Year 4 MBBS Interprofessional Education Guide

Aims

During Year 4, our purpose is for you to learn how Human Factors (see Appendix 1: Human Factors) affect interprofessional practice, with a particular focus on patient safety.   This will assist you to meet the GMC Tomorrow’s Doctors (2009) outcomes relating to learning and working effectively within a multi-professional team. 

We are specifically interested in you demonstrating the following:

Tomorrow’s Doctors Section 22

(a) Understand and respect the roles and expertise of health and social care professionals in the context of working and learning as a multi-professional team.

(b) Understand the contribution that effective interdisciplinary team working makes to the delivery of safe and high-quality care.

Tomorrow’s Doctors Section 23

(d) Promote, monitor and maintain health and safety in the clinical setting, understanding how errors can happen in practice, applying the principles of quality assurance, clinical governance and risk management to medical practice, and understanding responsibilities within the current systems for raising concerns about safety and quality.

To remind you of your roles from the new document: Outcomes for graduates (Tomorrow’s Doctors) July 2015

22 Learn and work effectively within a multi-professional team.

a. Understand and respect the roles and expertise of health and social care professionals in the context of working and learning as a multi-professional team.

b. Understand the contribution that effective interdisciplinary teamworking makes to the delivery of safe and high-quality care.

c. Work with colleagues in ways that best serve the interests of patients, passing on information and handing over care, demonstrating flexibility, adaptability and a problem-solving approach.

d. Demonstrate ability to build team capacity and positive working relationships and undertake various team roles including leadership and the ability to accept leadership by others.

Course Format

a)      Teaching & Learning Elements

Introductory lecture:  Interprofessional working, Human Factors and Patient Safety (during CSP week).

Video: ‘Just a Routine Operation’ http://patientsafety.health.org.uk/resources/just-routine-operation-human-factors-patient-safety

b)      Requirements and Assessment

During your clinical placements we want you to consider and write about the interprofessional elements involved in day-to-day practice, as they relate to team-working and human factors.

You are required to write two case reports with an Interprofessional Human Factors focus (both reports are due during your summer term placements).  You will need to get your supervisor to sign a paper copy, which you must keep safely.  We will be checking these randomly to ensure that supervisor signatures have been obtained.  The cases or situations you refer to may be based on any of your placement case studies during the fourth year.  The reports should focus on the Human Factors elements of collaboration between two or more different professions involved in patient care.   You should not write about collaborations that only involve members of the medical profession.

Format of the Report

In writing your case study we want you to consider an event or example of interprofessional collaboration that you have seen or been involved with during your placement.  We offer the format below (some elements of which are taken from a process outlined by Gibbs 1988) as a way of setting out your work.

Each report to be between 600 – 800 words.

Step 1: Describe in detail the event or example of interprofessional collaboration

Describe in detail the event you are considering.   For example: Where were you; who else was there; why were you there; what were you doing; what were other people doing; what was the context of the event; what happened; what was your part in this; what parts did the other people play and, what was the result?

Step 2: Focus on analysis and evaluation

Try to evaluate or make a judgment about the interprofessional collaboration from the perspective of the ‘SHEEP’ framework (see appendix 1): Systems, Human Interaction, Environment, Equipment, Personal.  For example, you might consider what were the advantages, positive or helpful aspects, and what were the limitations, negative, or hindering aspects?  How did these factors impact on patient safety?

Focus on going deeper into key aspects from your evaluation.  Ask yourself more detailed questions about the answers to the last stage, for example: why did things go well; what did you do well; what did others do well; what could be improved; what did not turn out how it should have done; in what way did you or others contribute to this; were any other professions who could have contributed missing?

Step 3: Conclusions

This differs from the evaluation and analysis stage in that now you have explored the issue from different angles and have a lot of information to base your decisions. It is here that you are likely to develop insight into your own and other people’s behaviour in terms of how it may have contributed to effectiveness of the collaboration and the patient safety outcome.

See appendix 2 for examples of types of interprofessional collaboration that you might consider in your reports.

Bibliography

Adair, John Eric. 1973. Action-centred leadership. New York, NY: McGraw-Hill.

General Medical Council. 2009.Tomorrow's doctors. GMC Education Committee. (Sections 22, 23.)

Gibbs G. (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford Further Education Unit, Oxford,

Rosenorn-Lanng, D. (2014). Human Factors in Healthcare: Level One. Oxford University Press.

Resource Websites:

http://www.hse.gov.uk/humanfactors/introduction.htm (accessed June 2014)

Clinical Human Factors Group (CHFG): http://chfg.org/

Designing Out Medical Error (DOME): http://www.domeproject.org.uk/

The Health Foundation: http://www.health.org.uk/

Institute for Ergonomics and Human Factors: http://iehf.org/

Patient Safety First: http://www.patientsafetyfirst.nhs.uk/

Appendix 1: Human Factors

Human factors have a major impact on any professional and interprofessional activity. A definition of human factors from the UK Health and Safety Executive: “Human factors refer to environmental, organisational and job factors and human and individual characteristics which influence behaviour at work in a way that can affect health and safety.” “In other words, human factors is concerned with:

• what people are being asked to do (the task and its characteristics),
• who is doing it (the individual and their competence) and
• where they are working (the organisation and its attributes),

All of these are influenced by the wider societal concern, both local and national.”

http://www.hse.gov.uk/humanfactors/introduction.htm accessed June 2014

These three domains are illustrated by John Adair as: Task, Team and Individual – in a figure that notes the overlap or interactions between each element.

Fig 1. John Adair's "Action-Centred Leadership

Appendix 2: SHEEP Framework

The below is an adaptation of Rosenorn-Lanng  SHEEP Sheet (2014:10/11), offering a brief range of elements for you to use in your analysis of your ‘case’.  Under these main headings we are sure that you will be able to construct many more of your own.

(NB For the full sheet of element see Figure 1.3. in Rosenorn-Lanng  text book pp 10-11)

Appendix 3: Case report examples

The following are three examples of interprofessional collaboration. The first outlines a potential system error and the second a new leadership process. The third is a case study submitted by an IPE student. From the first two examples you can see the broadness of the scope of interprofessional working that you might consider, and that we want you to recognise both positive and negative aspects.  The third example illustrates the depth and breath of considerations and personal reflections you might like to explore.

1. Intensive Care Patient

A middle aged gentleman had been in intensive care for three days, having been brought in by the emergency services with a suspected major stroke. The medical team is at the end of the bed talking to his wife about further treatment - which they believe was futile and are suggesting that life support is withdrawn. A new doctor in the team asks the group: ‘has anyone checked if he is in there?” and then goes up to the patient and says: “If you can hear me Mr Jones please blink”. The patient blinks. He has locked-in syndrome and has been fully conscious throughout the past three days*.

A communication assessment by a speech & language therapist, if carried out, could have alerted the team early on to the patient’s ability to communicate.

*Story recounted by the patient. BBC World Service 2 July 2014

2. Patient Safety First: The leadership intervention – Newham University Hospital.

Project aim. Patient Safety First was a voluntary campaign led by NHS clinicians and managers with the aim of encouraging trusts to effect measurable changes in practice and culture.  This leadership intervention was designed to encourage boards to put patient safety as their highest priority, to lead by example and to effect change for the better.

Why this project? The culture of an organisation can have a significant impact on patient safety and the quality of care received.

Approach. Leadership walkarounds consisted of the chief executive, the chief operating officer or the chief nurse touring the wards with the associate director of nursing, patient safety programme manager, the matron and key members of the medical team. The walkarounds were as multidisciplinary as possible, with all members of staff invited to comment, whether they were therapists, physiotherapists, porters or part of the housekeeping staff. This allows representatives from all staff to have face-to-face contact with the executive team and suggest areas for improvement.

Outcome. Awareness of patient safety was in each clinical area - and staff were empowered by seeing changes made for the better following their suggestions.

( Human Factors in Healthcare A Concordat from the National Quality Board. http://www.england.nhs.uk/ourwork/part-rel/nqb  accessed July 2014).

3. Example IPE Write Up from 4th Yr MBBS 2014/15: 

The Event

I was on an Ophthalmology attachment. I had been sitting in with a Consultant all morning on a Medical Retina Clinic. To expand my knowledge, I left the clinic, went across the corridor, to go and observe a Fundus Fluorescein Angiography.

I stepped into the Angiography room, as I mentally prepared to ask the Ophthalmic Photographer permission to observe the procedure – but was confronted by a scene I did not expect. I immediately noticed the seated patient looked dangerously unwell. Her eyes were open and staring up at the ceiling, and her head was lolled back into the chair. She was unconscious and unresponsive. I could sense there was an urgency – which, in all honesty, was bordering on panic – about the Opthalmic Photographer and the nurse. They were both standing over the seated patient, attempting to rouse the patient. The patient was very still, and there was no chest rise – no inspiration. The patient’s husband was also in the room, and I thought he looked extremely distressed.

“Get the crash team!” The Ophthalmic Photographer said to the nurse, and the nurse pushed the big red button on the wall.

If I’m being honest, I was a bit shell-shocked, and froze for a moment not knowing what to do. Although I have limited experience of dealing with a few cardiac arrests whilst on ambulance shifts, this was the first time I had seen it in hospital – and I was unsure of myself. Not only that, I was acutely aware there was no doctor present to tell me what to do.

“She’s having a cardiac arrest!” The Ophthalmic Photographer said to me, as I helped put an oxygen mask on the patient.

In that moment, both the Ophthalmic Photographer and the nurse looked to me, as if they were waiting for me to take the initiative. I realised they both thought I was a doctor, not just a medical student. I felt a heavy weight of responsibility slam down on my shoulders – and I took a few moments to decide what to do. In other words, I hesitated. I informed them I was not actually a doctor, and asked if there was any way I could assist. The Ophthalmic Photographer asked me to go and get an actual doctor.

I hurried across the corridor and burst into the consultant, as he was in the middle of examining a patient. He was intimately close to the patient’s eye, and I was sharply aware that I was disturbing a difficult part of the examination. He looked angry that I was interrupting, which made me hesitate.

“Can you come with me now,” I said forcefully. “There is a patient having a cardiac arrest.”

It felt bizarre to give an order to a consultant, but he jumped out of his seat and came with me. It is the first time in hospital I’ve ever ordered anyone to do anything, and it just so happened I was ordering a consultant eye surgeon to follow me! Because I was anxious and flustered, my tone of voice was a lot harsher than it should have been. Obviously I was justified, but still I was apprehensive of how he would respond to that once the emergency was over.

Analysis and Evaluation

System – The above emergency example shows some interesting facets of culture and hierarchy within a hospital. When the Ophthalmic Photographer and nurse thought a doctor (me) had arrived I felt the responsibility to lead shifted onto me, but the moment they knew I was a medical student I felt as if the onus swung back onto them.

When I went to get the consultant, I felt awkward about interrupting his examination of a patient, and then effectively commanding him to accompany me. It is senseless to think in an emergency situation that I would even hesitate in such a way, and I must acknowledge that the hesitation was due to my own short-comings and lack of confidence – but I think most medical students would be apprehensive about interrupting a consultant mid-examination. It does show how entrenched hierarchy is within hospital culture. I think hierarchy is important and leads to optimal team-working, but this example shows there are moments when hierarchy and protocol need to be over-ridden.

Human Interactions

I feel I was too indecisive, and I should have been more assertive. But this was a useful experience, and will make me more decisive in the future. I am disappointed that I hesitated when communicating with the consultant, because of my own lack of confidence – but I think what I did communicate was effective. Albeit, my tone was a lot sharper and harsher than it should have been. But this, again, I put down to my own inexperience and feeling out of my depth.

Once the event was over, I apologised to the consultant about speaking to him in such a commanding voice, and fearfully awaited a serious dressing down. But thankfully, he jokingly said, “That’s the only time you’ll ever be able to speak to a consultant like that!”

Fortunately the consultant could see the funny side of the incident (the patient was not as unwell as we all first thought). The incident definitely “broke the ice” between us, and he was a lot more enthusiastic and forthcoming with me for the remainder of the day.

Environment – nothing further to add

Equipment – Oxygen mask was effective and functional, crash trolley promptly arrived with crash team

Personal – As mentioned above, this incident taught me a fair amount about my own lack of confidence and assertiveness – but these are things I can improve.

I do think the consultant was initially angry that I’d dared to burst into his examination and interrupt him. But afterwards, I realised he actually respected me for the way I handled the situation.

Conclusions

This event does make me apprehensive about being a doctor, as in less than two years I will have to deal competently with similar situations – and I will not be able to go and find someone else to take responsibility. The onus will be on me to show leadership. I need to grow in terms of assertiveness, confidence and capability before then, but this experience will certainly help that. I feel like the road to becoming a competent doctor is long, but this is another significant step along that great journey.