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Background and the response

The Human Factors programme has been designed in response to the findings from the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013 and the recommendations that were drawn from the Berwick, Francis, Winterbourne and Keogh reports.


In December 2011, Sir Bruce Keogh commissioned an Expert Reference Group to advise the Department of Health on how Human Factors might be embedded in the NHS. An interim report was published as an output of this group and was received by the National Quality Board (NQB) in September 2013. The report was then reviewed by an NQB task and finish group, which worked together to produce the Human Factors in Healthcare Concordat. The NQB Concordat emphasises the importance of applying Human Factors and Ergonomics (HFE) in healthcare to significantly improve the quality of care for patients. In addition, a key recommendation given by Don Berwick in his review of patient safety is that health systems must give NHS staff career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

The focus of Health Education England is to develop HFE practice and principles through education and training, as well as deliver on its Mandate around quality and safety, specifically in developing the right people, with the right skills and the right values.

As a response to NQB Concordat and the Mandate, Health Education England, commissioned the Quality Improvement Clinic to explore the feasibility of a centre of expertise in Human Factors in the East Midlands as an enabler of improved quality and safety for patients, staff and learners, (herein termed as the Human Factors Exchange). For this purpose, an Accelerated Learning Event (ALE) was organised to determine the level of knowledge, expertise and energy that exists within the region to develop this enabler for the translation of Human Factors in healthcare.

There was agreement that connecting expertise across the East Midlands to build capability to address the quality and safety challenges would add real value. The principles of partnership working will underpin success and this will include diverse interests and organisations including academic, healthcare, education and independent expertise to enable service to tackle issues that require a HF solution. The link below contains the report produced as a result of the ALE.

Why apply Human Factors in healthcare?

Awareness of human factors can help you to:

  • understand why healthcare staff make errors, and which ‘systems factors’ threaten patient safety
  • improve the safety culture of teams and organisations
  • enhance teamwork and improve communication between healthcare staff
  • improve the design of healthcare and equipment
  • identify ‘what went wrong’ and predict ‘what could go wrong’.

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