Breakfast at Auchrannie’s (Or: How bad systems can make good people perform poorly) (by M Moneypenny)

Recently the family and I were lucky enough to be able to spend a few days at Auchrannie Spa and Resort on the isle of Arran. I would recommend both Arran and the resort to anyone. It has won a slew of awards and, according to trip advisor, is the #2 hotel in Brodick. However, goings-on during breakfast compelled me to write a blogpost…

A small selection of the awards

The problem with vegans

We are vegan which I had informed the hotel of weeks before, during the booking process. I received a lovely email in response which stated: “I have emailed the restaurant manager with regards to your request for vegan sausages.” On arrival at the breakfast buffet we were greeted by a very pleasant maître d’ who made sure we hadn’t just wandered in off the street, found us a table, and told me to talk to the waitering staff about the dietary requirement.

So we availed ourselves of the continental breakfast and then had chat with Sean who was looking after the hot food part of the buffet. Sean told me that they did have vegetarian sausages but that he thought they weren’t vegan. He said that he seemed to remember asking the chefs a while ago and that they had told him this, but that he would enquire.

Sean then went through to the kitchen and had a chat with one of the chefs. After a little while he came back and told us that the sausages were in fact vegan. Great, we said, we’ll have three breakfasts please. Sean said: “Two?” And we said: “No, three, one for each of the adults and one to share between the kids.” It would take a wee while to make he informed us, as they would cook everything fresh.

We sat back down and waited. And waited. And waited a little bit more. Then a friendly waiter called Will caught my eye and asked if we were okay. I told him we were waiting for our vegan breakfasts. Will said he would see what was happening. Unfortunately for him the swinging door into the corridor next to the kitchen has a clear glass window in it. This allowed me to see what happened next. Will walked through the door, looked into the kitchen, waited a little bit without speaking to anybody then turned around and came back to tell us that they were almost ready.

Great. So we waited. And waited. And waited a little bit more. I took the kids over to the play area while my other half went to find Sean. Sean was very apologetic. He went into the kitchen to find out what was happening. He came back and informed us that the breakfasts hadn’t even been started yet. He had only talked to and asked (he said) one of the chefs to make the breakfasts and because he hadn’t written the order down they hadn’t done anything. Sean apologised profusely and said he would be back with our breakfasts. About 5 minutes later there he was with 2 plates which we gave to my better half (it was her birthday after all) and the kids. Sean wandered off. He didn’t come back. A few minutes later we managed to call him over and ask him about my breakfast and he said he thought we’d only wanted two and we said, no, three. Sean then came back a few minutes later with a single sausage on a plate…

The following day things went much smoother, there was no maître d’ but Sean welcomed us, sat us down and brought us three breakfasts.

Good people in a bad system

Other than being a somewhat boring story from my holiday (at least I’m not making you sit through holiday photos) what is the point of this blogpost? One major learning point for me is that even very caring people, who want to do the right thing, can be let down by the system. What improvements could be made?

• There were more than enough waiting staff to allocate them specific tables. This would mean that “our” waiter/waitress would know we had been waiting longer than we should have been. The current system was chaotic with tables cleared ad hoc, sometimes one waiter would get the cleaning spray out, leave it on the table to do something else then another waiter would clean the table.
• If you take on a “problem” (and I’m using that term to describe us) then you own it until you have passed it on to someone else. We were Sean’s problem and he should’ve kept an eye on us.
• Empower your staff. I have no idea why Will didn’t actually speak to anybody in the kitchen, but he did recognise that something was amiss and he could have flagged up with the chefs that a table was awaiting a vegan breakfast.

The final give home message is that the staff at Auchrannie are some of the most pleasant and courteous I have ever met. However, they were let down by the lack of coordination at breakfast. The same can be true of healthcare, excellent staff working in a faulty system can still result in disappointed patients. (Names have been changed to protect the innocent) 

"They did too well"

When observing a new faculty member it is not unusual to see a look of relief on his/her face when the participants in a scenario (finally) make a mistake. The faculty member may believe that if no mistakes are made then the facilitator will have nothing to talk about in the debrief. Below are a few tips on how to deal with the participants who "did too well".

Don't create a special crisis

Some may be tempted to throw a curveball into the scenario. "They're doing great, okay... Your patient has now arrested and he's also aspirated." Try and avoid this. Your scenario should be running to your learning objectives. Creating a special crisis in order to have something to talk about in the debrief, means they're going to be talking about the crisis and not your learning objectives.

It's not you, it's them

The introductory paragraph contains an obvious mistake: "the facilitator will have nothing to talk about in the debrief". The debrief is not an opportunity for the facilitator to talk. The debrief allows the facilitator to facilitate the discussion the group is having. This means that the faculty member should concentrate on how to make sure the learning objectives get discussed, not on whether the participants did or didn't do well.

Good scenarios are not designed to create mistakes

Good scenarios are designed to explore performance based on the learning objectives of your course, some will do well, others less well. All performance can be discussed. The words of Peter Dieckmann and Charlotte Ringsted are worth remembering:

"Learners' errors should not be seen as a personal victory in scenario design and implementation." (p.55 - Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds)))

Be enthusiastic and explore

Although "advocacy and inquiry debriefing" may have its faults (see blogpost here), its appeal to the facilitator to display genuine curiosity is a valid point. When the participants "did too well", why did that happen? What was their communication, leadership, teamwork, etc. like? How can we ensure that the next group of participants will do just as well?

Final thoughts

The desire to see participants make mistakes is a phase in the evolution of the facilitator. Most move beyond it, happy in the knowledge that good performance is a fertile ground for discussion as much as poor performance is.

When the equipment fails...

On 18th July 2015 Martin Bromiley tweeted:

The implication is that one should not pretend that something hasn't failed in a sim session. There are a few points for reflection here.

1) There are considerable differences between aviation and healthcare sim

Airline pilots have much more exposure to simulation than the average healthcare worker, this means that equipment failure in aviation sim can be addressed by rescheduling the session. This is not normally the case in healthcare where a given participant may only be able to take part in a sim session every three years.

Aviation sims are much better funded than healthcare sims. In healthcare the use of out-of-date drugs and second-hand equipment is the norm. Equipment failure is therefore more likely in healthcare.

Healthcare sims also tend to involve the use of a plethora of equipment from different manufacturers and "cobbled-together" pieces of kit such as a simulated blood gas machine or a simulated X-ray machine. These are more likely to fail than bespoke flight simulators.

The bottom line? Aviation sims are less likely to fail and when they do, the ability to reschedule a sim session means that equipment failures can be "explored" to see how the participants cope with an unexpected problem.

2) There are different types of equipment failures

One of the most common types of failure in (mannequin-based) simulation is the mannequin itself. Loss of power or communications with the controlling device can mean the mannequin "dies". Other equipment failures may mean that, for example, one cannot feel a pulse on one arm, or that the pupils don't dilate, or that the simulated blood gas machine stops working. The faculty response to each of these equipment failures will be different and this brings us on to point 3.

3) Response to equipment failure depends on the type of failure, faculty experience, the scenario and your learners

If we take sudden mannequin failure as an example, and three different scenarios:

1. Patient in septic shock, hypoxic, hypotensive and moribund
2. Patient with life-threatening asthma, silent chest and tiring
3. Patient about to undergo elective surgery for laparoscopic cholecystectomy, chatting to anaesthetist

In the first two it would seem reasonable to continue the scenario, with a pulseless, lifeless patient while you try to re-establish connection to the mannequin (or plug him back in). In the third scenario, it would be best to interrupt the scenario, acknowledge a technical issue and fix it.

Of course, this still doesn't cover the "pretend it hasn't failed" situation. Imagine a home-made "X-ray machine" which displays an X-ray at the touch of a button. However, when the confederate radiographer goes to display the X-ray nothing happens. One option would be to get the participants to decide what they would do in such a situation in real life, e.g. get another X-ray machine, continue on clinical judgment, auscultate chest, ultrasound, etc.. Another option would be to "pretend it hasn't failed" with the confederate providing them with a hard-copy of the X-ray. This latter option may be particularly apt if the rest of the scenario depends on the ability of the participants to correctly interpret the X-ray.

Final thoughts

This post should not come across as a carte blanche to make up for poor equipment maintenance or scenario planning. The "pretend it hasn't failed" response should be rare and limited to minor failures which will not throw the participants out of the simulated reality you have created for them (e.g. "I wasn't sure when he stopped breathing that he had really stopped or that you wanted us to pretend that he hadn't.") "Pretend it hasn't failed" is not the correct wording even when that is what you want the participants to do; well-trained faculty and confederates will be able to sculpt the scenario so that the equipment failure is quickly forgotten. "Pretend it hasn't failed" is also not the correct response when you are carrying out in situ systems-testing; the participants should deal with this as they would in real life. Lastly, if it's a course and the scenario learning objectives can still be achieved when the equipment has failed then, by all means, the participants should be allowed to develop their own solution to the problem. As faculty experience (and expertise) increases, one will become better at predicting the likely consequences of a failure and the best response.

Two is a crowd

A team may, very loosely, be defined as two or more people working towards a common goal. The benefits of working in a team are manifold: shared physical and mental workload, balancing of strengths and weaknesses, error trapping, etc. More accurately, the preceding sentence should be modified to say "The benefits of working in a good team are manifold." We have all had experience of dysfunctional teams which were much less than the sum of their parts, and would probably have functioned better if the individuals had worked independently. As Reason and Hobbs state: "Team management errors are one of the most serious threats to safety... problems include":

• team leaders being over-preoccupied with minor technical problems
• failure to delegate tasks and responsibilities
• failure to set priorities
• inadequate monitoring and supervision
• failures in communication
• failure to detect and/or challenge non-compliance with SOPs
• excessively authoritarian leadership styles
• junior members of the crew or team being unwilling to correct the errors of their seniors

Although much depends on effective team members, the above list suggests that good leadership is paramount. Ironically, the education system from primary school on to postgraduate education praises and rewards individual excellence. This means that the A+ students who have become excellent personal achievers are then expected to work in, and lead, teams with very little prior preparation for this role. Although courses, such as Advanced Life Support (ALS), expect candidates to show leadership skills, the team members are often faculty members and have to be spoon-fed instructions. Ostensibly this allows candidates to be assessed on their skills, without variable support from the team, but it creates unrealistic scenarios.

It is perhaps not surprising for the director of a simulation centre to suggest that simulation is part of the solution to team training. However, this is one of the greatest benefits of inter-professional simulation, whether in situ or in the simulation centre. Repeated practice with a focused debrief allows, some might say forces, teams to become more effective. There is still too much expectation within healthcare that competent individuals, when placed in the same room, will work well together. Unfortunately this is not the case. And practicing on an ad hoc basis with real patients is not only unethical but also ineffective; the lack of time for a debrief and the lack of uninvolved observers makes learning from real patients difficult. So, could your team could be practicing working together in a simulation centre (or in situ)? And if your team isn't doing this then how do you justify poor performance in real cases?