p.85) or that it takes 10,000 hours to "achieve excellence" (p.15) 

Syed changes Ericsson's "deliberate practice" to "purposeful practice". Although he does explain his reasoning, this change does not improve our understanding of what the term stands for and is an unnecessary variation.

Syed states that "some jobs demand deep application... nurses are constantly challenged to operate at the upper limits off their powers: if they don't people die."(p.72) Unfortunately this is not the case. Most nurses (and most healthcare workers) do not work at the upper limits of their powers and patients do die. Healthcare currently neither rewards nor encourages excellence. Healthcare rewards, if not mediocrity, then not being noticed for the wrong reasons.

Although applicable to sports, Syed's writing on the dispelling of doubt, does not translate well into healthcare. "Positive thinking" must not turn into the cognitive trap of "false positivism" and a degree of doubt is necessary for safe care.

Part III: Deep reflections consists of 3 chapters which seem to have been added, slightly ad hoc, to the end of the book (perhaps it wasn't long enough?) Syed's argument in Chapter 9 that a policy of "regulated permissiveness" would be better than the current doping ban does not hold water. It is more likely that everybody (who can afford it) will then be on the permitted drugs and the cat-and-mouse game between the dopers and the doping agencies would continue with the illegal drugs. With respect to the Haemoglobin-boosting drug EPO, Syed states: "It is only when [the haematocrit] is elevated above 55 per cent that the risks begin to escalate..." (p.226). When it is more likely that there is no safe limit for the haematocrit. In the same vein Syed states: "Moderate steroid use improves strength and aids recovery without significant damaging side effects" This begs the question: "Why are we not all taking a moderate amount of steroids?"

Final thoughts

Syed argues that standards are spiralling upward in a number of fields because "people are practising longer, harder (due to professionalism), and smarter." He also talks about coasting (driving car) and unfortunately this is where many of us end up. Once the exams are finished we neither push ourselves nor are we pushed.

If we "institutionalised the principles of purposeful practice" (p.84) as Syed encourages us to do, our training would be more effective, healthcare workers more qualified and patients safer.

Thursday, 8 September 2016

Harnessing the Power of Mistakes (by Vicky Tallentire)

Mistakes are an inevitable aspect of any system that involves decision-making; healthcare is no exception.  For better or for worse, the mistakes that we make over the course of our careers define, to some extent, who and what we become.  In the early days they often influence career decisions.  Subsequently, they shape our approach to work, subtly impacting on our communications with patients, our investigative decisions and our willingness to discharge people home.  For many nearing retirement, the timeline of a career is a haze of professional satisfaction, punctuated by incidents of avoidable harm recalled with the clarity of yesterday.  

Henry Marsh (1) describes the impact of mistakes on his professional demeanour: “At the end of a successful day’s operating, when I was younger, I felt an intense exhilaration. As I walked round the wards after an operating list… I felt like a conquering general after a great battle. There have been too many disasters and unexpected tragedies over the years, and I have made too many mistakes for me to experience such feelings now…”(p.33)  Dealing with one’s own failures is, I think, the most challenging aspect of a career in healthcare.  How does one balance the inevitable sorrow and guilt with the need to hold one’s head high and continue to make high-stakes decisions?

Medical school lays the foundations for a career in medicine.  The thirst for knowledge is unparalleled.  As Atul Gawande (2) says, “We paid our medical tuition to learn about the inner process of the body, the intricate mechanisms of its pathologies, and the vast trove of discoveries and technologies that have accumulated to stop them. We didn’t imagine we needed to think about much else.”(p.3)  And yet we do.  At medical school I was introduced to the abstract concepts of error, unintended harm and, God forbid, mistakes.  But I didn’t understand them concretely, like I do now.  That I will make mistakes, I will cause harm, inflict distress and compound misery.  That one day I would be crouched on the floor beside a patient, with the hateful glare of a relative fixed on the back of my head, uttering “I’m sorry”.

Don’t we, as a profession, have a duty to better prepare our future doctors to deal with their own failings?  Shouldn’t we augment the vast knowledge of pathophysiology with self-awareness, emotional resilience and the language of professional but meaningful apology?  The challenges are great, but so too are the rewards. 

Immersive simulation is a tool that facilitates rehearsal of high-stakes decision-making in emotionally charged situations. Mistakes are more than likely in such contexts.  The debrief allows participants to reflect on their actions, off-load emotionally and discuss the possible consequences of alternative choices.  That journey of self-discovery and emotional development is, in my mind, what underpins the power of immersive simulation.  The challenge now is how that journey can be continued, and supported, in the workplace.

References
  1. Henry Marsh. Do No Harm: Stories of Life, Death and Brain Surgery. Published by Weidenfeld & Nicolson, 2014.
  2. Atul Gawande. Being Mortal: Illness, Medicine and What Matters in the End. Published by Profile Books Ltd, 2014
About the author:
Vicky Tallentire is a consultant in acute medicine at the Western General Hospital in Edinburgh.  She has an interest in the training of physicians, and has held a number of roles in the Royal College of Physicians in Edinburgh.  Vicky has a particular interest in simulation based research and completed a doctorate at the University of Edinburgh in 2013 using simulation as a tool to explore decision-making and error.  She is keen to develop the research profile of the centre and would like to hear from anyone, from any professional background and at any level, who is interested in undertaking research projects in the field of simulation.