OR Culture Part II If culture is the problem, what is the solution? Dr. Mark Fleming Mark.fleming@smu.ca

Outline Where are we? (Cultural typology) Improvement strategies Engagement Spread Improvement Assessment and improvement tools Surveys Team training

Safety Culture A culture of safety can be defined as an integrated pattern of individual and organizational behavior, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999).

Where are you? Generative Improvement Safety mountain Orientated Proactive Bureaucratic Reactive Pathological Status Quo

What level are you at? Pathological Reactive Bureaucratic Proactive Toxic environment (shoot the messenger), people actively do not want to improve Reactive Passive ignoring of improvement initiatives, until something bad happens Bureaucratic Willing adoption of proven safety interventions Proactive Active development and evaluation of new safety interventions Generative

Engagement Identify one (or more) supportive Physician to pilot checklist and promote benefits to colleagues Highlight need to change by identifying failures that could have been prevented Conduct team survey to highlight communication problems

Spread Track levels of checklist use Ask those who are not using the checklist why they are not using it Get current users to present benefits to colleagues (e.g. grand rounds) Create information sheet promoting benefits Get supportive dept heads to discuss checklist use with non users

Improvement Develop quality audit Develop checklist of key behaviours (timing, attention of team members etc) Develop schedule to observe each physician using audit Provide individual and group feedback Survey staff groups about how the audit is being used

Surveys Modified Stanford Instrument MapSaF ORMAQ Used by accreditation Canada, Does not measure team work MapSaF Developed for use in NHS, not sure about copyright issues for use in Canada ORMAQ Items are published, includes teamwork

ORMAQ teamwork items 17. The only people qualified to give me feedback are members of my own profession. 18. It is better to agree with the operating theatre team members than to voice a different opinion. 22. The doctor’s responsibilities include co-ordination between his or her work team and other support areas. 25. Operating theatre team members share responsibilities for prioritizing activities in high workload situations. 31. I enjoy working as part of a team. 44. To resolve conflicts, team members should openly discuss their differences with each other. 48. All members of the operating theatre team are qualified to give me feedback. 54. The concept of all operating theatre personnel working as a team does not work at this hospital. 56. Effective operating theatre team co-ordination requires members to take into account the personalities of other team members.

Team Training Dr. Donald Moorman (Beth Israel Deaconness Hospital in Boston) developed a 3 hour knowledge based team training program, based on CRM There is some evidence that it is effective Reduction in errors and adverse events Increase in teamwork behaviours Adapted for Canadian teams with permission by: Mark Taylor, Lesia Yasinski and Mike Rodgers

References Kizer, K. W. 1999. Large system change and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient Safety Foundation. Manchester Patient Safety Framework (MaPSaF) http://www.nrls.npsa.nhs.uk/resources/?entryid45=59796 Sexton J, Helmreich RL, Thomas E. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-50 Fleming, M., Smith, S. Slaunwhite, J. & Sullivan, J. (2006). Investigating interpersonal competencies in cardiac surgery teams. Canadian Journal of Surgery, Vol 49 No 1. Team Training materials files.me.com/markfleming/u3l77t

Team training video links files.me.com/markfleming/4xvafh files.me.com/markfleming/9pp0b6 files.me.com/markfleming/cm7cfk files.me.com/markfleming/dwoxeo files.me.com/markfleming/13b8vo files.me.com/markfleming/qcu7gr