A multiprofessional approach to improving theatre communication 25

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A multiprofessional approach to improving theatre communication 25 th Jan 2012 Lessons from The

A multiprofessional approach to improving theatre communication 25 th Jan 2012 Lessons from The Productive Operating Theatre Hugh Rogers, Consultant urologist, Senior Associate, NHS Institute, training faculty

The Productive Operating Theatre aim: To improve 4 key dimensions of quality

The Productive Operating Theatre aim: To improve 4 key dimensions of quality

How The Productive Operating Theatre has been developed Understand the real issues and challenges.

How The Productive Operating Theatre has been developed Understand the real issues and challenges. Identified coproduction partners: • NHS • Industry Observing high risk, lean organisations: Terminal 5, Unipart 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 Visiting other healthcare settings, UK & USA Internal & external peer review. Learning sets. Launch in Sept 2009, followed by regional startup 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.

The Boxed Set

The Boxed Set

Launched September 2009

Launched September 2009

Implementation support package Week 1 • Organisational Readiness Visit • Programme Implementation Training -days

Implementation support package Week 1 • Organisational Readiness Visit • Programme Implementation Training -days one and two for four members of the team Week 4 Weeks 4 -12 • One day Team-work Training for up to 100 participants • Four days Implementation Support enabling teams to tailor the programme to their particular needs Weeks 4 -12 • Programme Implementation Training -days 3 and 4 for four members of the team Week 12

Implementation support package Week 1 • Organisational Readiness Visit • Programme Implementation Training -days

Implementation support package Week 1 • Organisational Readiness Visit • Programme Implementation Training -days one and two for four members of the team Week 4 Weeks 4 -12 • One day Team-work Training for up to 100 participants • Four days Implementation Support enabling teams to tailor the programme to their particular needs Weeks 4 -12 • Programme Implementation Training -days 3 and 4 for four members of the team Week 12

Team performance: A key driver for improvement Team performance & Staff Well-being Safety &

Team performance: A key driver for improvement Team performance & Staff Well-being Safety & reliability of care Patient’s experience & outcomes Value & efficiency

Developing the training • Pilot sites had training from ex-pilots, experts in HF –

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

Session Outcomes Ø Understand harm and error in healthcare Ø Demonstrate how humans are

Session Outcomes Ø Understand harm and error in healthcare Ø Demonstrate how humans are all fallible Ø Ø Ø 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

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

Outline workshop agenda Lots of interactive elements, multi-media and group work Psychologist + clinician

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

We always start with interactive table session 5 minutes: Ø What have you already

We always start with interactive table session 5 minutes: Ø What have you already achieved? Ø What would you like to achieve? Ø What are your main challenges?

We always start with interactive table session 5 minutes: Ø Have you included human

We always start with interactive table session 5 minutes: Ø Have you included human factors & nontechnical skills in training? Ø Should you? Ø What are your main challenges?

How did that make you feel?

How did that make you feel?

Link to film from CHFG website www. chfg. org DVD available free from Safercare@institute.

Link to film from CHFG website www. chfg. org DVD available free from Safercare@institute. nhs. uk

Compelling evidence The National Reporting and Learning Service in England Wales: • 135, 000

Compelling evidence The National Reporting and Learning Service in England 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

Safety in healthcare compared with other activities In hospital mortality due to poor care

Safety in healthcare compared with other activities In hospital mortality due to poor care Blood Transfusion Mortality (UK) Chartered Flight Himalayan Mountaineering Coal Mining Microlight aircraft or Helicopters 10 -2 10 -3 VERY UNSAFE Road Safety Commercial Large Jet Aviation Railways Chemical Industry 10 -4 10 -5 Risk rate Nuclear Industry No system beyond this point Anaesthesia Mortality Surgical Mortality 10 -6 ULTRA Amalberti et al. An Int Med 2005

The complexity of disasters Wrong Engine, Kegworth Jan 1989

The complexity of disasters Wrong Engine, Kegworth Jan 1989

The ‘Swiss cheese’ model A systemic view Some holes due to active failures Losses

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

The complexity of disasters Wrong Kidney Llanelli Feb 2000

The complexity of disasters Wrong Kidney Llanelli Feb 2000

The Error Chain (Surgery) Safe Unsafe Question X-Rays back to front Duties assigned late

The Error Chain (Surgery) Safe Unsafe Question X-Rays back to front Duties assigned late Patient asleep Delay Transcription error Leave Cancelled operation

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

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

Exercise “Something that went wrong” Chat to another participant and exchange stories Describe what

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

Humans as hazards and heroes Invention & Improvisation Sheer professionalism Exceptional team-working

Humans as hazards and heroes Invention & Improvisation Sheer professionalism Exceptional team-working

Outline workshop agenda Lots of interactive elements, multi-media and group work Psychologist + clinician

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

What Affects Performance? Lack of sleep Tiredness Overwork Lack of attention Environment (e. g.

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

Typical ‘performance curve’

Typical ‘performance curve’

Types of Errors Lapses Skilled performance affected by memory failure Slips Skilled performance affected

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

HF demonstrations • Using a mix of – Film clips • The door study

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

How observant are you? • Why didn’t they notice? • Would you have noticed?

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…

What did you see? • What was in the picture? • How accurately can

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

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.

. . In the clinical context? Which drug? • Do___mine • Vin___tine

. . In the clinical context? Which drug? • Do___mine • Vin___tine

TALL MAN Lettering • Dobutamine • Dopamine Do. BUTamine DOPamine • Vinblastine • Vincristine

TALL MAN Lettering • Dobutamine • Dopamine Do. BUTamine DOPamine • Vinblastine • Vincristine Vin. BLAStine Vin. CRIStine Recently: Epinephrine vs Ephedrine • • www. ISMP. org http: //www. fda. gov/CDER/DRUG/Med. Errors/name. Diff. htm

Situational awareness • We build our situational awareness by piecing together fragments of information

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

Situational Awareness and Group Dynamics The smoke filled room experiment

Perceiving self & others • How do we see other people? – What does

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 Students are Nursing Students are Social Work Students think

Social Work Students are Medical Students are Nursing Students are Social Work Students think Medical Students think Nursing Students 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 Students are Nursing Students are Social Work Students think

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

Understanding the differences between us Merrill & Read’s framework: self-awareness and team-working

Understanding the differences between us Merrill & Read’s framework: self-awareness and team-working

Personal styles Analytical formal measured + systematic seek accuracy / precision dislike unpredictability and

Personal styles Analytical formal measured + systematic seek accuracy / precision dislike unpredictability and surprises Controls emotions Driver business like fast + decisive seek control dislike inefficiency and indecision Ask Amiable conforming less rushed + easy going seek appreciation dislike insensitivity and impatience Tell Expressive flamboyant fast + spontaneous seek recognition dislike routine and boredom Shows emotions

Think about how some of the human factors and phenoma you have seen might

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

Outline workshop agenda Lots of interactive elements, multi-media and group work Psychologist + clinician

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

Team-work • Essential clinical skill • Based on understanding of human factors • Non-technical

Team-work • Essential clinical skill • Based on understanding of human factors • Non-technical skills

t a e r Th Briefing & de-briefing k c a Thr eat Risk

t a e r Th Briefing & de-briefing k c a Thr eat Risk b d a e R Checkl ists Critical language PA CE Team performance and communication SB AR Risk y h c r a r hie r e t t Fla Threa t

Psychological Safety Flattening hierarchy People feel safe to speak up First names Clarity of

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

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)

Team-working Impact on culture (safety attitudes questionnaire) p<0. 05

Team-working Impact on culture (safety attitudes questionnaire) p<0. 05

Team-working

Team-working

The Model for Improvement Checkl ists k c ba d ea R Critical language

The Model for Improvement Checkl ists k c ba d ea R Critical language Team performance and communication SB AR archy r hier Flatte PA CE

Action planning What have you learned today? What will you do differently? What ideas

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

Debriefing principles

Debriefing principles