Eleanor Robertson

Compliance and use of the World Health Organization checklist in U.K. operating theatres.

The World Health Organization (WHO) Surgical Safety Checklist is reported to reduce surgical morbidity and mortality, and is mandatory in the UK National Health Service. Hospital audit data show high compliance rates, but direct observation suggests that actual performance may be suboptimal.

Oxford NOTECHS II: a modified theatre team non-technical skills scoring system.

Background We previously developed and validated the Oxford NOTECHS rating system for evaluating the non-technical skills of an entire operating theatre team. Experience with the scale identified the need for greater discrimination between levels of performance within the normal range. We report here the development of a modified scale (Oxford NOTECHS II) to facilitate this. The new measure uses an eight-point instead of a four point scale to measure each dimension of non-technical skills, and begins with a default rating of 6 for each element. We evaluated this new scale in 297 operations at five NHS sites in four surgical specialities. Measures of theatre process reliability (glitch count) and compliance with the WHO surgical safety checklist were scored contemporaneously, and relationships with NOTECHS II scores explored. Results Mean team Oxford NOTECHS II scores was 73.39 (range 37–92). The means for surgical, anaesthetic and nursing sub-teams were 24.61 (IQR 23, 27); 24.22 (IQR 23, 26) and 24.55 (IQR 23, 26). Oxford NOTECHS II showed good inter-rater reliability between human factors and clinical observers in each of the four domains. Teams with high WHO compliance had higher mean Oxford NOTECHS II scores (74.5) than those with low compliance (71.1) (p = 0.010). We observed only a weak correlation between Oxford NOTECHS II scores and glitch count; r = −0.26 (95% CI −0.36 to −0.15). Oxford NOTECHS II scores did not vary significantly between 5 different hospital sites, but a significant difference was seen between specialities (p = 0.001). Conclusions Oxford NOTECHS II provides good discrimination between teams while retaining reliability and correlation with other measures of teamwork performance, and is not confounded by technical performance. It is therefore suitable for combined use with a technical performance scale to provide a global description of operating theatre team performance.

Interventions employed to improve intrahospital handover: a systematic review

Background Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/or safety of the intrahospital handover process. Methods We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes. Results 631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention. Conclusions The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required.

The effect of teamwork training on team performance and clinical outcome in elective orthopaedic surgery: a controlled interrupted time series study.

Objectives To evaluate the effectiveness of aviation-style teamwork training in improving operating theatre team performance and clinical outcomes. Setting 3 operating theatres in a UK district general hospital, 1 acting as a control group and the other 2 as the intervention group. Participants 72 operations (37 intervention, 35 control) were observed in full by 2 trained observers during two 3-month observation periods, before and after the intervention period. Interventions A 1-day teamwork training course for all staff, followed by 6 weeks of weekly in-service coaching to embed learning. Primary and secondary outcome measures We measured team non-technical skills using Oxford NOTECHS II, (evaluating the whole team and the surgical, anaesthetic and nursing subteams, and evaluated technical performance using the Glitch count. We evaluated compliance with the WHO checklist by recording whether time-out (T/O) and sign-out (S/O) were attempted, and whether T/O was fully complied with. We recorded complications, re-admissions and duration of hospital stay using hospital administrative data. We compared the before–after change in the intervention and control groups using 2-way analysis of variance (ANOVA) and regression modelling. Results Mean NOTECHS II score increased significantly from 71.6 to 75.4 in the active group but remained static in the control group (p=0.047). Among staff subgroups, the nursing score increased significantly (p=0.006), but the anaesthetic and surgical scores did not. The attempt rate for WHO T/O procedures increased significantly in both active and control groups, but full compliance with T/O improved only in the active group (p=0.003). Mean glitch rate was unchanged in the control group but increased significantly (7.2–10.2/h, p=0.002) in the active group. Conclusions Teamwork training was associated with improved non-technical skills in theatre teams but also with a rise in operative glitches.

A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series study

Background Teamwork training and system standardisation have both been proposed to reduce error and harm in surgery. Since the approaches differ markedly, there is potential for synergy between them. Methods Design: Controlled interrupted time series with a 3 month intervention and observation phases before and after. Setting: Operating theatres conducting elective orthopaedic surgery in a single hospital system (UK Hospital Trust). Intervention: Teamwork training based on crew resource management plus training and follow-up support in developing standardised operating procedures. Focus of subsequent standardisation efforts decided by theatre staff. Measures: Paired observers watched whole procedures together. We assessed non-technical skills using NOTECHS II, technical performance using glitch rate and compliance with WHO checklist using a simple quality tool. We measured complication and readmission rates and hospital stay using hospital administrative records. Before/after change was compared in the active and control groups using two-way ANOVA and regression models. Results 1121 patients were operated on before and 1100 after intervention. 44 operations were observed before and 50 afterwards. Non-technical skills (p=0.002) and WHO compliance (p<0.001) improved significantly after the intervention in the active versus the control group. Glitch count improved in both groups and there was no significant effect on clinical outcomes. Discussion Combined training in teamwork and system improvement causes marked improvements in team behaviour and WHO performance, but not technical performance or outcome. These findings are consistent with the synergistic hypothesis, but larger controlled studies with a strong implementation strategy are required to test potential outcome effects.

Capturing intraoperative process deviations using a direct observational approach: the glitch method.

Objectives To develop a sensitive, reliable tool for enumerating and evaluating technical process imperfections during surgical operations. Design Prospective cohort study with direct observation. Setting Operating theatres on five sites in three National Health Service Trusts. Participants Staff taking part in elective and emergency surgical procedures in orthopaedics, trauma, vascular and plastic surgery; including anaesthetists, surgeons, nurses and operating department practitioners. Outcome measures Reliability and validity of the glitch count method; frequency, type, temporal pattern and rate of glitches in relation to site and surgical specialty. Results The glitch count has construct and face validity, and category agreement between observers is good (κ=0.7). Redundancy between pairs of observers significantly improves the sensitivity over a single observation. In total, 429 operations were observed and 5742 glitches were recorded (mean 14 per operation, range 0–83). Specialty-specific glitch rates varied from 6.9 to 8.3/h of operating (ns). The distribution of glitch categories was strikingly similar across specialties, with distractions the commonest type in all cases. The difference in glitch rate between specialty teams operating at different sites was larger than that between specialties (range 6.3–10.5/h, p<0.001). Forty per cent of glitches occurred in the first quarter of an operation, and only 10% occurred in the final quarter. Conclusions The glitch method allows collection of a rich dataset suitable for analysing the changes following interventions to improve process safety, and appears reliable and sensitive. Glitches occur more frequently in the early stages of an operation. Hospital environment, culture and work systems may influence the operative process more strongly than the specialty.

Quality Improvement in Surgery Combining Lean Improvement Methods with Teamwork Training: A Controlled Before-After Study.

Background To investigate the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. We conducted a controlled interrupted time series study in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control. Study Design We used a 3 month intervention with 3 months data collection period before and after it. A combined teamwork training and lean process improvement intervention was delivered by an experienced specialist team. Before and after the intervention we evaluated team non-technical skills using NOTECHS II, technical performance using the glitch rate and WHO checklist compliance using a simple 3 point scale. We recorded complication rate, readmission rate and length of hospital stay data for 6 months before and after the intervention. Results In the active group, but not the control group, full compliance with WHO Time Out (T/O) increased from 14 to 71% (p = 0.032), Sign Out attempt rate (S/O) increased from 0% to 50% (p<0.001) and Oxford NOTECHS II scores increased after the intervention (P = 0.058). Glitch rate decreased in the active group and increased in the control group (p = 0.001). Complications and length of stay appeared to rise in the control group and fall in the active group. Conclusions Combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. We suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients.

Intentional Rounding: a staff-led quality improvement intervention in the prevention of patient falls

AIMS AND OBJECTIVES This study designed and evaluated the use of a specific implementation strategy to deliver a nursing staff-led Intentional Rounding intervention to reduce inpatient falls. BACKGROUND Patient falls are a common cause of harm during hospital treatment. Intentional Rounding has been proposed as a potential strategy for prevention, but has not received much objective evaluation. Previous work has suggested that logical interventions to improve patient care require an integrated implementation strategy, using teamwork training and systems improvement training, to instigate positive change and improvement. METHODS Customised Intentional Rounding was implemented and evaluated as part of a staff-led quality improvement intervention to reduce falls on a neuroscience ward. Intentional Rounding was instigated using a prespecified implementation strategy, which comprised of: (1) engagement and communication activities, (2) teamwork and systems improvement training, (3) support and coaching and (4) iterative Plan-Do-Check-Act cycles. Process (compliance with hourly visiting to patients by staff) and outcome (incidence of falls) measures were recorded pre- and postintervention. Falls measured on the active ward were compared with incidence of falls in 50 wards across the rest of the same Trust. RESULTS There was a 50% reduction in patient falls on the active ward vs. a minimal increase across the rest of the Trust (3·48%). Customised Intentional Rounding, designed by staff specifically for the context, appeared to be effective in reducing patient falls. CONCLUSIONS Improvement programmes based on integrating teamwork training and staff-led systems redesign, together with a preplanned implementation strategy, can deliver effective change and improvement. RELEVANCE TO CLINICAL PRACTICE This study demonstrates, through the implementation of a specific strategy, an effective improvement intervention to reduce patient falls. It provides insight into the effective design and practical implementation of integrated improvement programmes to reduce risk to patients at the frontline.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems.

Objective: To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies. Summary Background Data: Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs. Methods: Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3. Results: The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach. Conclusions: Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Observing and Categorising Process Deviations in Orthopaedic Surgery

This aim of this research was to identify events in the operating theatre process (described as glitches) during elective orthopaedic operations. Two pairs of observers, each consisting of a clinician and a human factors professional, examined primary and revision hip and knee arthroplasties, arthroscopies and knee ligament reconstructions in two UK hospitals. The categorisation procedure revealed 11 key areas of glitches within the collected data. Observations of 42 operations revealed 314 glitches within the 11 categories. The rate of glitches per operation ranged from 1 to 18, with an average of 8 per operation. Most commonly observed were distractions, equipment design and technical process deviation issues. A coordinated intervention to address a range of areas could benefit the efficiency and safety of orthopaedic surgery, and there are benefits in considering the standardisation of observation studies in the operating room.