Christofer Rydenfält

Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements.

BACKGROUND Previous research suggests that the World Health Organization Surgical Safety Checklist time-out reduces communication failures and medical complications and supports development of better safety attitudes. Previous research also indicates that different values can affect the implementation of interventions. OBJECTIVE To investigate the actual usage of the checklist in practice and to catalogue deviations for the purpose of identifying improvements. DESIGN Twenty-four surgical procedures were video recorded. The time-out was analysed quantitatively assessing compliance with a predefined observational protocol based on the checklist and qualitatively to describe reasons for non-compliance. SETTING The operating unit of a Swedish county hospital. MAIN OUTCOME MEASURES Compliance with checklist items and the participation of different personnel groups. Activities were conducted during the time-out. RESULTS Highest compliance was associated with patient ID, type of procedure and antibiotics; the worst with site of incision, theatre nurse team reviews and imaging information. Team member introductions occurred in half of the operations. Surgeons and the anaesthesia team dominated the time-out. CONCLUSION The checklist is not always applied as intended. The components that facilitate communication are often neglected. The time-out does not appear to be conducted as a team effort. It is plausible that the personnels conception of risk and the perceived importance of different checklist items are factors that influence checklist usage. To improve compliance and involve the whole team, the concept of risk and the perceived relevance of checklist items for all team members should be addressed.

Safety checklist compliance and a false sense of safety: new directions for research

In recent years, checklists to improve patient safety have gained considerable support.1–,4 The most well-known checklist introduced for this purpose is probably the WHO surgical safety checklist.5 The WHO checklist consists of three parts: (1) the sign in before anaesthesia, (2) the timeout before incision and (3) the sign out before the patient leaves the operating room. Previous studies show that the WHO checklist reduces both complications from care and the 30-day mortality rate.2 ,3 These results are supported by other studies using similar checklist methodologies.1 ,6 Initially, the evaluation focus was on the effects of checklists using measures such as complications and mortality. Recently, though, researchers have started to pay attention to the actual usage of checklists in practice by investigating compliance.7–,10 The compliance rate reported in these studies could at best be considered as moderate. Rydenfalt et al 8 report a compliance of the timeout part of 54%, despite timeouts being initiated in 96% of the cases studied. In the study by Cullati et al ,7 the mean percentage of validated checklist items in the timeout was 50% and in the sign out 41%. Despite previous studies showing that both complications and 30-day mortality decreased,2 ,3 this raises the question: do safety checklists used with this level of compliance really make practice safer? Could it even be that the lack of compliance actually introduces new risks not present before? In the following viewpoint, we investigate the latter question from a safety science perspective to introduce new perspectives on the usage and implementation of checklists in healthcare and outline suitable directions for future research. ### The checklist as a defence against failure The main idea with checklists such as the WHO surgical safety checklist is to serve as a defence or barrier between …

Social structures in the operating theatre: how contradicting rationalities and trust affect work.

AIM This article is a report of a study of how healthcare professionals involved in surgery orientate themselves to their common task, and how this orientation can be affected by the social and organizational context. BACKGROUND Previous research indicates that surgical teams are not as cohesive as could be expected and that communication failures frequently occur. However, little is known about how these problems are related to their social, cultural and organizational context. METHODS Semi-structured interviews were conducted with 15 healthcare professionals, representing all personnel categories of the surgical team. During the interview, a virtual model, visualizing a real operating theatre, was used to facilitate reflection. The interviews were conducted in 2009. Themes were created from the interviews, with a focus on similarities and differences. An activity analysis was conducted based on the themes. FINDINGS Poor team functionality and communication failures in the operating theatre can to some degree be explained by differences in activity orientation between professions and by insufficient support from social and organizational structures. Differences in activity orientation resulted in different views between professional groups in their perceptions of work activities, resulting in tension. Insufficient support resulted in communication thresholds that inhibited the sharing of information. CONCLUSION Organizing work to promote cross-professional interaction can help the creation of social relations and norms, providing support for a common view. It can also help to decrease communication thresholds and establish stronger relations of trust. How this organization structure should be developed needs to be further investigated.

Distributed leadership in the operating room: a naturalistic observation study

Previous research shows that distributed leadership can improve performance and safety. Studies of leadership in the operating room have not considered distributed leadership, and the focus has primarily been on the leadership of the surgeon. The aim of this study was to explore leadership behaviors in the operating room and to test an approach to study leadership in complex socio-technical healthcare systems based on a distributed process perspective on leadership. Using an explorative naturalistic approach, ten surgical procedures were video recorded and observed. Based on predefined criteria, 248 leadership behaviors were identified and described. For each behavior, the person who was considered to be the leader was assigned according to profession. An inductive iterative process was used to develop nine leadership behavior categories grounded in the data. Our results show that while the surgeons conducted the most leadership, nurse anesthetists and scrub nurses also conducted leadership. The distribution of leadership differed from previous studies of surgeons’ leadership alone. Some behavior categories were more associated with specific professions, others more distributed over the whole team. Leadership behaviors associated with patient safety appeared to be more distributed. A distributed leadership perspective, as applied here, could give a more holistic view of work processes. To better use the potential of distributed leadership in relation to performance and safety, the distributed nature of leadership should be considered. With this in mind, it becomes obvious that a distributed leadership perspective can complement a traditional leader-centered perspective when studying complex socio-technical healthcare systems.

An action-oriented method for interprofessional organization development at a hospital operating unit

The complexity of modern interdisciplinary health care practices, where different specialties work together to solve complex problems, challenges traditional approaches to organizational development and quality improvement. An example of this is surgery. This article describes and evaluates an action-oriented method to facilitate organizational development and innovation at an operating unit, centered on interprofessional aspects of health care, a method that shares some features with action learning. At its core the method had a group with members from all specialties in an operating team, who participated in regular meetings facilitated by a process leader, according to experiential learning principles. The group was evaluated using mixed methods (including interaction process analysis (IPA)), of which video recorded group meetings and interviews constituted the main sources of data. Results showed that the group achieved a successful organizational change. Indications of the success of the group process were the low level of conflicts and the high level of task focus. Interprofessional boundaries appeared to be bridged as all members participated in formulation of both problems and solutions while not being afraid to voice different opinions. Problems could be attributed to lack of awareness of the group at the operating unit at which the intervention took place.

Driving for successful change processes in healthcare by putting staff at the wheel

Purpose The purpose of this paper is to describe five salient factors that emerge in two successful change processes in healthcare. Organizational changes in healthcare are often characterized by problems and solutions that have been formulated by higher levels of management. This top-down management approach has not been well received by the professional community. As a result, improvement processes are frequently abandoned, resulting in disrupted and dysfunctional organizations. This paper presents two successful change processes where managerial leadership was used to coach the change processes by distributing mandates and resources. After being managerially initiated, both processes were driven by local agency, decisions, planning and engagement. Design/methodology/approach The data in the paper derive from two qualitative case studies. Data were collected through in-depth interviews, observations and document studies. The cases are presented as process descriptions covering the different phases of the change processes. The focus in the studies is on the roles and interactions of the actors involved, the type of leadership and the distribution of agency. Findings Five factors emerged as paramount to the successful change processes in the two cases: local ownership of problems; a coached process where management initiates the change process and the problem recognition, and then lets the staff define the problems, formulate solutions and drive necessary changes; distributed leadership directed at enabling and supporting the staffs intentions and long-term self-leadership; mutually formulated norms and values that serve as a unifying force for the staff; and generous time allocation and planning, which allows the process to take time, and creates room for reevaluation. The authors also noted that in both cases, reorganization into multi-professional teams lent stability and endurance to the completed changes. Originality/value The research shows how management can initiate and support successful change processes that are staff driven and characterized by local agency, decisions, planning and engagement. Empirical descriptions of successful change processes are rare, which is why the description of such processes in this research increases the value of the paper.

Organizing for teamwork in healthcare : an alternative to team training?

Purpose The purpose of this paper is to explore how organizational design could support teamwork and to identify organizational design principles that promote successful teamwork. Design/methodology/approach Since traditional team training sessions take resources away from production, the alternative approach pursued here explores the promotion of teamwork by means of organizational design. A wide and pragmatic definition of teamwork is applied: a team is considered to be a group of people that are set to work together on a task, and teamwork is then what they do in relation to their task. The input - process - output model of teamwork provides structure to the investigation. Findings Six teamwork enablers from the healthcare team literature - cohesion, collaboration, communication, conflict resolution, coordination, and leadership - are discussed, and the organizational design measures required to implement them are identified. Three organizational principles are argued to facilitate the teamwork enablers: team stability, occasions for communication, and a participative and adaptive approach to leadership. Research limitations/implications The findings could be used as a foundation for intervention studies to improve team performance or as a framework for evaluation of existing organizations. Practical implications By implementing these organizational principles, it is possible to achieve many of the organizational traits associated with good teamwork. Thus, thoughtful organization for teamwork can be used as an alternative or complement to the traditional team training approach. Originality/value With regards to the vast literature on team training, this paper offers an alternative perspective on how to improve team performance in healthcare.

What do doctors mean when they talk about teamwork? possible implications for interprofessional care

ABSTRACT The concept of teamwork has been associated with improved patient safety, more effective care and a better work environment. However, the academic literature on teamwork is pluralistic, and there are reports on discrepancies between theory and practice. Furthermore, healthcare professionals’ direct conceptualizations of teamwork are sometimes missing in the research. In this study, we examine doctors’ conceptualizations of teamwork. We also investigate what doctors think is important in order to achieve good teamwork, and how the empirical findings relate to theory. Finally, we discuss the methodological implications for future studies. The research design was explorative. The main data consisted of semi-structured interviews with twenty clinically active doctors, analyzed with conventional content analysis. Additional data sources included field observations and interviews with management staff. There was large variation in the doctors’ conceptualizations of teamwork. The only characteristic they shared in common was that team members should have specific roles. This could have consequences for practice, because the rationale behind different behaviors depends on how teamwork is conceptualized. Several of the teamwork-enabling factors identified concerned non-technical skills. Future studies should put more emphasis on the practitioners’ perspective in the research design, to create a more grounded foundation for both research and practice.

Conceptual Design of E-health Services by, and for Support of, Home Care Staff

Together with staff from home care from four municipalities we investigated how e-health services can improve the work environment. In a series of four workshops we coached the participants in (1) describing their work process and pinpointing the problematic situations in the process, (2) formulating their wishes for an ideal work process, (3) conceptualizing how e-health solutions can be used to obtain the ideal work process and describing scenarios (4) illustrating the scenarios and the design process on storyboards. The storyboards describe, amongst other, how support through e-health systems may be used to: gain access to adequate information; get in touch with other professionals as doctors or other colleagues; prevent medication errors, and to transfer images or physiological data to an expert who can directly provide personal support.

Republished: Safety checklist compliance and a false sense of safety: new directions for research.

In recent years, checklists to improve patient safety have gained considerable support.1–,4 The most well-known checklist introduced for this purpose is probably the WHO surgical safety checklist.5 The WHO checklist consists of three parts: (1) the sign in before anaesthesia, (2) the timeout before incision and (3) the sign out before the patient leaves the operating room. Previous studies show that the WHO checklist reduces both complications from care and the 30-day mortality rate.2 ,3 These results are supported by other studies using similar checklist methodologies.1 ,6 Initially, the evaluation focus was on the effects of checklists using measures such as complications and mortality. Recently, though, researchers have started to pay attention to the actual usage of checklists in practice by investigating compliance.7–,10 The compliance rate reported in these studies could at best be considered as moderate. Rydenfalt et al 8 report a compliance of the timeout part of 54%, despite timeouts being initiated in 96% of the cases studied. In the study by Cullati et al ,7 the mean percentage of validated checklist items in the timeout was 50% and in the sign out 41%. Despite previous studies showing that both complications and 30-day mortality decreased,2 ,3 this raises the question: do safety checklists used with this level of compliance really make practice safer? Could it even be that the lack of compliance actually introduces new risks not present before? In the following viewpoint, we investigate the latter question from a safety science perspective to introduce new perspectives on the usage and implementation of checklists in healthcare and outline suitable directions for future research. ### The checklist as a defence against failure The main idea with checklists such as the WHO surgical safety checklist is to serve as a defence or barrier between …