Published: 17/02/2005, Volume II5, No. 5943 Page 34

Redesigning your health community is now a popular buzz phrase, but in practice it can pose great challenges in terms of engaging staff and changing cultures. This was certainly the case with the Better Care for Norfolk programme that started last year, bringing together the area's seven trusts as part of a wider public consultation.

'Doing more of the same thing as before is not the answer, ' says Phyllis Shelton, Central Norfolk Health and Social Care trust's director of performance improvement and organisational development, who runs the programme.

To kick things off, a series of day-long strategy workshops were devised.

Nothing unusual there, you might think.

But these workshops were run by Afterburner, a firm of former US Airforce pilots who now teach organisational skills. It is the kind of initiative beloved by corporate America, and one that might bring some healthcare managers out in a rash.

But Afterburner has a long list of healthcare clients and, Phyllis adds, the firm had researched the situation in Norfolk before arriving for the seminars.

Participants at the first Afterburner seminars must have been surprised at what awaited them: several rooms in a Norfolk hotel transformed into operation rooms, complete with camouflage netting and several men in all-in-one flight suits striding around (think Top Gun ).

Each participant is given a new identity; names have been replaced by the names of different aircraft such as Falcon, Stormy and Blackbird, complete with details about what speeds they are capable of, what weather they can fly in, what weapons they carry and what they are capable of 'taking out'.

It is a mission-planning scenario. Each group of around 18 people sit at a table covered with a large aerial map and hard hats (these are worn later in the morning when everyone is told to dive under the table because they are 'under attack').

There is also a walkie-talkie, from which instructions constantly emerge. The scenario is the bombing of an unnamed place to take out 'strategic targets', with tight timelines for each mission. Full details of the raids must be reported back.

After each attack, the team members work out how much ammunition has been used and how many planes lost.

By mid-morning, questions such as 'what can a dumb bomb destroy' and 'what weather can a stealth fly in' are being asked by team members of their colleagues while one participant - who is clearly not destined for a career in air traffic control - wants to know why all the planes cannot take off together.

After lunch, Afterburner's Rick 'Dewey' White and Scott 'Slick' Vasina begin to impress on the participants why they are here. They show footage that recreates the scene inside a commercial aircraft's cabin shortly before it crashed. The crew were all so busy focusing on a faulty light switch that they failed to notice they were losing altitude; 99 people died.

'Are there any burnt-out light switches in your organisation?' asks Dewey. 'Task saturation is the silent killer. Most of us deal with a scenario by focusing on only one task, and that can be a dangerous way to handle it. Is there open communication?' He recommends daily, weekly or monthly debriefs being given in a nameless, rankless way, with no apportioning of blame.

'Set the time and tone for the debriefs, analyse the execution of the task, go over lessons learnt, transfer the lessons learnt and leave on a high note, ' he explains.

Later, each of the groups mark up a list of profit and losses from the mission scenario and are asked to consider what they have learnt. They are then given an outline on how to complete future 'missions': plan, brief, execute, debrief, win.

In the afternoon the attention shifts to Better Care for Norfolk's work streams; today is the turn of infection and complications, diagnostics and therapies and palliative care work groups. Each is supposed to use the 'flawless execution' model adapted for the earlier scenario to help them define the objectives each work group has to focus on.

One hundred senior managers are evaluating the progress of the Better Care programme. It is early days yet - it is a three to five-year programme- but Phyllis says she expects to see results within this financial year and claims to have already noticed differences.

'Staff are already more confident and relationships with the strategic health authority have improved, ' she says.

Techniques used in the seminars are thought to have contributed to reductions in bed stays, delayed discharges and referrals in various clinical areas.