Collaborating for a safety culture in primary care

At the end of May, colleagues from 13 primary care practices from across the West of England, including GPs, practice managers, practice nurses and quality and safety leads, came together for the first meeting of our new Primary Care Collaborative.

The event was opened by our  Patient Safety Programme Director Ann Remmers who spoke about the context for collaboration. Dr Hein Le Roux, GP & Primary Care Lead for Patient Safety for the West of England AHSN, then explained how collaboration was a combination of people and technical skills. He told a cautionary tale of the Choluteca bridge and painted a picture of what better could look like in primary care. He explained how taking a systems approach could tackle some of the challenges through collaboration, and gave an example of a patient in his care where their care could have been better, and shared the learning from that incident.

Stephen Ray, Quality Improvement Programme Manager, expored why things go wrong in a systems context and some of the methods to take a systematic approach to quality improvement to build reliable systems. He explained the clinical microsystems approach, the model for improvement, and case studies from his experience working on improvement with GP practices.

All the presentations from our speakers are available here.

Attendees told us they really valued the time to meet other practices, learn from others and discuss subjects that they don’t normally get time to. There was great feedback about the speakers and group sessions, and the bacon sandwiches first thing were a big hit! They made a list of actions to take away from the day including looking at their existing processes and communications, developing a map of responsibilities, using PDSA and changing their language from “significant event” to “learning event”.

At our next meeting in September, the Collaborative agreed to focus more on sharing learning from particular examples from practices, with in-depth support on a topic chosen by attendees. Suggestions included:

  • Engaging and motivating staff to make changes
  • Putting changes into practice
  • How to engage all staff to make real change
  • Motivating staff and changing culture
  • Bringing on board difficult characters – what impact can individuals have on instigating change?

About the Primary Care Collaborative

The Collaborative has been set up to promote a safety culture in the primary care setting through the use of incident reporting, whilst giving the practices involved tools and training in quality improvement methodology. It will also help practices to undertake their own improvement journeys and network with other practices in the region to share learning and facilitate collaboration.

Benefits for the practices involved in the new Primary Care Collaborative include helping their practice in its next Care Quality Commission inspection and will contribute to the revalidation and appraisal processes for all staff. Staff are receiving quality improvement methodology training and resources throughout. Being a part of the collaborative will also increase awareness amongst practice teams of the patient safety agenda, while promoting an open and honest culture.

Patient safety is high on the public agenda, and practice’s involvement in the scheme will improve assurance that their practice has an open and transparent approach towards patient safety, in addition to improving the overall patient experience. Patient representatives for each practice have also been invited to take part as members of the practice core team.

Future events

  • Swindon| Hilton Swindon, Wednesday, 7 September 2016 from 08:00 to 12:30
  • Gloucestershire | Stonehouse Court Hotel, Wednesday, 30 November 2016 from 08:00 to 12:30
  • Bath | Royal United Hospital, Wednesday, 1 March 2017 from 08:00 to 12:30


For more information on the Primary Care Collaborative, please contact Kevin Hunter at

Building strong foundations to support the most vulnerable in society

The West of England AHSN held a meeting recently, marking the first steps towards building a valuable partnership with the regional voluntary and community sectors.

The aim was to build relationships with organisations that could help us effectively engage with the most vulnerable groups in society, those who are isolated, housebound, the frail and elderly. Organisations that attended were Age UK, LinkAge, the Red Cross and West of England Care and Repair.

Two of our workstreams found the meeting particularly useful in terms of informing and supporting future areas of work.

Our Enterprise team is keen to make sure they are reaching people who might want to get involved in the next phase of our Design Together, Live Better project. This is providing the opportunity for people living with long-term health conditions, carers, family, friends and anyone else interested in healthcare, to suggest or give feedback on product ideas that might improve quality of life and independence. Last year, the first phase of the project developed three product prototypes, based on the experiences of people that attended a series of workshops and crowd-sourcing activities across the region. This next phase is looking to widen and increase our reach, and so voluntary and community organisations, through their membership and users, are extremely well placed to help us do that.

For some time, our Patient Safety Collaborative has been aware that its focus has been on acute care. With an increasing emphasis on healthcare in the community, it is important for us to influence those who have a role to play in safety in the home. Organisations like the Red Cross and Care & Repair often go into people’s homes and provide support to vulnerable people who might be just under the radar of health professionals. The role of staff in these organisations could be vital in improving patient safety and preventing avoidable Emergency Department admissions.

By the end of the meeting, there was great excitement about the potential for working together. A start was been made at the recent ‘Wisdom of the Crowd’ event to launch phase two of Design Together, Live Better, attended by several voluntary and community sector organisations. The Patient Safety team is also planning to offer SBAR (Situation, Background, Assessment, Recommendation ) training to several of the organisations.

Emergency Department Safety Checklist Masterclass

“Checklists are like toothbrushes; everyone wants one, but they don’t want to use anyone else’s!”

On Monday 25 April 2016, the West of England Academic Health Science Network (AHSN) hosted a free masterclass on the Emergency Department (ED) Safety Checklist, piloted at University Hospitals Bristol NHS Foundation Trust (UHB). Delegates were invited from EDs and AHSNs around the country that had expressed an interest in the project.

The masterclass was attended by 22 delegates from 12 different organisations.

Dr Emma Redfern, ED Consultant from UHB, explained why they had developed the ED Safety Checklist: to respond to the challenges of crowding in ED; to be able to quickly assess the sickest patients (by using the National Early Warning Score (NEWS) as an indicator); and to be able to triage according to patient’s needs.

Alex Hastie and Caroline Clark, ED Nurses from UHB, explained how the ED Safety Checklist had been developed. They described the quality improvement methods and the plan-do-study-act (PDSA) cycles employed to test the checklist, and described the benefits they had realised ‘on the shop-floor’:

  • an aide memoire for basic clinical care,
  • NEWScores used to differentiate the sickest patients,
  • a tool for measuring performance in real time
  • a tool to support staff when they are at full capacity
  • a tool to resource plan during periods of crowing
  • a ‘how to’ guide for bank and agency staff unfamiliar with the setting
  • a reduction in free-text writing in notes which has consequently improved patient contact time.

The West of England AHSN presented the implementation toolkit developed to assist adopting Trusts with how they might introduce the principle of the ED Safety Checklist. We also explored the principle of measurement to prove an intervention has an impact, key performance indicators and the ‘Life’ web-based platform to support quality improvement projects.

Dr Phil Cowburn, Acute Care Medical Director at South Western Ambulance Service NHS Foundation Trust (SWASFT) and Consultant in Emergency Medicine at UHB described the challenges of interfacing the ED Safety Checklist with the ambulance trust, particularly where the responsibility of risk sits for patients waiting to off load into ED in the queue.

Feedback from delegates on the day was very positive and the masterclass was well received. Funding, staff capacity and general ‘intervention fatigue’ were seen as challenges. However, the benefits of the ED Safety Checklist, the improvements to patient safety, improved patient triage, improved patient flow through ED, and improved staff resourcing and management were recognised and agreed across the board.

The slide show from the ED Safety Checklist masterclass can be downloaded here.

A full event write up on the ED Safety Checklist masterclass can be found here.

The ED Safety Checklist Toolkit can be downloaded here.

If you’d like any further information on this programme, please contact

How inspiring leadership makes honesty possible

In his latest blog post, GP Hein Le Roux reflects on the differences between strategy and culture when it comes to patient safety.

In patient safety, an academic definition for strategy is a plan that takes you to your long-term safety goal, whilst the culture is more about people; the practice’s personality or ‘the way we do things around here’.  So for me, strategy is about talking the talk, whereas culture is about walking the walk. Clearly strategy and culture are both important, but often there is a gap between the two. Leadership attitudes and behaviours, particularly on honesty, form a crucial bridge in the quest to connect a safety strategy to the generative patient safety culture that we are all trying to build.

Changing mindsets

If our leadership is able to create a supportive environment, then it is so much easier to talk about an error or near miss in an open and just way. Whilst system and process factors are very important, my firm belief for what underpins the culture we are trying to create revolves around the mind-set of people. Medicine traditionally has been very hierarchical, often with power and thus decision-making based on tenure rather than merit. In my experience, this can inhibit openness and learning.

One recognised antidote is a move to a flatter organisational structure where leadership is distributed to the frontline; this is where the real clinical responsibility lies and is to be welcomed. Often this is where the safety and quality challenges occur, but it is also where much of the determination to change things for the better lies.

I feel attitudes are changing and in my view leaders need to continue to foster a culture of honesty particularly by exhibiting more versatile leadership, based less on command and control and more on coaching and visionary leadership styles. These behaviours can empower and liberate the front line to make things much better for patients.

“Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic”

We regularly talk as a practice about our individual significant events which provide powerful learning. Encouragingly, we are also talking more about the systems and processes which underpin our work, with an appreciation of the impact of a decision or behaviour on other parts of the practice. A recent example was where one of my nursing colleagues came to me saying that she had given an incorrect vaccine to a patient and what should she do? She could have kept quiet and no one would probably have been the wiser, but she actively chose to be open and honest. We discussed the incident and she phoned Public Health England, finding out that there was a low risk of harm. She then phoned up the patient to let them know what had happened and to say sorry. They valued her candour. Furthermore, she reported it on the National Reporting and Learning System.

As is often the case, our internal practice significant event analysis revealed more of a system and process error and some ‘human factor’ issues – in this case, a busy clinic. We have all learned from this and the nursing team are developing a vaccine check list to reduce the chances of such errors occurring again. On a personal level I found my colleague’s attitude to be both brave and inspiring. In particular I noticed her feelings of anxiety, which made her honesty in coming forward even more of an act of ‘bottle’. Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic.

Difficult conversations

So why can it be difficult to come forward with an error or near miss? What psychological factors can bring out our defensive feelings? The themes contained in a book that I read recently called ‘Difficult Conversations’ by Stone, Patton and Sheen seems very relevant to this particular blog. Whilst it is dangerous to generalise, an observation I would make about myself and some GP colleagues is that we can cling to a purely positive identity of ourselves, which leaves no place in our self-concept for negative feedback.

If I think of myself as a super-competent person who never makes mistakes, then feedback suggesting that I have made a mistake presents a problem. The only way to keep my identity intact is to deny the feedback – to figure out why it’s not really true, why it doesn’t really matter, or why what I did wasn’t actually a mistake. If we are going to engage in honesty and candour then we are going to come up against information about ourselves that we find unpleasant.

We all make mistakes

The bigger the gap between what we hope is true and what we fear is true, the easier it is for us to lose our balance. One way to get around the overly simplistic all-or-nothing thinking is to be aware that we are all probably more complex than just ‘I am perfect’ or ‘I am worthless’. Just because something is missed or goes awry does not mean that I am a bad person. We all make mistakes and if we can’t admit that to ourselves it becomes harder to learn, improve and move on because we spend all our time and energy defending ourselves.

One reason people are reluctant to admit to a mistake is that they fear being seen as weak or incompetent. Paradoxically, from my experience, it is generally competent people who take the possibility of mistakes in their stride and are seen as confident, secure and ‘big enough’ not to have to be perfect.

Bridging the gap

In summary there is a saying that ‘culture eats strategy for breakfast’. In other words, it is easy to talk the talk on honesty at a superficial level, but walking the walk is psychologically much more complex. Leadership attitudes and behaviours are crucial in order to bridge this gap. What I would say about our practice is that whilst we readily acknowledge that we are not perfect, we actively try to be open and reflective, so we can learn and improve the service we offer. Honesty has obvious benefits for our patients and also to our colleagues both within the practice and across the wider health and social care community.

As everyone already knows it is tough in general practice these days, but the esprit de corps that this honest culture generates is immeasurable.

This post was originally published on the Sign Up To Safety website.

Stephen’s story

In partnership with Sirona Care & Health and North Bristol NHS Trust, our Human Factors programme offers tailored training to support staff working in community health settings. A toolkit has been developed, supported by face-to-face train-the-trainer sessions and collaborative events for shared learning and problem solving.

Stephen Early is a service user and volunteer with Sirona who has been actively involved in the development of this training programme, from designing scenarios to reflect realistic situations that staff might encounter to giving talks at staff inductions.

This is Stephen’s story, introduced by Karen Gleave, Project Lead for Sirona Care & Health.

Stephen is a service user living in one of our Extra Care Services, and currently is a volunteer with Sirona Care & Health and sits on the service user panel/forum.

I met Stephen just over a year ago when I approached members of the panel about working with me to provide a service user’s perspective for the Sirona support worker induction on what it is like to receive a service.

Once Stephen started it became quickly apparent that he was a “natural” talking with people and able to get his message across about how important communication and human factors are when supporting people. Stephen is able to bring the scenarios alive for the audience, has made people laugh and at times brought people to tears.

Stephen is a very inspirational person and has touched the lives of many. The feedback we receive after each induction is really very positive…


It really shows the great value that service users can make to organisations and how they can help to shape future services.

Stephen’s story

Unfortunately I’ve caught pneumonia about six or seven times, and on about four or five occasions I’ve been took into hospital…

… because I was living by myself I’ve had problems with eating for about six years.

… one of the things they do here is try and make me eat and drink so they make me a sandwich now and then, or every time they come in, no matter what they’re going to do they always make me a cup of tea and put it in front of me, and I feel if they’ve made me a cup of tea, then I should drink it, even thought I don’t feel thirsty if that makes sense, and when I go up to Karen’s they the same, everyone does the same. “Tea Steve!” and it’s great.

So one day the doorbell went and the lady came in and she was a support worker. I think she was, I’m not sure now. She came in and said [grunting] “Alright.”

Well, straight away you know that you were not going to have a conversation with this lady about anything and the worst thing is that these sort of five, ten minutes ones which you might get spread out between the day, maybe three times, maybe four, not sure, all depends on what your needs are, are very important to everyone because it’s communication. It’s talking to someone.

And loneliness in these sort of places is quite bad actually because you know it has an effect on them and on their health as well. Because if you’re feeling down, you’re more likely I feel to get things wrong with you and depressed and things like that, so it’s quite important when people come in that they’re a bit… and say things. So when she came in I knew straight away I wasn’t going to have a conversation with her.

Now if I was feeling a bit unwell or anything like that, or had troubles or things, I wouldn’t have talked to her about it because I knew she wasn’t in the right mood to receive any sort of information. And then she came and said, “Got to make you a drink.” Now “got to”, so that hit me home that “got to” is not “Oh, I’m going to make you a…”, “Got to make you a drink. Can’t understand why you can’t do it yourself.” That was a little whisper underneath the voice.

And then the sandwiches… “What do you want in your sandwiches?” I said, “Well anything please” and then again I heard her say, “Can’t understand why you can’t do it yourself” and then she left. And as soon as she left I got up and I chucked the tea down the sink, and I put her sandwiches in the bin because I wasn’t going to eat or drink anything from someone who didn’t’ want to do anything for me and it made me feel really bad.

So that went on for about six or seven weeks. I stopped taking food, and when they did make me food I just tipped in the bin, and the drinks, because I felt like no one wanted to do it and they didn’t understand me. They didn’t’ understand my problems. They just thought I was lazy. So it didn’t matter if they came in happy or joyful, I would still do it. That was quite a bad experience.

And then a good experience was one lady come to see me, well lots of them. And they come in and ring the bell [brightly] “Hi Steve!” Straight away you know you’re going to have a positive talk to that person and positive reaction. And you’re going to say to that person if there is something troubling you, you’re going to mention it to them, you know, “Oh I don’t feel too good today… Oh I’ve got this problem” or whatever.

And the other thing is they come in and say, “What have you been up to today? What’s been going on? What are you going to do this afternoon?” All them little things, you know, it helps the conversation to go through and it is brilliant. “Oh,” she said, “Is it two sugars, Steve, innit? It’s two innit?” Them little things, it’s not like “Oh, I gotta make you a cup of tea” or anything like that. It’s “I’m going to put in two sugars.” Some don’t even talk about it they just do it and bring it out and put on the table which is brilliant so it’s them sort of things…

…unfortunately the people, some of the residents we have here, I call them my family because they are they’re all my family, and I tell them that. Anyway, they’ve got problems some of them and some of them suffer with memory loss, Alzheimer’s, so they’re not able and some of them can’t speak properly and they cannot relay to the support workers what it means, what they mean to us and they mean everything.

I call all of my support workers “my ladies” because that’s what they are. They’re my ladies. And they’re here… if it wasn’t for them I wouldn’t be here, they mean so much. Doesn’t matter if they come in and make me a cup of tea or just the simplest of things like help me taking off my shoes. My legs swell up around about half past two in the afternoon. They come in and take my shoes off and they always make me a cup of tea when they do it, and they have a little chat whilst they do it, and it means so much.

And I’m able when I go on my induction days to translate to them what they actually mean to people like me and the rest of the residents what they’re doing. Their job’s just as much important as a doctor or anyone like that because they’re doing something to help and they’re not only helping in the sense of doing something like giving someone tablets at the right time or doing some domestic or whatever or making sure someone eats. They’re actually talking to that person, which is fantastic, which makes them feel good.

… if I can hit that one person at induction day and she stays doing caring for maybe ten years? So she might see thousands and thousands of people on her journey through her career. If she carries that through, with all of them, what a magnificent difference that’s going to make! So that’s how I think of it.

Stephen was the winner of Sirona Volunteer of the Year 2015 for his work on the project:

Reducing harm from falls

Colleagues from 35 organisations across the South West took part in a workshop last month in Taunton exploring how we can do more to reduce harm from falls, including occupational therapists, physiotherapists, nurses, falls leads, rehabilitation nurses, falls specialists and ward managers.

Following previous work on falls in this region, the two AHSNs (West of England and South West) were asked to support local organisations to collaborate to reduce harm from falls locally. The aims of the workshop were to:

  • Further develop the collaborative approach to prevention and better management of falls
  • Create a forum to share best practice and learn from each other
  • Encourage networking of like-minded colleagues across the West of England and South West Academic Health Science Networks
  • Embrace quality improvement methodology to effect changes and drive improvement
  • Encourage organisations to develop their own plans and ideas on how to reduce harm from falls in their region.

91% of attendees rated the event as either “good” or “excellent”, and comments included:

“Great to hear good practice from other organisations”

“Really interesting and diverse collection of ideas and projects

“Informal approach was lovely”

“Good to have opportunity to plan way forward as a team”

Attendees worked on organisations action plans. As part of the evaluation, attendees were asked what they would do as a result of today – with many committing to take actions back within their own organisations:


The event was organised using the Open Space. Read Ann Remmer’s blog here reflecting on this approach.

For more information, download the full event report here and do take a look at this excellent video telling the story of Mrs Andrews – a resource that was recommended during the event:

Just say sepsis!

We had an excellent turnout for our third sepsis masterclass held in Taunton in early February, bringing together health professionals from across the region and with a particular focus on paediatric and maternity sepsis, as well as antibiotic stewardship.

A total of 66 attendees were at the event, representing 32 different organisations, exploring how we as healthcare professionals can fight the fight against sepsis.

The event opened with an extremely moving talk by Susanna Morrish who shared Sam’s Story, a heartbreaking account of her little boy who died from sepsis.

Other speakers included Dr Ron Daniels who talked about the work of the UK Sepsis Trust in awareness raising, Dr Mark Juniper from the West of England Patient Safety Collaborative on the NCEPOD 2015 sepsis report, and Dr Akash Deep from King’s College Hospital London on the challenges the recognition and management of paediatric sepsis. Marian Knight from the National Perinatal Epidemiology Unit and Dr Imogen Montague from Derriford Hospital Plymouth both explored maternal sepsis, while Dr Kordo Saeed considered Procalcitonin (PCT) and its application in sepsis, SIRS and localised infections.

The slides from the event can be viewed here and you can download the full event report here.

To find out more about our work to tackle sepsis in the West of England, please contact:

Ann Remmers
Patient Safety Programme Director


Nathalie Delaney
Improvement Lead


Recent highlights of our work together

The West of England AHSN continues to be recognised for successfully bringing together healthcare, industry and academic partners across the region – but what are we are actually achieving together? Here are a few highlights from the last quarter, October to December 2015…

Patient safety

  • 10,000 people have benefitted from the emergency department safety checklist so far this last year, which has been piloted by University Hospitals Bristol NHS Foundation Trust. We are now supporting four other EDs to implement the checklist: Weston Area Health NHS Trust, North Bristol NHS Trust, Gloucestershire Hospitals NHS Foundation Trust, and Great Western Hospitals NHS Foundation Trust.
  • The two Bristol Trusts have successfully converted from the Bristol Early Warning Score to the National Early Warning Score (NEWS).
  • A great example of collaborative working: 80 delegates from across the South of England attended our Mental Health Collaborative learning event in December.
  • The Emergency Laparotomy Collaborative is live including all six acute trusts. This work will benefit 1,000 patients a year in the West of England.
  • To date, 435 staff from community organisations have already received Human Factors training. We are now providing funding to Bath & North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership to enable a further 2,500 staff in community settings to receive training.


  • Connecting Care has been used to review patient records on 110,000 occasions. Gloucestershire CCG has a final business case which will deliver interoperability in 2016/17. Wiltshire and BaNES are enhancing local systems to connect data for patient benefit across care settings.
  • Patients in the West of England are set to benefit from a new NHS Genomic Medicine Centre based in Bristol, which gained approval in December.

Quality improvement

  • 80 GP practices in Gloucestershire are working with us on our Atrial Fibrillation programme. The first 11 practices found 533 high risk patients who may need clinical review.
  • We have trained 46 GPs, 15 nurse practitioners and health care assistants, and 12 pharmacists as part of Don’t Wait to Anticoagulate, with a further pharmacist training session planned.


  • The OpenPrescribing platform been used on 25,000 occasions, with 94,000 page views, and shares on Twitter have reached a potential audience of 46 million people. The concept has now spread to Wales and Scotland.

Join Dementia Research

  • At Christmas the West of England had achieved number one slot for the highest number of local registrations to the Join Dementia Research service in the country.

Diabetes Digital Coach

  • The Diabetes Digital Coach programme, developed by a consortium led by the West of England AHSN, has been selected as an ‘internet of things’ Test Bed to help people with diabetes in the region self-manage their condition.

Supporting innovation

  • We have supported Folium Optics who have been awarded £1 million funding from SBRI Healthcare competition to further developed their ‘smart tag’ which reminds people to take their medication.

Everything we do and achieve is in collaboration with an extensive range of individuals and organisations across the West of England and beyond. Thank you to all our members, partners, public contributors and staff!

Be sepsis savvy

Every year in the UK there are 150,000 cases of sepsis, resulting in a staggering 44,000 deaths – more than bowel, breast and colon cancer combined. Sepsis is the biggest direct cause of death in UK pregnancies and affects about 10,000 children every year in the UK.

A recent report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) emphasised the need for early recognition to saves lives.

Attendees from across the South West and West of England are gathering today at the third sepsis masterclass in Taunton with a particular focus on improving care for children and mothers with sepsis. You can follow along discussions throughout the day on Twitter using the hashtag #sepsissavvy.

The BBC programme Trust Me I’m A Doctor recently covered sepsis with some powerful stories from survivors about the impact sepsis had on their life. Here’s a clip…

NHS England has published a cross-system action plan ‘Improving outcomes for patients with sepsis’, outlining a number of actions that will be taken across the health and care landscape. This report recognised the role of Patient Safety Collaborative, part of the Academic Health Science Networks, to support local organisations to identify and spread best practice. Today’s masterclass forms part of this work.

Dr Mark Juniper, a consultant in respiratory and intensive care medicine, and Lead Clinical Co-ordinator of NCEPOD will be a speaker at today’s masterclass. Commenting on NHS England action plan, he said: “This is a really important report. If we all take action, fewer people will die from sepsis. All healthcare professionals need to be prepared to treat these patients. Improved recognition, assessment and treatment of sepsis will save lives. Reading this report and acting on its recommendations will help all of us to do this.”

Human Factors training for 3,000 community health and social care staff across the West of England

The West of England AHSN is awarding £65,000 in funding to four community organisations to support the roll-out of Human Factors training for support staff.

Communication and team working are recognised to have significant impact on the quality of safe services for patients. Following the Cavendish Review, the Care Certificate specified standards for support workers (Bands 1 – 4) working in all NHS and social care settings.

Although an appreciation of the principles of Human Factors has been implemented in acute care services in recent years, it has been found that training packages and resources are less applicable to the community health and social care context.

Health Education South West has therefore funded the West of England AHSN to develop an intervention using the SBAR tool (situation, background, assessment, recommendation) to support Human Factors training in patient safety focussing on support works in community settings.

The curriculum for this training was developed by Sirona Care & Health and North Bristol NHS Trust. It is based on how teams communicate and uses communication tools such as SBAR to develop a baseline awareness, which is built upon and embedded during the training using different scenarios. These scenarios were co-designed by the programme lead and service user representative to reflect realistic scenarios that staff might encounter.

To date, 435 staff from community organisations have already received Human Factors training. The West of England AHSN is now providing £65,000 funding to Bath & North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership, which will enable a further 2,500 staff in community settings to receive training.

Train the Trainer

In conjunction with  North Bristol NHS Trust and Sirona Care & Health, we are also training up to 45 facilitators across the region in order to create a faculty with specialist knowledge and experience in Human Factors training for community services.

Organisations that have been successful in their bid for West of England AHSN support are invited to book training dates for facilitators to build the faculty in their organisation skilled in delivering Human Factors training. In order to book you will need a code for access. If you have not received your code, please email


For more information about the Human Factors programme, which is one of our Patient Safety Collaborative’s priority areas, contact Nathalie Delaney at