Error in health service delivery causes an average of 354 “untoward incidents” each day. To bring this down, the challenge is to shift the focus from a blame culture to one of identifying opportunities to improve processes. Finnamore consultant Lucy Reynolds and University Hospitals of Coventry and Warwick trust’s Anne Mawson look at a programme aiming to do just that.
Each year 7.9 million surgical events take place in England, of which 129,416 result in “untoward incidents”, averaging 354 per day.
Error in health service delivery has long been recognised as a significant cause of inpatient morbidity and mortality. Within any hospital operating theatre, the development of well-integrated, efficient teams is essential for patient safety and quality of care.
However, this requires not only the development of non-technical skills (such as planning and communication) within operating theatres, but also a commitment to team working and communication across bands to ensure whole team coordination.
Root cause analysis of untoward surgical incidents identifies communication failure within teams as one of the most frequent contributing factors. A significant challenge therefore exists in operating theatres to move from a culture of blame, in which errors are seen as personal failures, to a culture in which errors are seen as opportunities to improve the system.
An approach to process improvement
In response to this challenge, the NHS Institute for Innovation and Improvement developed The Productive Operating Theatre (TPOT) improvement package, to help NHS organisations improve outcomes of care by improving team working and supporting theatre staff, including surgeons, anaesthetists, theatre matrons, theatre nurses, managers and operating department practitioners.
The improvement package involves the use of lean tools and techniques, and preliminary trials by NHS theatre teams have demonstrated strong results in:
- Improving start time and turnaround, session uptake and utilisation, and staff well-being;
- Reducing time wasted searching for equipment, and improving coordination of staff and lists via real time operational status boards;
- Improving rates of normothermia and pain control in recovery;
- Embedding the safety culture and improving smooth running of theatre lists by introducing team briefing and debriefing, and using the WHO surgical safety checklist.
Inspired by these outcomes, University Hospitals of Coventry and Warwick Trust (UHCW), one of the largest acute hospitals in the country, serving a population of over 1 million people, has implemented The Productive Operating Theatre programme.
Becoming a lean trust
To improve quality and efficiency across the trust’s services, via process and system redesign and cultural transformation, UHCW has introduced an IMPaCT Programme - Improve, Motivate, Participate and Create Transformation - which employs lean techniques to improve quality and efficiency.
Members of the IMPaCT team have been coached in the effective deployment of lean and change management methodologies, which are now being cascaded through the trust to enable removal of waste (e.g. inefficiency or duplication) from hospital systems.
As part of this commitment to making UHCW lean, the TPOT programme was launched in February 2010, led by two programme leads, (theatre manager and theatre matron) a surgeon lead (clinical director for theatres), an anaesthetic lead (consultant anaesthetist) and members of the IMPaCT team.
Implementation of the programme began on a specialty by specialty basis, with gynaecology theatres beginning implementation in February 2010, followed by general surgery and urology (April 2010), then ENT, head and neck and max fax (May 2010).
Understanding the status quo
For each specialty, a series of workshops were held, with representation from all sites, including the main Coventry site, day surgery unit, and Rugby theatres where applicable. Workshop invitees included at least one surgeon, anaesthetist, scrub nurse, operational department practitioner, administrator (for list planning) and members of the ward staff.
One day visioning workshop
At the first workshop, the group was supported to articulate their perception of a “good day” in theatre; and the problems which they believe impede their ability to achieve a good day, as well as their root causes. Groups were then supported to develop an improvement plan, outlining what could be changed to overcome the barriers identified.
Identifying the issues
During visioning workshops with each specialty, significant issues were identified, ranging from contradictory ways of working between different team members, last minute changes to list orders, and delayed arrival of patients from the wards; to unapproachability of surgeons, a mismatch of required skills sets with surgery lists; and delays in escalating problems to floor control as they arise.
Practical solutions have been implemented to address some of the operational issues identified, such as better advance communication with wards, and increased hospital signage. However, the most commonly cited issue was that of communication and team-working within the theatre environment, with this being noted as an issue 39 times during preliminary one day workshops.
The frequency with which team working and communications were raised has thus given the programme team a strong direction for developing the focus of TPOT work.
Skilling staff to work together
In response to this, theatre teams have participated in the TPOT Team Working enabler module, which applies safety techniques from aviation and other high risk industries to improve patient safety in the operating theatre.
The module is designed to help teams understand the importance of good team working and communication; opportunities for overcoming hierarchies within the theatre environment; and the positive impact this can have on quality and safety of care.
One of the key communication tools underpinning this approach is team briefing, and by October 2010, all selected specialties had implemented regular team briefings to improve communication, knowledge sharing, smooth running of theatre lists, and management of the theatre environment.
The team brief is a short, open team discussion which takes place at the beginning of the operating list. It involves the team working through structured topics, to aid planning for the expected, and the unexpected. This establishes an environment where the team can ask questions freely and support each other as necessary. It also ensures that the whole team is on the same page, ensuring that full situational awareness increases safety and reduces opportunities for error.
Before each operating list is commenced, the whole team will review:
- Who is present on the team – introductions, including new members and roles.
- Any staffing issues (e.g. potential staff changeover times).
- The theatre list order, including any changes to the order.
- The types of patient on the list.
- Equipment issues or any specialist requirements.
- Anaesthetic issues.
- Any visitors expected.
- Any breaks which may need to be scheduled.
The team briefing only takes around five minutes. In light of the fact that, for instance, missing equipment can create delay of several hours, this investment of time up front yields significant savings across the course of the day.
The benefits of team briefs
Situational awareness is where each member of the team understands the current working environment, and is able to anticipate future problems in order to take effective actions to either eliminate, or minimise their impact.
It is a key requirement for sound decision making by all staff members, and is considered to be a moral obligation for all consultant surgeons, to ensure patient safety and the accountability of clinical staff.
“Team brief is definitely the right thing to do as problems are now identified at the start of a list, giving time to resolve issues. This has prevented delays and cancellations of patients, which has helped the theatre team by reducing anxiety and harassment. In taking this forward, I would like to see more support from surgeons in implementing team brief fully.” - Carolyn Bradshaw, Rugby St Cross Theatres.
Enhancement of non-technical skills
Discussing non-technical elements, for example break times, locum staff, sickness leave, at the start of the list enables action to be taken to remedy potential delays before they occur.
Research has shown that in other high risk industries, adverse events and breaches of safety are primarily attributed to human failures. In many instances, individuals think they have communicated with the rest of the team but their method of communication means the message has not always been received.
This is one of the reasons why the introduction of briefings has been shown to reduce unexpected delays by up to 31 per cent and decrease the frequency of communication breakdowns that lead to these delays.
“I like team brief - it adds a lot of value to the theatre team’s day, by simplifying what could be tricky situations, just through better communication.” - Derrick Hammond, Rugby St Cross Theatres.
Reduced negative impact of personality traits
There is naturally a mix of personalities in the operating room, which can lead to some team members feeling intimidated about asking questions or requesting clarification. The briefing process helps to diffuse this, by giving staff, especially temporary agency staff, an opportunity to contribute to the on-the-day operational execution of the list.
By encouraging whole team communications in this manner, issues of hierarchy are reduced. Cross-sectional studies carried out in 2000 found that, while only 55 per cent of surgeons from a control sample rejected steep hierarchies (whereby senior team members resisted input from junior members), 97 per cent of consultant surgeons involved in TPOT pilots rejected these hierarchical structures and encouraged open dialogue across bands.
“Where it has been implemented it has opened lines of communication giving the whole team the opportunity to ask questions. It provides an opportunity for two way communication between the theatre staff and surgeon in clarifying that everything is in place with regards equipment etc, which has saved time and helped plan the theatre lists better.” - Larissa Belgrove, Rugby St Cross Theatres
Auditing tool to improve issues in the wider theatre environment
By taking a structured approach to reviewing operational issues during each brief, information is captured which can then be used to provide a theatre “audit”. During each briefing, a glitch count is taken, as well as a review of categories of glitches (e.g. planning and scheduling, equipment).
This provides useful evaluation data for measuring impact of team briefs, but also ensures day-to-day improvements in how the list is run, as frequently arising issues are then fed back to the appropriate department for action.
For instance, if a list contains a patient whose surgery requires specialised equipment, this can be identified at the start of the list (during team brief), allowing time for staff to source the equipment (sometimes from another hospital site) in time for the planned operation. Similarly, if two operations require the same item of equipment, these can be moved so that they are not next to one another on the list, allowing time for equipment to be sterilised and returned between procedures.
A complementary tool to the WHO checklist
The WHO safety checklist is a national requirement, which has been introduced across the Trust and embedded as trust policy in line with Department of Health guidance. Like team briefings, the checklist is designed to reduce incidence of harm, risk and glitches. However, the WHO checklist focuses primarily on patient-specific issues, whereas the briefing focuses primarily on issues relating to the list as a whole.
There has been debate that the WHO checklist is often completed too late in the surgery process to enable issues to be effectively remedied. For instance, it is too late to query whether specialist equipment is required once the patient is already in the anaesthetic room?
In this regard, team briefings have been structured innovatively at the Trust to complement the WHO checklist, by identifying such list-related issues before the list is started. This ensures that pre-emptive mitigating action can be taken, thus reducing delays later on in the session.
“The Productive Operating Theatre programme has opened our eyes to different ways of working. We thought we were doing fine, but we weren’t! The day is now better planned, highlighting issues and reducing delays.” - Missie Lawrence, gynaecology theatres.
Additional communications approaches
As well as regular team briefings, theatres have also introduced de-briefing sessions, post list or procedure. These learning discussions enable the theatre team to reflect upon the list, discussing what went well; any issues that arose; and opportunities for avoiding repeat errors in the future.
In addition, the theatre intranet site now hosts up-to-date information, including:
- Data on theatre utilisation, start and finish times;
- General information;
- Training and development information.
The management team now meet regularly as a result of implementing briefings, resulting in better communication and support for the theatre teams. This has led to the teams being more forthcoming in escalating issues, and action is being taken to resolve issues in a more timely manner.
Since implementation, theatre utilisation has remained steady at 80-90 per cent. This in spite of delays and cancellations that have been caused as a result of bed shortage, demonstrating the potential for a well-managed operating theatre to maintain patient flow in the face of significant systems challenges.
As well as contributing to efficiency improvements, the work has also helped to raise staff satisfaction within theatre. In September 2010, a staff survey was carried out to capture the experiences of staff involved in team-briefing. All day surgery staff at UH and Rugby St Cross were approached, with response rates of 45 per cent and 25 per cent respectively (N=32). Of those interviewed:
- 56 per cent agreed with the statement, “Communication has improved since introducing team brief”.
- 53 per cent agreed with the statement, “Team brief is useful structure approach to communication”.
- 47 per cent agreed with the statement, “I feel more confident about raising issues queries since its introduction”.
- 59 per cent agreed with the statement, “When we undertake team brief, I feel lists run more smoothly”.
- 72 per cent agreed with the statement, “Brief helps sort out issues early reducing delays later in session”.
- 59 per cent agreed with the statement, “Team brief should be undertaken for every theatre list across the trust”.
The survey did identify some frustration among surgeons that Team Briefs are “like High Mass” – taking too long, and in themselves causing delays to surgery. Work is underway to address this, and ensure that, as the briefing process becomes more familiar, it can be kept below five minutes.
However, despite these minor residual issues, the trust has made a strong start in implementing theatre team briefing, and is now working towards full implementation of team brief in all theatres at UHCW. Initial adoption of the programme was relatively straight forward at the smaller UHCW hospital sites (St Cross and the Day Unit).
Lessons from these more controlled sites (where procedures are mainly elective) will be invaluable when team brief is implemented in a hospital with a significantly higher number of theatres.
Top tips for implementing team briefings
Based on the UHCW experience of implementation, the following lessons might help other trusts in pursuing this approach:
- Secure executive sponsorship: top level support is essential in overcoming resistance to implementation at specialty level.
- Identify departmental leaders: compliance from surgeons/ anaesthetists is essential, and they will need to lead by example when it comes to improved communications approaches.
- Scale up: agree to introduce team briefing across the whole department at the same time.
- Plan for the long term: this should not be seen as “yet another short term initiative”. Engage your teams from the start, and reassure them that changes will be permanent and lasting
- Plan for implementation: agree a start date for implementation, and prepare the department for launch by developing guidance for all staff so they understand what is involved.
- Be adaptable: agree a suitable time so as many team members as possible can attend the briefing, (it is important that the anaesthetist and ODP are there).
- Standardise documentation: agree and follow a structure for team briefings, to ensure consistency of delivery, auditing, and impact assessment.
- Value everyone’s knowledge: any team member may hold that “final piece of the jigsaw”, so it is crucial to set an encouraging tone to encourage active participation.
- Be positive: raise important issues, but remove blame – if sessions are used to criticise, the essence of trust will be lost!
Finally, remember that every member of the healthcare team has a responsibility to actively use the communication techniques and behaviours agreed by the team. Strong communication is everybody’s responsibility, and needs to proactively pursued at all levels.
“What I’ve learned from the process is that it really is a process. If you try to change things too quickly you can meet with resistance. If people are taken on board from the start they will bring lots of ideas and solutions, and will learn from one another. People do want things to work better - if you ask them, they will bring you solutions.” - Dr Ratidzo Danha, consultant Anaesthetist