OPENING CEREMONY WELCOME TO THE CONFERENCE !
MUSIC PERFORMANCE BY THE S.O.U.L. 50 VOICES GROOVE CHOIR
WELCOME BY THE EDTNA/ERCA PRESIDENT Jitka Pancířová
WELCOME Welcome to Hamburg, the international metropolis on the river Elbe. As a scientific, business and tourism centre, Hamburg with its Congress Centre Hamburg is one of the leading congress cities worldwide. Unique opportunity to meet colleagues representing nearly 60 countries worldwide and discuss the latest developments in renal care.
LOCAL ORGANIZING COMMITTEESCIENTIFIC PROGRAMME COMMITTEE Jutta Balhorn – Honorary LOC Chair Waltraud Kuntzle – LOC Coordinator Christa Tast – LOC member Leo Micosse – LOC member Carmen Reiher – LOC member Hedi Luckerath – LOC member Dieter Ruger – LOC member Paula Ormandy – SPC Chair Martin Gerrish – SPC Co-Chair Jitka Pancírová – EC Link Maria Fettouhi – SPC member Jutta Balhorn – SPC member Waltraud Kuntzle – SPC member
INDUSTRY SYMPOSIA Corporate Education Sessions Supported Sessions
NEW PROJECT A campaign to achieve more environmental sustainability in dialysis care Project objectives: • Create awareness for environmental aspects in dialysis • Change habits for a more “environmental friendly” dialysis • Prepare environmental guidelines for dialysis Go Green in Dialysis! Survey at the Conference 2009 Project Team set up Project framework finalization Project roll-out 2010 Project evaluation 2011 Guidelines Launch 2012
NEW COLLABORATIONS Positioning of EDTNA/ERCA towards an international concept EDTNA/ERCA continues to explore the possibility of closer collaboration with national and international associations. We have established contact with a number of associations about future collaboration. • Recently signed collaborative agreement with CANNT(Canada) • Recently signed collaborative agreement with SOBEN (Brazil) • Recently signed collaborative agreement with RSA (Australasia) • Recently signed collaborative agreement with NKF (USA) New ILM positions • International Link member for Australia • International Link member for Canada • International Link member for Thailand
SEVENTY VOLUNTEERS WORKING FOR THE SUCCESS OF EDTNA/ERCA
WELCOME BY THE HONORARY LOC CHAIR Jutta Balhorn
WELCOME BY THE COUNCILER OF STATE OF HAMBURG Dr.Vogels
GUEST LECTURE Capt.Timothy Crowch President Advanced System Safety Management Managing risks-lessons healthcare may learn from aviation
Managing Risks -Lessons Healthcare may learn from Aviation Presented by: Capt. Timothy Crowch 38th EDTNA/ERCA International Conference Hamburg - 5th September 2009
Programme • Introduction • A Short History of Modern Aviation Safety • The Philosophy of “Pro-Active Safety Management” • What we have gained - so can you! • Towards a Safer Future
Why Safety Management today? • It forms the “Heart“ of a company’s Operating Culture • Promotes a Learning Culture • Improves efficiency of the working environment • Fewer incidents and accidents • Raises productivity • Increases profits
2. A Short History of Modern Aviation Safety • 1960 First Flight Data Recorder (UK, USA) • 1965 Voice Recorder 30 min.(CVR) • 1970 First FDR Analysis (Swissair, BOAC) • 1980 Simplified Data Analysis • 1985 Digital Flight Data Recorders (DFDR) • 1990 „Quick Access Recorders“ & SSCVR • 2000 CVR 2 Hours • 2008 Flight Deck Cameras (Video)??
A Short History of Modern Aviation Safety • Monitoring of Technical Systems • Trend Analysis But ........ the most important was still missing ..... • Monitoring of the Human Operator
A Short History of Modern Aviation Safety 1977 Teneriffe : 583 dead in one afternoon • KLM “KHUFAC” launched (Frank Hawkins) • Focus on Human Behaviour • 70% of all accidents resulting from Human Error • “Pilot Error” - (Who?) • Background, Latent Conditions, System Failures - James Reason, Robert Helmreich, John Lauber - NASA, UT, et al. - (How? Why?) • Result - Introduction of formal Safety Programmes and Human Factors Training
3. The Philosophy of “Pro-Active Safety Management” • Accidents are caused by normal activities being carried out by normal people in abnormal circumstances. • The most efficient use, maintenance and protection of all of a company‘s resources
The Philosophy of “Pro-Active Safety Management” Why the emphasis on Safety now? • Changes in the Operating Environment • Competition • Production vs. Protection • Cost control • Increasing costs of: • Property • Research • Technology • Losses/Claims • Errors will become increasingly expensive
The Philosophy of “Pro-Active Safety Management” • Safety Management = Risk Management • Risk Control = Cost Control • Cost Control = Efficiency • Efficiency = Productivity • Productivity = PROFIT
What were our priorities? • Accept that Human Error as Inevitable • Establish Error Tolerant Procedures • Train Communication Strategies • Briefing, Intervention, De-Briefing • Checklist and Procedure Design • Threat & Error Management (CRM 6th Gen) • Mandatory Recurrent HF Training
What we have gained - and so can You! • A new working culture • A new working environment • Mutual trust and confidence • A flatter hierarchical structure • Open communication • More pleasure • Much improved safety performance
What we have gained .... How did we achieve these gains? • Full involvement of Senior Management • Required allocation of resources • Regular training & development programmes (CRM) • Structured and systematic training • All professional levels & ranks are fully integrated • Unified/single doctrine
What we have gained ..... • “Learn from the mistakes of others, you will not live long enough to make them all yourself.” • Safety management is change management • People inherently resist change & fight against it. • “If you do what you did, you‘re gonna get what you got“ Yogi Berra
Our Similarities ... • Multi-discipline • Complex Systems - entrenched hierarchies • Highly qualified people (Licensed) • Success dependent upon crew performance • Pilots - Cabin crew • Medical - Nursing Teams • Communication can be a matter of life and death • Verbal • Written
..... and so can You! • Irregular working regimes 24/7 • Initiative continuously called upon • You seldom have a second chance to perform • Dependent upon support/suppliers
Imbalance in Training Management Errors Poor Leadership Teamwork Communication Cultural Aspects Human Factors Non-Technical Skills Technical Skills Equipment etc Technical Skills Causes of Accidents Training
5. Towards a Safer Future The Way Ahead • Human Error is the Symptom, not the Disease • Invest in changing the system - it is easier than the human • Create a “Just” Safety Culture (a Learning Culture) • Improved training - (quality and quantity) - is unavoidable • Increased emphasis on non-technical skills • Establish SOPs • Introduction of Checklists and Procedures
Our Aim: All Team Members must be able constantly to adapt to the Hazards, Risks and Dynamic Changes the Situation confronts them with and instinctively respond to these correctly.
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