1. 30 April 2008RCOG/ENTER TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD Leroy Edozien

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3. 30 April 2008RCOG/ENTER 5496 perinatal deaths in 2005 Unexplained antepartum 33% Congenital abnormality 17% Prematurity17% Intrapartum deaths 11% 2006: Risk of intrapartum stillbirth = 1 in 1486

4. 30 April 2008RCOG/ENTER Intrapartum stillbirth Failure to act on CTG Teamwork/communication Task saturation Loss of situation awareness Plan continuation bias

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7. 30 April 2008RCOG/ENTER Interventions to make childbirth safer, reduce number of intrapartum stillbirths ‘Safer Childbirth’ CNST/NHSLA Healthcare Commission King’s Fund RCOG Service Standards, Obstetrics

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9. 30 April 2008RCOG/ENTER Making maternity care safer First order v Second order change change Transactional v Transformational change change

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11. 30 April 2008RCOG/ENTER Achieving change Systems resist change Changing a system by changing its ‘centre of gravity’ It is far better to attack your centres of gravity in parallel – all at once, rapidly

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13. 30 April 2008RCOG/ENTER Three themes No observations made for a prolonged period and therefore changes in a patient’s vital signs not detected No recognition of the deterioration and/or no action taken other than recording of observation Delay in the patient receiving medical attention, even when deterioration has been detected and recognised

14. 30 April 2008RCOG/ENTER Contributory factors Communication – ‘the biggest problem area’ Work and environment Task factors Education and training Patient factors Team work and social Equipment and resources Individual factors

15. 30 April 2008RCOG/ENTER Do you work in a team or teams?

16. 30 April 2008RCOG/ENTER How do you rate the quality of teamwork in your workplace?

17. 30 April 2008RCOG/ENTER Do you have formal briefing/debriefing sessions on your labour ward?

18. 30 April 2008RCOG/ENTER Survey of O&G staff LTH LWH SMH % staff working extra hours due to demands of job 93 70 72 % staff saying they work in teams1009795 % staff working in a well structured 295037 team environment Extracted from the National NHS Staff Survey 2005

19. 30 April 2008RCOG/ENTER Team communication Communication is central to team work Handover Briefing Debriefing Minimise parallel processes

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21. 30 April 2008RCOG/ENTER Flawless execution ‘If I failed to execute my mission properly there was an incredibly good chance I was going to be a smoking hole in the ground. Not a nice day. The pursuit of flawless execution was the dividing line between life and death….’

22. 30 April 2008RCOG/ENTER Flawless execution ‘Businesses rarely see execution as a process and almost never debrief’ Hospitals

23. 30 April 2008RCOG/ENTER Flawless execution ‘There were far too many examples around me that together seemed to say that flawless execution really didn’t matter….. if you failed to execute your mission properly, there was always another day’

24. 30 April 2008RCOG/ENTER Flawless execution …is not the pursuit of perfection …is all about expecting things could go wrong, and managing this risk

25. 30 April 2008RCOG/ENTER Flawless Execution cycle Plan – influence destiny by being proactive Brief – ‘the brief is the mission, the mission is the brief’ Execute - we know where we are and what we are going to do next Debrief - the enduring step Win – start another mission

26. 30 April 2008RCOG/ENTER Mission planning Identify threats Identify available resources Apply lessons learned Determine courses of action/tactics Plan for contingencies

27. 30 April 2008RCOG/ENTER Determine courses of action/tactics Mandatory to attach a timeline to the mission – who will do what, when?

28. 30 April 2008RCOG/ENTER Identify threats Internal and external Complacency, apathy Communication

29. 30 April 2008RCOG/ENTER Identify available resources Staff Training Environment

30. 30 April 2008RCOG/ENTER Flawless Execution cycle Plan – influence destiny by being proactive Brief – ‘the brief is the mission, the mission is the brief’ Execute - we know where we are and what we are going to do next Debrief - the enduring step Win – start another mission

31. 30 April 2008RCOG/ENTER Briefing ‘When one walks into a fighter pilot’s briefing room, first impressions are everything’ Sharpening the senses Standard operating procedures

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34. 30 April 2008RCOG/ENTER Situation awareness

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37. 30 April 2008RCOG/ENTER Flawless Execution cycle Plan – influence destiny by being proactive Brief – ‘the brief is the mission, the mission is the brief’ Execute - we know where we are and what we are going to do next Debrief - the enduring step Win – start another mission

38. 30 April 2008RCOG/ENTER Execution Task saturation - the biggest stumbling block to flawless execution Common responses to task saturation: quit – shut down compartmentalise – time sharing b/w important and unimportant tasks channelised attention – fixated on one thing

39. 30 April 2008RCOG/ENTER Task saturation – coping mechanisms Checklists – memory joggers and actions Cross-checks – never channelising, always scanning Mutual support – operating as a team

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41. 30 April 2008RCOG/ENTER CDU WARD ROUNDDATE: TIME: 08:30/13:00/17:00/21:30/01:00/05:00 If late: time and reason why - Present on WR

42. 30 April 2008RCOG/ENTER Effective communication Concise, clear; not a lot of filler material Extraneous conversation S.B.A.R

43. 30 April 2008RCOG/ENTER Flawless Execution cycle Plan – influence destiny by being proactive Brief – ‘the brief is the mission, the mission is the brief’ Execute - we know where we are and what we are going to do next Debrief - the enduring step Win – start another mission

44. 30 April 2008RCOG/ENTER Debrief The good, the bad and the ugly Open communication

45. 30 April 2008RCOG/ENTER Rankless debriefs ‘ When they cross the threshold of the briefing room door, they throw away their name and rank. All they bring in is truth, an open mind, and open communication. If there was a mistake they want to admit it in front of their peers, supervisors, or subordinates; if they’ve forgotten a mistake, a fellow pilot is going to point it out to them. A two-star general or a green lieutenant, they’re al on the same side of the table’

46. 30 April 2008RCOG/ENTER Rankless debriefs Failure to start at the top will lead to a failed debrief Inside outside approach – starting inside reaffirms the importance of rankless debriefs

47. 30 April 2008RCOG/ENTER The ‘Swiss cheese’ model of accident causation

48. 30 April 2008RCOG/ENTER System plus individual Mental skills People at the sharp end can thwart sequence

49. 30 April 2008RCOG/ENTER Improving safety in maternity care: focus on strategy as well as tactics Tactics are rarely decisive; it is strategy that makes the difference Iraq Apple

50. 30 April 2008RCOG/ENTER Conclusion The concept of flawless execution, borrowed from military aviation, can and should be applied in maternity care. This concept, in conjunction with other interventions, has potential to improve the safety of maternity care and reduce intrapartum mortality and morbidity.

51. Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers