Lessons from The Productive Operating Theatre

Lessons from The Productive Operating Theatre
A multiprofessional approach to improving theatre communication 25th Jan 2012 Hugh Rogers, Consultant urologist, Senior Associate, NHS Institute, training faculty Lessons from The Productive Operating Theatre Customise this slide for venue and presenters. The local team will often want to present some slides of their own as an introduction. You can insert their slides before this without losing their formatting as follows (for Windows 2007 users): Go to slide sorter view. Click before first slide From Home toolbar drop down the New Slide menu Click Reuse slides In the new window select Browse, then Browse file Find their presentation (on USB stick select My Computer, then External drive usually E or F) and double click it. IMPORTANT: Now check the box for Maintain slide formatting Right click any slide and go to Select All Close the side window and save. Also a quick short cut to start the slide show at first slide is available on most laptops. For Toshiba (and some others) it’s key F5.

The Productive Operating Theatre aim: To improve 4 key dimensions of quality
Key message Balanced scorecard Message to deliver Not just productivity but about all aspects of delivering the quality agenda – 4 aims to improve patient experience and outcomes, safety and reliability, staff well being and team work and of course efficiency and value Explain strap line: Building teams for safer care Notes

How The Productive Operating Theatre has been developed
Understand the real issues and challenges. Identified co-production partners: NHS Industry Observing high risk, lean organisations: Terminal 5, Unipart Visiting other healthcare settings, UK & USA Generated and tested lots of ideas with 3 field test sites Test the idea with 3 Associate sites. “All failure is learning” Develop delivery mechanisms, Modules, marketing, launch Launch in Sept 2009, followed by regional start-up events for NHS England Ongoing ROI and benefits realisation capture Since April 2010 initiated 10 cohorts of training and implementation support to 90 of 174 acute trusts in England. Internal & external peer review. Learning sets. Key message: Rigour, timescales and investment that has gone into developing the programme. Where the Programme came from, where we are with TPOT currently This is not about a ‘lone inventor’, sitting in a darkened room. This has been developed using a process taken from the experience of world class best practice and leading companies, such as Nike, Apple and IDEO, that rely on innovation to maintain their market position. This slide shows the institutes work process and how we’ve used it to develop TPOT Importantly, this process started with gaining a true understanding of the ‘customers’ requirements, i.e. what is the problem we are trying to solve? In Theatres, this was Creating the Perfect Operating List, and we’ll come back to this when we do the Visioning session later today. Incorporates analysis, creativity and prototyping of ideas Based on experience with The Productive Ward Co-production with 3 hospitals starting small: 2 theatres Combining strategies: lean thinking (staff empowerment) team working (human factors & non-technical skills) Testing prototypes and measuring their impact 3 further hospitals Sequence of modules Rolling out to the NHS and internationally Implementation support package You may want to pick up on specific areas of the slide 3

Team working It is important to implement the programme sequentially, from setting up the project team and steering group, running the opening workshops: Visioning workshop, trust board workshop, and the measures workshop. Then working through the foundation modules before moving on to the enablers and subsequently the process modules. However, of all the modules in the house, we believe Team-working has the biggest impact on reducing errors, near misses, and saving lives. Theatre teams are being trained together in communication and non-technical skills. These skills are now compulsory for teams in aviation and other high risk industries, because the evidence of their effect in improving safety is so strong. 4

The Boxed Set Your box set Ask: How many of you have read the modules?
It is likely that only a handful of delegates will have read them, this is an opportunity to reinforce how good/useful they are, ask for feedback from those that have read them. Invariably this will be positive We will refer to them throughout the training Included is a DVD including an introduction to the Programme and a short film for each of the modules featuring the staff on the test sites who have developed and tested the modules Useful tools for communication with your teams A3 summary of the TPOT house to put on your wall 5

Launched September 2009 Ask the delegates to introduce themselves
If you have, or know your TPOT role, please mention this 6

Implementation support package
Week 1 Organisational Readiness Visit Week 4 Programme Implementation Training -days one and two for four members of the team Weeks 4-12 One day Team-work Training for up to 100 participants Weeks 4-12 Four days Implementation Support enabling teams to tailor the programme to their particular needs Week 12 Programme Implementation Training -days 3 and 4 for four members of the team The principle of the Implementation Support Package is to transfer skills and knowledge to enable teams to implement The Productive Operating Theatre successfully. The package provides support over three months, where teams will be supported as they establish their programme and implement it in their initial showcase theatres. At the end of Day 2, we would like you to select which of the on site support days you want. 7

Implementation support package
Week 1 Organisational Readiness Visit Week 4 Programme Implementation Training -days one and two for four members of the team Weeks 4-12 One day Team-work Training for up to 100 participants Weeks 4-12 Four days Implementation Support enabling teams to tailor the programme to their particular needs Week 12 Programme Implementation Training -days 3 and 4 for four members of the team The principle of the Implementation Support Package is to transfer skills and knowledge to enable teams to implement The Productive Operating Theatre successfully. The package provides support over three months, where teams will be supported as they establish their programme and implement it in their initial showcase theatres. At the end of Day 2, we would like you to select which of the on site support days you want. 8

Team performance: A key driver for improvement
Introduction to The Productive Ward Team performance: A key driver for improvement Team performance & Staff Well-being Patient’s experience & outcomes Safety & reliability of care Value & efficiency Test sites have found that the team-working module is transformational. In Productive Ward the ‘Well Organised Ward’ module seemed to provide the turning point at which ward staff start to see real transformation in their environment, with a positive impact on their work. In TPOT, the staff in theatres certainly get a lot out of the ‘Well Organised Theatres’, but it is the training in human factors and the implementation of communication tools to address them, particularly brief and de-brief, that engages some of the doctors and seems to be a spur to the whole programme. It is also apparent that improved team-working has a beneficial impact on all the other dimensions of quality

Self-explanatory, illustrates previous.

Developing the training
Pilot sites had training from ex-pilots, experts in HF Not scalable Trials with psychologist from Derby and surgeon Based on elements from the LIPS programme Initially full day, condensed to half day Evaluated at every workshop Faculty debrief and review Roll-out to England Train the trainer events in Scotland, Wales, Ireland, New Zealand more planned in Australia, Qatar

“Making it easy to do the right thing”
Session Outcomes Understand harm and error in healthcare Demonstrate how humans are all fallible Experience factors that affect individual human performance Understand how personal styles affect interactions Develop new knowledge tools and skills to prevent or mitigate human error “Making it easy to do the right thing”

Outline workshop agenda Lots of interactive elements, multi-media and group work Psychologist + clinician How unsafe is healthcare frequency of harm complexity of disaster The psychology bit humans as hazards and heroes how errors occur self-awareness exercise Implementation effective communication tools the model for improvement action planning A suggested outline agenda is in the module, although we have constantly improved this for the ISP on-site training 13

Outline workshop agenda Lots of interactive elements, multi-media and group work Psychologist + clinician (surgeon or anaesthetist) How unsafe is healthcare frequency of harm complexity of disaster The psychology bit humans as hazards and heroes how errors occur self-awareness exercise Implementation effective communication tools the model for improvement action planning A suggested outline agenda is in the module, although we have constantly improved this for the ISP on-site training 14

We always start with interactive table session
5 minutes: What have you already achieved? What would you like to achieve? What are your main challenges? Before getting into the presentation, recognise that , following the NPSA alert in February 2009, all trusts have been implementing the Surgical safety checklist in some form, and many are also using the ‘five step model’ (i.e. Checklist for each patient, with team briefing and de-briefing at start and finish of the list). What else are they doing? Is it going well? How much coverage do they have? What blocks have they found? Ask them to talk at tables in their teams and agree on the answers to these questions. In feedback from tables, use the opportunity to learn about the organisation’s state of development, and try to focus on the difficulties in implementation that arise when the new way is simply mandated. Point out the findings of the Patient Safety First campaign evaluation which demonstrated that those trusts which encouraged local customisation, refinement and modification using the model for improvement have been more successful with implementation than those that mandated the NPSA checklist. Also refer to our TPOT experience that implementation is much easier in teams who have had some training in the human factors that impact on care, and the non-technical skills that can be applied to overcome them.

We always start with interactive table session
5 minutes: Have you included human factors & non-technical skills in training? Should you? What are your main challenges? Before getting into the presentation, recognise that , following the NPSA alert in February 2009, all trusts have been implementing the Surgical safety checklist in some form, and many are also using the ‘five step model’ (i.e. Checklist for each patient, with team briefing and de-briefing at start and finish of the list). What else are they doing? Is it going well? How much coverage do they have? What blocks have they found? Ask them to talk at tables in their teams and agree on the answers to these questions. In feedback from tables, use the opportunity to learn about the organisation’s state of development, and try to focus on the difficulties in implementation that arise when the new way is simply mandated. Point out the findings of the Patient Safety First campaign evaluation which demonstrated that those trusts which encouraged local customisation, refinement and modification using the model for improvement have been more successful with implementation than those that mandated the NPSA checklist. Also refer to our TPOT experience that implementation is much easier in teams who have had some training in the human factors that impact on care, and the non-technical skills that can be applied to overcome them. 16

How did that make you feel?
We pause here for delegates to reflect on what they’ve seen and talk to neighbours. Ask them to consider what happened to all the people in the story, not the technicalities. Quite often we get someone who wants to discuss whether the patient was pre-oxygenated or not or what tracheostomy should be used and other technicalities. Ask them to accept that what they saw was a reconstruction of an event that happened several years ago and they need to focus on the response of the staff to the stressful situation.

Link to film from CHFG website www. chfg
Link to film from CHFG website DVD available free from We pause here for delegates to reflect on what they’ve seen and talk to neighbours. Ask them to consider what happened to all the people in the story, not the technicalities. Quite often we get someone who wants to discuss whether the patient was pre-oxygenated or not or what tracheostomy should be used and other technicalities. Ask them to accept that what they saw was a reconstruction of an event that happened several years ago and they need to focus on the response of the staff to the stressful situation. 18

Compelling evidence The National Reporting and Learning Service in England and Wales: 135,000 reports of patient safety incidents relating to surgical specialties in a year For an average English trust this equates to approximately: 90 patients who suffer severe harm two deaths per year This slide shows only those incidents reported to the NPSA’s National Reporting and Learning Service. We know that most incidents are not reported so this slide shows only the tip of the iceberg.

Safety in healthcare compared with other activities
Anaesthesia Mortality Surgical Mortality In hospital mortality due to poor care Blood Transfusion Mortality (UK) No system beyond this point Chartered Flight Himalayan Mountaineering Commercial Large Jet Aviation Coal Mining Road Safety Railways Microlight aircraft or Helicopters Build this by explaining the logarithmic scale first (it will not be familiar to all in the room) Then the high risk industries and activities Then healthcare – overall is unsafe, but there are some elements where it is now ultra safe: Anaesthesia and blood transfusion. Many of these activities have learned to reduce risk through appreciation of human factors. Chemical Industry Nuclear Industry VERY UNSAFE Risk rate ULTRA SAFE Amalberti et al. An Int Med 2005

The complexity of disasters
47 died 79 survived Wrong Engine, Kegworth Jan 1989

The ‘Swiss cheese’ model A systemic view
Some holes due to active failures Hazards Other holes due to latent conditions Losses Successive layers of defences, barriers, & safeguards With thanks to Prof J Reason

The complexity of disasters
Take care – who is in the room? Wrong Kidney Llanelli Feb 2000

The Error Chain (Surgery)
Safe Unsafe Question X-Rays back to front Duties assigned late Patient asleep Delay There had been an unsuccessful nephrostomy procedure on Right Kidney Patient consented for correct procedure Operation cancelled due no ITU bed Registrar away for 10 days on study leave Data entered incorrectly on TCI (to come in) slip transferred without error being noticed 5 weeks until operation (evidence of previous efforts not obvious or forgotten) Patient asleep when pre theatre ward round undertaken Consultant only told registrar that he would like him to carry out procedure once in theatre X-Ray plates were placed in viewer back to front Junior staff member questioned whether patient was in correct position but this failed to trigger a re-evaluation. Transcription error Leave Cancelled operation

The 5 most dangerous words…
“ it could never happen here…”

Exercise “Something that went wrong”
Chat to another participant and exchange stories Describe what happened What was the chain of events What were the environmental conditions At this point, before we get into the detail of how human factors impact on errors and performance, ask the audience to find someone they would like to work with and share stories of “something that went wrong”. This may have happened to them, or maybe a friend or relative. Sometimes stories from clinical practice are useful. “On your tables discuss events/experiences which called into question the safety of a patient- select one of these stories and write a summary of your selected story up on a flipchart using the following headings (who was involved; what happened)” Emphasise that this will be used to review and reflect on during the day when we begin to learn more about human factors and the ways in which we are fallible- susceptible to error“ Take some feedback briefly to get out some example stories. Depending on time facilitators can ask for a few examples of safety stories..The delegates are then asked to "save" their stories (possibly to pin them around the room) until after the psychology bit when they will be asked to identify the human factor issues within their story- leading to also identify how their story could have been prevented. Confidentiality and management of delegates is important for this stage. It is important to highlight that this exercise is as much to do with encouraging open debate as it is to identify the human factors. The facilitators need to use this exercise to develop team sharing as well as emphasising that safety issues are apparent in all workplaces. Many delegates come to the session with the view that "it couldn't happen here" and then their own colleagues bring up stories! The other tip is to manage the timeframe here as stories can take over. With the writing up of the group's story it is useful to have a template ready or flipchart paper. They often need managing to write up the story in the timeframe allotted. With this exercise it is very dependent on who is in the room and the timeframe you have- but you need to be very flexible to account for this diversity. This is perhaps you may have some ideas of you own on new ways of exploring personal experiences of safety and new ideas on eliciting human factors in personal accounts.

Humans as hazards and heroes
Invention & Improvisation Sheer professionalism Exceptional team-working The final defence in Reason’s model is the capacity of humans to recognise the risks. He talks of humans as hazards and heroes (see his talk on heroes on the Risky Business website): For a well-known example, Captain Sullenberger landing his plane on the Hudson River is known to most people. One of the causes of catastrophe is when our ability to recognise a potentially dangerous situation and retrieve it has been undermined.

What Affects Performance?
Lack of sleep Tiredness Overwork Lack of attention Environment (e.g. heat) Fatigue Boredom Frustration Distractions Team work Illness Stress Anxiety Fear Confidence Training/Expertise Procedures Policies Leadership Communication 29

Typical ‘performance curve’
Talk through. Arousal always seems to get a snigger. 30

Types of Errors Common types of error Lapses
Skilled performance affected by memory failure Common types of error Slips Skilled performance affected by concentration level Violations Deviations from the agreed process/ protocol Mistakes Result of inappropriate intent or diagnosis

HF demonstrations Using a mix of
Film clips The door study The smoke-filled room Colour changing card trick Images Stories Discussion Intended to develop insights into how errors occur

The door study: Attention
33

How observant are you? Why didn’t they notice? Would you have noticed?
How good are you at spotting things? Let’s put that to the test…

Localisation 35

What did you see? What was in the picture?
How accurately can you describe it? How confident are you? Would you trust others’ judgements more than your own?

Filling in the gaps.. Aoccdrnig to rscheearch at an Elingsh uinervtisy it deosn’t mttaer in waht oredrr the ltteers in a wrod are the olny iprmoatnt tihng is that the frist and lsat ltteer is at the rghit pclae. The rset can be a toatl mses and you can s itll raed it wouthit a porbelm. Tihs is bcuseae we do not raed ervey lteter by itslef but the word as a wlohe. We fill in the gaps (self-evident) 37

Do___mine Vin___tine .. In the clinical context? Which drug?
How we read is by skimming beginning and end of words, lines. Humans estimate a surprising amount of information that isn’t there…ask the participants to write down the drug names on their papers - picked up in the strategy slide 38

TALL MAN Lettering Dobutamine DoBUTamine Dopamine DOPamine
Vinblastine VinBLAStine Vincristine VinCRIStine Recently: Epinephrine vs Ephedrine Impossible for the eye to ignore the bold capitals here 39

Situational awareness
We build our situational awareness by piecing together fragments of information Gathering information Interpreting information Anticipating future states Situational awareness was highlighted in the Martin Bromiley introductory DVD How can situational awareness be improved in the operating theatre?

Situational Awareness and Group Dynamics The smoke filled room experiment
This is the smoke filled room 41

Perceiving self & others
How do we see other people? What does this mean for how we interact with them How much do we value their input How do we see ourselves? What are you good at? Gorillas or cards? How do you deal with your weaknesses? Denial? Working practices? Support of others?

Social Work Students are Medical Nursing think
Pietroni, P. 1996, "A study of perceptions amongst health care students," in Innovations in community care and primary care, P. Pietroni & C. Pietroni, eds., Churchill Livingstone, Edinburgh.

Social Work Students are Medical Nursing think Caring Overworked
Scapegoats Guardian readers Arrogant Beer drinkers Immature Intelligent Hard working Unimaginative Female 2 Cvs Lesbian Left wing Self opinionated Intellectual Underpaid Rugby players Heavy drinkers Chip on shoulder 2 CVs Vegetarians Snobby 44

Understanding the differences between us
Merrill & Read’s framework: self-awareness and team-working The next part is an interactive exercise to enhance self-awareness in order to improve our team-working abilities

Personal styles Analytical Driver Expressive Amiable Controls emotions
formal measured + systematic seek accuracy / precision dislike unpredictability and surprises Driver business like fast + decisive seek control dislike inefficiency and indecision Ask Tell Amiable conforming less rushed + easy going seek appreciation dislike insensitivity and impatience Expressive flamboyant fast + spontaneous seek recognition dislike routine and boredom Introduce the 2x2 matrix. Then build up the slide, bringing in each personal style. Embelish with some reference to public figures of known local personalities (yourself?) Shows emotions

Think about how some of the human factors and phenoma you have seen might lead to errors, mistakes or harm in the operating theatre

Team-work Essential clinical skill
Based on understanding of human factors Non-technical skills If clinical skills are any skill required to give the patient the best opportunity of a good outcome Notechs are an essential clinical skill Benefits for everyone, pt, anaesthetist, surgeon, scrub nurse, ODA, etc and finance director and commissioner

Team performance and communication
Threat Briefing & de-briefing Team performance and communication SBAR Flatter hierarchy Checklists Read-back PACE Critical language Threat Risk Risk Briefing, debriefing and checklist are important defences but they are ‘the tip of the iceberg’ in terms of the range of non-technical skills that can be deployed. Threat

Psychological Safety Flattening hierarchy People feel safe to speak up
First names Clarity of roles and responsibilities Ask: Do I feel safe to say it? Will I be treated with respect? Will I get help to fix the problem?

Critical language – escalation and assertion
Probe Assert Challenge Emergency: A word or phrase that means; “Stop, I’m not comfortable with this” Makes it easier to speak up Removes ambiguity Use names (maybe more formal)

Aide memoire, laminated by phone, many other possibilities, eg sticky notes pads etc

Impact on culture (safety attitudes questionnaire)
Team-working Impact on culture (safety attitudes questionnaire) This graph shows the impact of team brief on staff attitudes assessed by the Texas University safety attitudes questionnaire, version customised for English theatre teams. By conducting a staff attitudes questionnaire before and after implementing team briefing this test site were able to demonstrate an improvement on staff attitudes to team-working, safety and job satisfaction but it was not expected that perceptions of management, working conditions or stress recognition would improve p<0.05

Team-working

The Model for Improvement
Team performance and communication SBAR Flatter hierarchy Checklists Read-back PACE Critical language

Here’s how the team in Luton devised their own version of the checklist, literally cutting and pasting, scribbling and testing on one patient or one list before trying something a bit more sophisticated (next slide)

This version allowed for both a Yes and a ‘Not applicable’ response
Even better might be ‘No, but we fixed it’ option

Action planning What have you learned today? What will you do differently? What ideas would you like implemented, where?

Debriefing principles

Lessons from The Productive Operating Theatre

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