“The workshop provided robust tools to help consider and understand why things go wrong. I now look at incidents and investigations in a different way, using a human factors approach.”

Miranda Berry is a Quality Manager in Wakefield CCG, a commissioning organisation. Miranda’s role involves monitoring and assuring patient safety, experience and outcomes across a range of NHS organisations. Her focus is acute care and Miranda works alongside a large NHS Trust and independent service providers. Miranda also contributes to service redesign and transformation projects, e.g. changes to clinical pathways. This is always from the standpoint of patient safety and outcomes.

Miranda is currently involved in:

• Working with Mid Yorkshire Hospitals NHS Trust and the West Yorkshire Serious Incident Team on how they investigate and learn from serious incidents. Miranda is particularly interested in the work of the Health Safety Investigation Branch following maternity incidents.
• Working with Mid Yorkshire Hospitals NHS Trust and Wakefield Local Authority to design and deliver safe, effective and caring maternity services. Miranda’s team are looking at how they deliver the commitments in the NHS Long Term Plan to continuity of carer, choice, safety and perinatal mental health.
• Raising awareness and encouraging the use of continuous improvement methodologies as an intrinsic part of commissioning.

Miranda attended the Silver Human Factors training along with colleagues from Mid Yorkshire Hospitals NHS Trust and the West Yorkshire Serious Incident Team. This enabled a collaborative approach to taking forward Human Factors across Miranda’s partner organisations and meant that members from each organisation were all speaking the same language.

Miranda is spreading learning within the broader Quality Team, promoting the Improvement Academy’s Human Factors Bronze online training package and running a short human factors training session tailored to commissioners. Miranda is engaging with other Quality Managers so that they can adopt a similar approach across the ambulance sector, community services and primary care commissioning.

One of the key learning points for Miranda was the Safety II approach, which views healthcare as inherently risky and encourages staff to factor in ways of working to make it safe. Miranda feels that this is a proactive approach to designing safety mechanisms into healthcare processes – rather than responding after an incident has occurred. The workshop provided Miranda with robust tools to help consider and understand why things go wrong.
Prior to attending the training, Miranda often felt dissatisfied with serious investigations and actions plans that were based on ‘root cause analysis’.

Miranda now looks at incidents and investigations in a different way, using a Human Factors approach.

Going forward, Miranda would like Human Factors and Safety II perspective to be the routine approach to patient safety amongst commissioning colleagues. It would be wonderful if all partner organisations adopted the same perspective. The NHS Long Term Plan commits to a reduction in mortality in maternity services, improved clinical outcomes and reduction in harm. Human Factors will have a large part to play in this.

Miranda will continue to encourage and support local providers to adopt Human Factors and Safety II. She will continue to share learning during patient safety walkabouts and continue to discuss patient safety and learning from this standpoint.

Colleagues across Mid Yorkshire Hospitals NHS Trust, Wakefield CCG and West Yorkshire Serious Incident Team are working collaboratively to promote patient safety. Miranda feels that the Human Factors Training has helped enormously in ensuring that they speak the same language and come from a common standpoint.

Miranda attended the Improvement Academy Silver Human Factors training day, funded through the Yorkshire and Humber AHSN on 24th January 2019.