Tuesday, 25 February 2014

Books of the month: Why Hospitals Should Fly & Charting the Course by John J Nance (Dr Ronnie Glavin, Hon Ed Co)

What went wrong with the quality and safety agenda?

This is the title of an essay by Michael Buist and Sarah Middleton published in the BMJ in October 2013 (1).  Why after the wake-up call of “To Err is Human” (2) have we made so little progress?  What we need, these authors conclude, is a culture change.  We know what our existing healthcare culture is like but what should the new culture look like and how could we get there?  Answers are provided by two works of fiction from John J. Nance: “Why Hospitals Should Fly” and “Charting the Course”.  So it seems a good time to review these two books and address how they might impact on those of us who are involved in the development and delivery of simulation-based courses in healthcare.

Who are these books for?

With any book review there are two questions – who should read this?  What might you gain from it?  Well, anyone involved in the quality and safety agenda will benefit from reading these books.  The author has a credible background – pilot involved in the early days of CRM training, involvement with the patient safety movement, published author of fiction and married to an ex-nurse with expertise in business studies.  What this means is that these books are readable, populated with recognisable characters from healthcare world, and have something to say that is made explicit and reinforced without being too much like a lecture or sermon.  It may not rival Moby Dick as a work of literature but it is not intended to.  What might you gain?  In addition to the vision Nance provides access to a lot of relevant evidence and lays out some of the key steps that need to be taken.  What he is good at doing is providing some very useful, practical tips that individuals can adopt without losing sense of the larger picture. 

The plot (no spoiler alert required):

Will Jenkins, a former physician and CEO of a hospital in Oregon is visiting St. Michaels Hospital on the outskirts of Denver Colorado to observe a success story.  Over the course of few days Will takes his own personal journey and discovers why he has not been able to implement the quality and healthcare agenda in his former institution.  At the end of the first book Will is asked by the CEO to consider applying for the post of CEO in a hospital in Las Vegas.  The second book describes the early part of Will’s arrival and attempts to apply the lessons he learned from St Michaels.  Will is married to a former nurse and head of a business school, who helps him apply sound business theory to help him manage change effectively.  At the end of the second book Nance provides notes and questions similar to those found for book groups.

What is good about these books?

The main strength is the clarity of vision that Nance conveys.  Through Will’s experiences Nance provides details of how healthcare staff members deal with their day to day challenges within an overall framework that supports their activities.  The use of particular examples brings it to life.  One example is a description of how the intensive care staff looking after neurosurgical patients with dural leaks have modified the ventilator acquired pneumonia bundle to deal with this specific problem.  This illustrates the point that staff members have to work with these initiatives and make them work.  The CEO of St Michaels uses a comparison between James T. Kirk and Jean-Luc Picard to illustrate different leadership styles and you don’t have to be a trekkie to get the point that a didactic ‘do as I tell you’ approach works less well than ‘I would appreciate your input into this before I make a final decision’ collaborative approach.  In the second book I liked the two converging stories – Will’s experiences at board and senior management level and the experiences of staff on the front line of Las Vegas Memorial.  This illustrated the culture that Will was trying to change.  So how did change come about?  Nance pulls no punches; there is no quick fix but he makes his points through Will via the discussions between Will and his Wife.  The application of Maslow’s hierarchy pyramid in not conventional fiction pillow-talk (unless Maslow’s pyramid means something different from what I understand) but it allows Nance and his wife to introduce good practical applications from business management and psychology.  So what are the key points?
1.  Have a clear sense of purpose that you can articulate – missions and values that mean something to whole workforce.
2.  Invest in strong leadership – the leaders at all different levels are there to facilitate conditions that allow the front line staff to get on with their jobs, which includes reflecting on their performance and making changes to the system as appropriate to improve the system.  Strong leadership is about setting standards, making them explicit and not tolerating performance below those standards.

3.  Staff can only perform in this way if they are prepared for their new roles.  This requires a significant investment in time and training resources.

4.  Unnecessary variation is not tolerated – this does not mean applying rigid protocols to the treatment of patients but means consistent use of checklists, sepsis bundles etc.

5.  Strong sanctions have to be applied when appropriate – if staff who do not comply with the new way fail to respond to further training then they have to go.  This applies irrespective of their rank or position. 

6.  This is always work in progress because the aim is to continually improve and adapt to new challenges.  A successful culture change is defined in terms of no-one being able to remember what it used to be like. 

7.  Increase the involvement of patients in forcing the pace of change.

I was impressed by the high standards set and expected.  This is articulated as no unnecessary patient deaths or harmful events.  This contrasts with the present culture and was nicely illustrated in Buist and Middleton’s essay when Buist describes his CEOs response to a series of disasters in the ITU as “we don’t appear to be worse than the other hospitals in our area”.  In terms of the simulation-based education does he mention us?  Does he say nice things about us?  Yes, of course he does but places more emphasis on in-situ work for career grade staff.

What could be improved?

So what could be changed?   Nance deals with the culture in the US and that has its own hurdles to overcome.  Nevertheless, I found it an interesting exercise to think about where the challenges arise in the devolved healthcare systems of the UK.  Nance highlights the need to reassure Chief Financial Officers that those initial heavy investments will pay off by reducing the fiscal costs of patient harm, reduce turnover in staff, fewer sick days with a more contented workforce and so on.  These are relevant in the UK but involve political will because most of healthcare is government funded.  Can politicians be persuaded to take a longer term view?   If I were still active in clinical practice I would be recommending these books to the patient representatives and encouraging them to share the vision. 

Final thoughts...

I took early retirement for many reasons but I recognised that sense of demoralisation that Nance captured in the front line work force.  Would I have retired early if my hospital had been a St Michaels’ type of hospital – I suspect not. 


1) Buist M, Middleton S.  What went wrong with the quality and safety agenda? British Medical Journal 2013: 347; October 5th, 20-21
2) Kohn L T, Corrigan J M, Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000

Thursday, 20 February 2014

Life as a simulation fellow… so far! (Dr Pam Milligan)

My journey into the world of simulation began 6 months ago, at the beginning of August 2013, when I bravely stepped ‘out-of-programme’ from my day job as an Anaesthetic trainee in the West of Scotland. With a developing interest in education, and an awareness of the increasing use of simulation as a training modality, I thought this would be an exciting, useful, and most importantly fun fellowship to undertake for a year…And so far I have been right!

The first six months

In the beginning there were a lot of ‘first day at school’ moments for me. This included a crash course in technology… The limited amount of simulation I had done before during my ALS instructing had not really prepared me for mannequins who can talk, bleed, be anaesthetised and even have caesarean sections!

But being immersed with the technology, and surrounded by expert technicians and supportive educational co-ordinators at the centre, made the steep learning curve possible to climb.  I eventually felt competent to turn on the plugs, connect up the wires, and keep my fingers crossed that all the bits of equipment talked to each other. And if not, to turn them off and turn them on again…So far so good!

However, then I was introduced to the world of mobile simulation…. The centre director announced that we were packing up SimMan and Smots (our audio-visual recording systems), and going on a SimFamily day out to the SECC in Glasgow, to provide some mobile simulation for the Society of Acute Medicine Conference.   One large van and one very tiny elevator later we were, to my amazement, on the second floor of the SECC running immersive simulated scenarios, 30 miles from our home in Larbert.

SimLady showing signs of sepsis at the Sepsis Study Day, FVRH, Oct 2013
This proved to be very valuable training, as I was previously unaware that our SimMan (or SimLady,  depending on occasion) actually has a very active social life out-with the confines of the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF) (S)he regularly visits the staff in theatre recovery, the staff in ICU, and most recently made a cameo appearance at our Education Centre, helping provide training at the very successful national Sepsis Study Day for more than 100 delegates.

Non-technical skills and human factors

However, in addition to learning the technical side of simulation training, one of the most beneficial aspects of my fellowship so far, has been learning how simulation can be used to provide ‘non-technical’ skills training, in all branches of clinical practice. As the SCSCHF is a centre of expertise not only for high-fidelity simulation, but also for Human Factors training, I have been privileged to work alongside faculty who are national experts in Patient Safety, Human Factors and non-technical skills.
I have gained huge insight into how this type of simulation training can be used to help groups of individuals work together better as teams, within their own specialist area and inter-professionally.  From the knowledge I have gained regarding the influence of human factors in healthcare, I now also understand why this type of training is so important in developing the patient-centred, safety culture which we are striving for.

The final six months

My final thoughts are on what the next 6 months of my fellowship hold in store. As an anaesthetic trainee with an interest in non-technical skills, my main project for the year has been to set up a new Anaesthetists’ Non-Technical Skills (ANTS) course, which will be run at the SCSCHF and also at the Royal College of Anaesthetists in London as part of the Anaesthetists as Educators programme. With much help and guidance from the faculty at the SCSCHF, which includes some of the experts who developed the ANTS framework in 2003, I am very excited that the first pilot of this course will run at the SCSC in March 2014.
And last, but most certainly not least, I am looking forward to visiting Rwanda in July 2014. Over the last few years, the SCSCHF has formed close links with the University of Rwanda, Kigali, who have developed a programme of simulation training in partnership with visiting colleagues from Canada (CASIEF).  During my 2 week visit, I hope to run some anaesthetists’ non-technical skills training, and provide a faculty development course for the Rwandan clinicians.
In conclusion, the first 6 months of my simulation fellowship have been challenging, interesting and fun in equal measure, and I am grateful to all the fantastic staff at the SCSCHF who have made it so.  I have no doubt the next 6 will be the same…

Wednesday, 12 February 2014

What's in a name? Emphasising the Human Factors work of the SCSC.

Looking back

The Scottish Clinical Simulation Centre (SCSC) was founded in 1998 as a partnership between the four Scottish University Departments of Anaesthesia, the Scottish Council for Postgraduate Medical & Dental Education, and Stirling Royal Infirmary NHS Trust. The stimulus for the project came from the four Professors of Anaesthesia in Scotland at the time, led by Professor Alastair Spence. Dr Ronnie Glavin and Dr Nikki Maran shared the post of Educational Director and they were supported by a full-time technician, Ian Ballard and a fellow consultant anaesthetist, Dr Hamish Finlay. In 1998 the SCSC trained 200 anaesthetists.

In 2010 the SCSC moved from Stirling to Larbert with the construction of a bespoke simulation centre encompassing 2 simulation suites and full in-situ capabilities.

Where are we now?

With support from NHS Education Scotland (NES) and Forth Valley Health Board we now have a director, 2 administrators, 2 technicians, 2 simulation fellows and 8 physician educational co-ordinators and we are about to appoint 2 non-physician educational co-ordinators. We run courses for surgeons (in collaboration with the Cuschieri Centre in Dundee), paramedics, obstetricians, physicians' assistants, nurses, midwives, foundation doctors, emergency medics, paediatricians and more. These courses are uni- or multi-professional as required, inside the simulation centre or in-situ.

Where are we going?

According to Gaba(1) "simulation is a technique… to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner". I would argue that simulation, when done well, looks at human factors: the effects of the equipment, the person,  the team, the environment and the organisation on performance.

When I look back over the blogposts on this site I find much of the subject matter is on human factors. Our latest vision statement is: "Simulation training and an understanding of human factors are applied throughout the healthcare environment to support effective, efficient and safe patient care".

In addition, we are currently involved in human factors training for over 1200 NHS Lothian healthcare staff and we are also about to appoint our first educational co-ordinator with a specific focus on human factors. 

In order to underline our focus on human factors and simulation the SCSC is changing its name. We look forward to welcoming you to the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF) on your next visit.


1) Gaba DM. Qual Saf Health Care 2004;13:i2-i10