Conference Highlights

Presentation Highlights

Observing decontamination through a human factors’ lens

The first speaker, Dr Dawn Benson, programme manager Clinical Human Factors Group, outlined the case of a single mum with a disabled child and her search for answers and support. It became apparent to delegates that Dawn was speaking of her own experience, which led Dawn to move into disability studies.

A BMJ paper by Vincent and Taylor-Adams on the investigation and analysis of clinical incidents stated: “While a particular practice or omission may be the immediate cause of an incident, closer analysis usually reveals a series of events and departures from safe practice, each influenced by the working environment and the wider organisational context.” Dawn said: “You have to look at the bigger picture and look at all the that influences that. Ergonomic and human factors are the same thing. They are all part of the system and work system. Humans do not exist in isolation.”

Dawn explained: “The Chartered Institute of Ergonomics and Human Factors works across many sectors. Healthcare does not invest in it very well.”

The first time and motion studies looked at operating theatres. Dawn said: “Humans rescue the situation more times than it goes wrong. We tend to measure when things go wrong not when it goes well.”

When the wife of Martin Bromiley sadly died following an operation, Martin, who as an airline pilot was well versed in human factors training to avoid accidents, asked: “Why don’t people in operating theatres do human factors training?” His experience led Martin to establish the Clinical Human Factors Group. Martin believes that “the politics around safety in healthcare is critical.”

Expanding on this theme, Dawn told delegates: “We need to professionalise safety in healthcare - as you are doing in decontamination. It is a mixture of people and technology. It brings in the socio technical world. For improvements in safety, we need to look at the whole world.

“Systems Engineering Initiative for Patient Safety (SEIPS) is now being rolled out across healthcare,” explained Dawn, who considered James Reason’s work on sequential versus system approved, for which SEIPS 1.0 is a good start. This shows that healthcare is a complex system. Root cause can lead to a linear narrative of events, while other methods can help identify broader factors. Sidney Dekker’s ‘Just Culture’ aims to restore trust and accountability in your organisation. It looks at ‘what went wrong?’ Not ‘who did it?’ Dekker said: “… an accident is an investment the next thing is to get the return on the investment.”

Dawn also mentioned ‘Managing the Unexpected’ a book by Karl Weick and Kathleen Sutcliffe. This says that there should be:

• A preoccupation with failure: about detecting small discrepancies as they develop

• A reluctance to simplify: ‘clarification should not be confused with simplification’

• Sensitivity to operations: ‘what is really happening NOW?’ or ‘sensitivity to operating in an evolving situation’

• Commitment to resilience: ‘It takes a lot of knowledge to run a complex system and even more when the system is surprised’

• Deference to expertise: or ‘how we solve problems, reorganising around problems’ 

Saying we should expect the unexpected, Dawn explained: “Status does not mean expertise.” 

Looked at safer organisations, Dawn highlighted:

• Local rationality: understanding why someone did what they did at that particular time. Considerations include: what information was available to them? Was there something unique to that area, that situation, that moment? Are there work-arounds in common practice that always give the required outcome but are strictly in line with procedure?

Also considered were: efficiency and safety, and performance variability and adaptation. Dawn explained that it’s important we know what normal looks like, pointing out that pressure and cost push safer practice.

Shorrock’s ‘Variations of human work’ considers: work as imagined, work as prescribed, work as disclosed, and work as done - this is critical as it often looks different in reality in real live work.

Considering ‘The Hierarchy of Intervention Effectiveness’, Dawn highlighted these considerations when making recommendations:

• Need to understand relative strengths of recommendations we make

• Work with staff to develop effective recommendations

• Ensure we understand Work as Done

• Context: recommendations may not work the same in every clinical context

• Requires a ‘tapestry’ of approaches

In 2022, Healthcare Safety Investigation Branch published ‘Decontamination of surgical instruments’ which covers many safety recommendations. Summarising these, Dawn posed the question: “Do we focus on the message or the messenger when an issue is raised?” Adding: “It’s easier to shoot the messenger than do something.”

In closing, Dawn said: “The Chartered Institute of Ergonomics and Human Factors would welcome people from decontamination.”

The presentation’s Q&A session included comments on “Hierarchy consent which brings people together using names rather than rank.” Dawn also commented on the Upstanding Theory - which tasks a community to be upstanding.

Why decontamination needs management

‘A selection of horror stories’, was the alternative title Wayne Spencer, authorising engineer - decontamination, proposed for his presentation on ‘Why decontamination needs management’

Showing alarming photographs from bad practice he had witnessed over the years, Wayne said: “Surely, we have to manage our process. Devices are more complex than they used to be

“The Spaulding Classification maybe needs updating but its premises are still relevant.,” said Wayne, taking delegates through the levels of risk - low, intermediate and high, detailing the application of the item and the relevant recommendation

“Risk comes from the unlikeliest places.,” explained Wayne. “Ventilators are number 7 in the top 10 technology risks in 2023.” The findings state: reprocessing instructions provided by ventilator manufacturers are, in some cases, incomplete or confusing; and even guidance from regulatory authorities is not always clear

Wayne pointed out that Scotland introduced guidance for ultrasound procedures some years ago. This followed an analysis of linked national databases which demonstrated a greater risk of infection within 30 days of undergoing semi-invasive ultrasound probe procedures, using microbiological reports and antibiotic prescriptions as proxy measures of infection. England has yet to follow suit.

Research by Kovaleva et al states: “Inadequate decontamination procedures and equipment malfunction were two leading causes of post endoscopic infection and contamination. More than 91% of the infections could be prevented if quality control systems were improved.

”Wayne also looked at issues around bronchoscope and duodenoscope-related outbreaks.

With the device complexity of endoscopes bringing its own issues, Wayne posed the questions: “Are we as diligent on inspecting endoscopes as we are in our packing area? How many of you use magnification? Do you inspect the distal end? What happens when we don’t manage our maintenance?

“Issues with third-party repairs have also been identified,” explained Wayne, adding: “With borescopes look at the internal channel.” Emphasising these points, Wayne said: “The margin for safety is so low.

”A paper by William A Rutala posed the question: “Why is endoscopy so risky”. Wayne gave an example of ineffectual cleaning to demonstrate how low the margin of safety is

Showing a photograph of incorrect storage of wrapped items, Wayne questioned: “High risk? Or, we’ve been doing it a very long time and should know better management.

”TASS (Toxic Anterior Segment Syndrome) is an acute inflammatory response following the introduction of foreign material into the anterior chamber of the eye. It is associated with: contaminated solutions, detergent residues, endotoxins from overgrowth of gram-negative bacilli in ultrasound cleaners, foreign matter, preservatives, degradation of brass on surgical instruments sterilized with gas plasma, and impurities of autoclave steam. “Most cases of TASS appear to result from inadequate instrument cleaning and sterilization,” stated Nick Mamalis MD

Next, Wayne turned the spotlight on Pedicle screws, illustrating the issues by referencing a paper entitled ‘Harbouring contaminants in repeatedly reprocessed pedicle screws.’ It has been against guidance to do this in Scotland since 2006

Asking, “Why manage?” Wayne said. “I don’t fancy prison!” Citing the Consumer Protection Act, Health and Safety at Work Act and the Criminal Offence of Manslaughter, Wayne explained: “You need to protect the consumer. You need to prove you are innocent. You need proof.

”Where are the risks? Wayne highlighted

• Failure to clean, disinfect and sterilize properly

• Failure to irrigate all channels on a lumened device

• Rinsing/sterilizing with poor quality water

• Inappropriate validation - unrepresentative test loads

• Device design

• Inadequate drying and storage

• Damaged wraps/packs and protective coverings

• Events - maintaining clean/disinfection/sterility status is event related!

The ‘user’ is defined as the person designated by management to have operational responsibility of the process. The user is also responsible for

• the operators

• the operation of decontamination equipment under their responsibility (including those responsible for drying cabinets)

• reporting issues of concern

• compliance with guidance contained in the HTMs

The user’s key responsibility is to ensure that procedures for production, quality control and safe working are documented and adhered to.

Answering the question: “So, what do I do?” Wayne explained

• Validate special case: 

- device complexity

- PQ testing for both cleaning and sterilization is needed more and more

- Advice should be sought from your AE(D)

• Ensure each decontamination area has a user identified to take responsibility

• Communication:

- If you don’t have a decontamination group then form one!

- Peer group support is essential

- Multi-disciplinary teams are required to support decontamination

• Training, training and more training

• Never think a device is too low risk or inconsequential to have an impact!

Wayne stressed: “100% of mobile phones have services issues on them.” In a study clinically relevant pathogenic bacteria were found on 28 phones. Don’t keep your mobile phone in your pocket in the department. Leave it outside

Closing on a lighter note, “Perception is also an issue,” said Wayne. “Would it be safe to have a dog in the MRI scanner before your own examination?

”A multicentre study to establish hygiene facts related to dogs and humans concluded: “Our study shows that bearded men harbour significantly higher burden of microbes and more human-pathogenic strains than dogs. As the MRI scanner used for both dogs and humans was routinely cleaned after animal scanning, it was found to have substantially lower bacterial load compared with scanners used exclusively for humans.

The good, the bad and everything in between. Identifying excellence as a JAG inspector

Dr Helen Griffiths’ topic considered ‘The good, the bad and everything in between. Identifying excellence as a JAG inspector’.

Everything has a start point. The inventor of the first rudimentary endoscope device employed a sword swallower, said Helen, who explained: “As the starting point for JAG we look for quality of service, safety, respect of dignity.” The influences on endoscope decontamination in the UK were HIV in 1988, vCJD in 1996 and the Hine Report in 2004.

”JAG (the Joint Advisory Group on GI Endoscopy formed within the Royal College of Physicians) was established in 1994 in response to concerns around colonoscope training

A prospective study in 2004 showed that the caecum was reached in colonoscopy only in 56.9% of patients and only 17% of colonoscopists had had supervised training. The Global Rating Scale, a QI tool for endoscopy services was launched in 2005 for services to self-assess against, alongside a set of standards. This was rolled out nationally in 2005, when it became compulsory for services who wanted to participate in bowel cancer screening in England

Helen said: “Nurse endoscopists set up the first training programme. Now people who visit all work within the service.” Departments are re-assessed every five years

“We do not fine people,” said Helen. “It’s all about improving the service. Patients are now looking for it.

”JAG’s focuses is on quality and safety and looks for

• A patient-centred service/pathway

• A listening responsive service

• Use of national/other standards and guidelines to continually improve

• Strong leadership and effective teamwork

• Culture of safety first

• Facilities and equipment to support the delivery of service

• Competent staff

• Productive and efficient service

• Quality improvement culture

• Excellent training environment to support teams

“We need to know it’s sustainable and will carry on,” said Helen

What is assessed? There are three key questions: Do you, do it? Can you prove it? Is it embodied and resilient? “We say: ‘have you looked for solutions?’ explained Helen. “We will support you.

”So, what do we see now? Helen looked at what was best practice at this time and how things have moved on

The good points

• Good leadership - particularly with centralised services

• Culture shift - pride in work and performance. People are excited to see JAG

• Better access to training and skill acquisition. More courses

• Improving environments. Rebuilds/refurbishments. JAG will support this

• Working smartly within a poor environment

• Excellent processes - such as evacuation plan for chemical spillages

Summarising these points, Helen said: “It’s amazing how far we have come, when you look at the old departments. We have improved hugely. The big change has been centralisation. House it where there are experts, where there is strong leadership.

”JAG is “The stick and the carrot for your exec team to do something about issues,” explained Helen, adding: “If you’ve done something that is good, put it out there, share what you have done to help others.

”The bad (environment)

• Ventilation issues - excessive heat with doors propped open, windows open or use of fans

• Work surfaces - insufficient (use of waste bins as surfaces), not of medical grade wipeable quality, lined with incontinence sheets

• Poor storage of equipment. Clean equipment subject to splash contamination

• Transportation of endoscopes off-site. Observation of three-hour rule or keeping instruments moist

• Less issue with poor flows

The poor (training)

• Training deficiencies - see one, do one, teach one

• Outdated certificates

• Poor understanding of rationale guiding practice. How long does your drying cabinet take to dry your scopes?

• DIY practice

• Attitude issues isolated

“There are still examples of people with 20-years’ experience who repeat that training for 20 years,” said Helen. “DIY practice - there are still some around.

”Helen then looked forward to the impact of clinical practice in the foreseeable future. This included the effects of the pandemic, services struggling to regain control of waits, the ongoing 6% per annum growth in endoscopy demand. “Major, concerted and coordinated national, regional and local efforts are required to restore endoscopy capacity and to prevent an impending cancer healthcare crisis,” said Helen

As Bu Hussain Hayee observed: “The greatest waste is the procedure that didn’t need to be done in the first place.”

Looking at delivering a ‘Net Zero’ NHS, it is now a GI standard to have a ‘Green team’. Pointing out that endoscopy is the third highest generator of waste within healthcare, Helen observed: “There is a lot of work going into single-use and reusable. They have their place but not mainstream.

”In closing, Helen described the iceberg illusion: People see success. What people don’t see is that this is achieved through a combination of persistence, failure, sacrifice, disappointment, discipline, hard work and dedication. JAG finds this in successful teams and departments

“Decontamination has come on amazingly,” said Helen. “Do not underestimate your role. I make people who use a scope go into your department to understand the work that goes into making them safe.

Safe rinse water management

The subject of Wayne Spencer’s topic was ‘Final rinse water quality for flexible endoscopy to minimise the risk of post-endoscopic infection’. Wayne described this as a ‘twist’ from an earlier, similar presentation to include a paper from 2022.

On water quality, HTM 01-06 Part B 2.32 states: ‘The nature and extent of the microbial contamination in the final rinse-water should not present a potential hazard to the patient, either through infection or by leading to an erroneous diagnosis. Appropriate treatment to control or reduce the microbial contamination in in water may be required.

“This sums up all you need to know,” said Wayne. “It’s how you get there that’s important. The endoscope as a diagnostic tool must not be compromised by the rinse water.

”The 2022 paper is the Report from Healthcare Infection Society Working Party: Evidence-based recommendations. Two points are particularly relevant

EB1.2 Ensure engineering controls are in place to control the presence of micro-organisms in the water system which supplies the final rinse water to the endoscope washer-disinfectors

EB1.3 Monitor the microbial quality of the water system which supplies the final rinse water to the endoscope washer-disinfectors

Quoting specific details, Wayne said: “At each stage the water quality should be compatible with: the materials of construction of the EWD, the load items to be processed, the chemical additive used (detergent/disinfectant), and the process requirements of that particular stage. Regular monitoring and checking are vital.

”Wayne considered the various engineering water challenges, including endoscope design, biofilm build-up, insufficient ‘self-disinfect’, rinse water supply design, over/under-sized water treatment plant, and the rinse water sanitisation regime.

“Remember this is an international paper,” said Wayne, when mentioning section EB1.3 Water - Properties. This includes: Hardness, organic contamination, microbial contamination, bacterial endotoxins, temperature, compliance with water by-laws, and pipework and fitting regulations

EB1.3 also considers Water Quality - TVCs. “The European Standard says 48-hours,” explained Wayne. “The UK says four hours. The key is maintaining the scope at the specified temperature. This pushes the Green Agenda as well

“Water will fail!” stressed Wayne. “No matter how good your system is you will get failures.

”From the report’s ‘Expert recommendations’, Wayne highlighted: ER1.5 Use either culture-based or molecular methods to test for the presence of micro-organisms of significance (e.g. Pseudomonas aeruginosa, environmental mycobacteria and Legionella pneumophila)

ER1.6 When molecule-based methods are used to detect the presence of micro-organisms of significance, ensure that conventional methods for weekly TVC and endotoxins are still in place

These led to further recommendation: consider using a flow chart for final rinse water results; collate weekly TVC results to assess trends; take action when unsatisfactory or unacceptable TVC results are received; and actions for management of endoscopes based on TVC results

Wayne stressed the benefits of trend for management of the washer-disinfector and management of the endoscope. Trend highlights the difference between one-off results and trend analysis

What do you do when it fails? Wayne asked the following questions

• Who carried out the testing - was it somebody different?

• Was an aseptic technique used for collecting the sample

• Where was the sample taken?

• How was the sample transported to the laboratory?

• Was there a delay in collection?

• Was the sample out of specification when it arrived at the lab?

• Were isolates identified or was an oxidase test performed?

Tips on buying water treatment plant included: measure the raw water quality, then measure it again before buying anything: give the results to the water treatment supplier and get them to do their own; think about the level of silicates - RO gives a reduction, not an absolute barrier; identify critical spares; thermal or chemical self-disinfect - thermal if you can afford it; the interface with the EWD; sample points to sanitary stainless steel and plenty of them

In conclusion, for good water control, Wayne said: “Have a policy and use it, not ignore it. Trend test results. Integrate with the hospital’s water group - do not sit in isolation

“Water is transient and failures can be a one-off,” stressed Wayne. “When failures are experienced, full documentation must be kept, to show who did what and when. Look at the system as a whole - water supply, RO plant, filters, EWD and behaviour. Most of all, avoid over reaction.”

Turn the SSD around - leading excellence in sterile services

Gordon Allan, decontamination services manager Manchester University NHS Foundation Trust, said: “Staff can be the best aspect and the most challenging.” 

Explaining how he had followed the Leader-Leader Model of David Marquet, an ex-US submarine commander, Gordon paraphrased Marquet’s ‘Turn the ship around’ to ‘Turn the SSD around’ - a true story of implementing the Leader-Leader model in sterile services.

By way of background, Gordon explained: “The decon departments are a bit fragmented, on different floors. Operating 24/7, the DSD (decontamination services department) services the six hospitals in the central Manchester area, processing 30,000 trays and supplementaries each month.” The department recently reopened following an extensive redevelopment programme which began two-years ago

As he was introducing a naval slant, Gordon referred to an old Naval Academy Leadership Book which stated: “Leadership is the art, science or gift by which a person is enabled and privileged to direct the thoughts, plans and actions of others in such a manner as to obtain and command their obedience, their confidence, their respect and their cooperation”. Neither the audience nor Gordon approved of this definition

“Leadership - it just doesn’t happen,” said Gordon. “That leadership style does not work in decontamination.” Gordon then played an entertaining YouTube video in which David Marquet described the Leader-Leader Model.

“The model is all about psychological ownership being passed to the team. The team has control over the work they do as they have the technical competence and the model produces clarity. “However, it still falls on your shoulders,” said Gordon. “It gives people the ability to think about what they do.

”The Leader-Leader structure is fundamentally different from the Leader-Follower structure. At its core is the belief that we can all be leaders and in fact it is best when we are all leaders

• People feel inspired to take responsibility and have the authority to rise to the occasion

• People are technically competent to make the decisions they make

• People know the organisation’s goals and thoughtfully contribute toward achieving them

The Model’s mechanisms for control are

• Find the genetic code for control and rewrite it

• Act your way to new thinking

• Short early conversations make efficient work

• Use “I intend to…” to turn passive followers into active leaders

• Resist the urge to provide solutions

Gordon posed the question: “Is sterile services/decontamination a physical or cognitive role?”

In a cognitive role you have to think about what they do. Sterile services/decontamination is also a physical job. The cognitive part is more important. People need to think about what they are doing and why they are doing it - all of the time and at all of the stages

The Leader-Follower model does not work in decontamination. “I was new to the department,” explained Gordon. “We had to use all the knowledge and skills we had in the department. The people on the shopfloor knew everything, while all of the ruling was done at management level

“I had to find a way to feed information up and the authority down to people when I trust they are competent and have clarity around what the department is meant to do

“There was a gap between ‘shopfloor’ and ‘management’ level,” said Gordon. “We added-in two production managers, who were made supervisors. We flipped it on its head. Which showed how important the technicians and supervisors are within the department. I wanted to give them pride and responsibility over what they do.

”Responsibility was handed back for: absence call backs, return to work meetings, appraisals/performance review, setting up loan kit and new trays, managing repairs, staff technical training. “None of this would have been possible without training,” stressed Gordon, who then outlined the route to developing competence

If all you need to do is what you are told, then you don’t need to understand your craft. However, as your ability to make decisions increases, then you need intimate technical knowledge on which to base those decisions

Competence means that people are technically capable of making the decisions they make. You need more knowledge to face your new delegated responsibilities but also to enable more delegation. You want people to grow in knowledge in their role, so you have to let them find solutions and only specify the intent and, if any, constraints

The extended training module took the department’s team through: introductory session, team building, people skills values and behaviours, resilience and emotional intelligence. Training used Affina Team Journey - a team assessment and development tool for team leaders to use within their teams. It improves performance by giving teams a structured, evidence-based experience they will value and enjoy

Next was clarity. The goal of a leader is to give no orders. Leaders are to provide direction and intent and allow others to figure out what to do and how to get there

Clarity means people at all levels understand the purpose of their organisation. Delegation is not possible if people do not understand the big picture and how their contribution fits in it. If clarity of purpose is misunderstood, then the criteria by which a decision is made will be skewed and suboptimal decisions will be made

On David Marquet’s submarine, excellence was the target. As a consequence, inspection was just an opportunity to get feedback. Echoing this, Gordon said: “We look at audits as an opportunity to get feedback.

”Gordon explained: “The way the departments were structured wasn’t having any benefit for the department. I asked the supervisors to lead their meetings and attend management meetings to feedback, and introduced the ‘Daily Huddle’.” In the ‘Huddle’ the little things that impact teams are talked about every day, such as accomplishments from yesterday, top priorities of today, DSD/tier updates and quick questions

The staff know how they contribute to the delivery of DSD objectives during their appraisal as they are used to inform their personal objectives and development plans

Gordon said: “We’ve tried to get as much information out there as possible to get our name out there, get everyone to know what DSD is and make people proud of what they do.” The overall customer satisfaction rate is showing a marked improvement, with 100% now scored across the board

Photographs illustrated the impressive, spacious and now fully operational new department. Gordon stressed that full credit must go to the team, many off whom worked off-site where they reprocessed the equipment at other locations while the redevelopment was completed. 

“We’re not finished there,” explained Gordon. There are now 39 technicians and responsibilities need to feed down. The training programme continues through Back 2 Basics, Aspire 2 Be, Values and Behaviour, and Apprenticeships and Training Certificate

Change Management

Introducing the final session, Wayne Spencer said: “Following the presentation enabling a change in culture in the workplace by Gordon, here’s a few slides on the way to go.”

Wayne began by considering Change Magnitude versus Breadth. This ranged from high change with high impact to low change with low impact - these can be subtle changes. They cover: evolutionary change, moderate change - but comprehensive; focused radical change, and revolutionary change. “Most of us fit somewhere in the middle,” explained Wayne

“Change is always sold through rose coloured spectacles,” said Wayne. “Change should be led from the top and delivered from the bottom. You need to measure it to be able to know that there has been a benefit.”

Describing Kurt Lewin’s ‘Change Model’ - unfreeze, change, then freeze again -Wayne said: “Going backwards to go forwards is the only way to unfreeze what people do, before you ‘freeze’ in the new method so that it becomes automatic.

”When planning change, there are five key principles that need to be kept in mind

• Different people react differently to change

• Everyone has fundamental needs that have to be met

• Change often involves a loss, and people go through the ‘loss’ curve

• Expectations need to be managed realistically

• Fears have to be dealt with

The Kubler Ross Transition Curve charts the three stages people can go through during a period of change, showing how morale and competence alter over time as they become accustomed to the new practice. “People go through the ‘loss curve’ at different times,” said Wayne. “You have to address their fears. There can be fear, anger and depression. It’s essential you talk to people. You get understanding, you get acceptance, and finally moving on. The ‘loss curve’ applies to different people at different rates

“The faster communication of change is to all levels the better,” explained Wayne. “You have champions in there who applaud and welcome change. This grows. You work with the ones who are willing to make the change. Involve as many people as possible as early as possible.

”You need a focus of effort during change management. The attitude of people towards the change can be improved through involvement

Create a plan for: involving as many people as possible, as early as possible in the change process. Involve all stakeholders, process owners, and staff who will feel the impact of the changes, as much as possible, in the learning, planning, decisions, and implementation of the change

In the plan: tell a compelling story, rally stakeholders, articulate goals, nominate roles, and solidify strategy

In the execution: focus on outcomes, optimise, reinforce change, and measure success

It is important to consider the J-curve effect, which observes the various stages of the change process. It anticipates an initial dip in performance as change is implemented. “Stakeholders think things are generally going to get better,” said Wayne. “But performance drops because people are doing different things and are getting used to them. They gradually improve and eventually they reach the desired effect.

”Summarising the principles of change management

• address the ‘human side’ systematically

• start at the top; involve every layer - real change happens at the bottom

• make the formal case

• create ownership

• communicate the message

• assess the cultural landscape; address culture specifically

• prepare for the unexpected

• speak to the individual

“Communication is key,” stressed Wayne. “Some organisations are power cultures. Some are pyramid. Some are group.