Mohammed Hadi

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.

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.

Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program.

Importance: Patient safety improvement interventions usually address either work systems or team culture. We do not know which is more effective, or whether combining approaches is beneficial. Objective: To compare improvement in surgical team performance after interventions addressing teamwork culture, work systems, or both. Design: Suite of 5 identical controlled before–after intervention studies, with preplanned analysis of pooled data for indirect comparisons of strategies. Setting: Operating theatres in 5 UK hospitals performing elective orthopedic, plastic, or vascular surgery Participants: All operating theatres staff, including surgeons, nurses, anaesthetists, and others Interventions: 4-month safety improvement interventions, using teamwork training (TT), systems redesign and standardization (SOP), Lean quality improvement, SOP + TT combination, or Lean + TT combination. Main Outcomes and Measures: Team technical and nontechnical performance and World Health Organization (WHO) checklist compliance, measured for 3 months before and after intervention using validated scales. Pooled data analysis of before—after change in active and control groups, comparing combined versus single and systems versus teamwork interventions, using 2-way ANOVA. Results: We studied 453 operations, (255 intervention, 198 control). TT improved nontechnical skills and WHO compliance (P < 0.001), but not technical performance; systems interventions (Lean & SOP, 2 & 3) improved nontechnical skills and technical performance (P < 0.001) but improved WHO compliance less. Combined interventions (4 & 5) improved all performance measures except WHO time-out attempts, whereas single approaches (1 & 2 & 3) improved WHO compliance less (P < 0.001) and failed to improve technical performance. Conclusions & Relevance: Safety interventions combining teamwork training and systems rationalization are more effective than those adopting either approach alone. This has important implications for safety improvement strategies in hospitals.

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.

Simulation provides a window on the quality and safety of the system

Interest in patient safety and human error in medicine over he last 15 years was initiated through a growing realisation that ealthcare does not always deliver the care that was intended.1 nitially the focus on was understanding what had gone wrong by ooking at events after the fact, which can provide a window now nly into what can go wrong, but also how and why the system orks at all.2 However, responding only when injury occurs has wo major drawbacks. The first is that it is deeply undesirable to ave to learn lessons after a tragedy. The second is that all such xaminations are prone to hindsight bias, which makes it difficult o work out exactly why the erroneous chain of decisions seemed erfectly rational and appropriate at the time.3 It is becoming more mportant to look beyond individual performance to understand ow the working environment and healthcare systems in which linicians work create the situations in which errors happen. By oing so, it might be possible to develop better systems of work that ot only reduce errors, but are more efficient and help clinicians to erform better every day. To understand the minor imperfections in the process that can ventually accumulate to create errors, direct observation is probbly the best – and possibly only – method. As a result, the process f care delivery – not why something is done, or to what end, ut how it is done – has been studied in the last decade in more etail than ever before. Research became increasingly frequent that escribed the systematic observation of dynamic healthcare situaions in different healthcare contexts. Deviations from the optimal are process – sometimes substantial and safety-critical – were xtremely frequent, disruptive, added to the risk, and in a few cases o demonstrable effects on outcome.4–7 More usually, however, his research merely counted the frequency and types of workflow nterruptions, sometimes failing to describe the causes on account f the complexity of the sources, and often failing to make direct inks with outcome, on account of the indirect relationship with rocess. Around the same time, the combination of research, enabling echnologies, and changes in training demands contributed to a uge and rapid growth in simulation techniques and application. nitially this was used for the training of individual technical skills,8 ut as techniques, technologies and expertise improved, this was xtend to whole team, and whole task simulation, with technial and non-technical (teamwork) training combined.9,10 Though xpensive, with the required levels of fidelity and efficacy as yet ot clearly evidenced, this enthusiasm and socio-technical enabling rove an explosion in the availability and use of simulation. There re still insufficient resources to emulate the extent or fidelity of pplication in other industries, but simulation is now part of the

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.

Lean Participative Process Improvement: Outcomes and Obstacles in Trauma Orthopaedics.

Objectives To examine the effectiveness of a “systems” approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches. Setting A controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control. Participants All staff involved in surgical procedures in both theatres. Interventions A one-day “lean” training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements. Outcome Measures We compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, “glitch count” and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance. Results We studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention. Conclusions This version of “lean” system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in “lean” projects. Space and time for staff to conduct improvement activities are important for success.