Liberating Surgical Teams

1
Liberating Surgical Teams The People Why
dont we want to be a team?
Dr Adrian Hobbs I Dr Alan Bleakley
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Theatre Team Resource Management (TTRM)
projectRoyal Cornwall Hospitals Trust
Peninsula Medical School

• Improving patient safety and operating theatre
  efficiency
• Dr Alan Bleakley Reader in Clinical Education,
  Peninsula Medical School
• Dr Adrian Hobbs Consultant Anaesthetist, Royal
  Cornwall Hospital, Truro
• Dr Tony Simcock retired Consultant
  Anaesthetist, RCH, Truro
• Dr Paul Rich - Consultant Anaesthetist, RCH,
  Truro
• Mr Paul Peyser - Consultant GI Surgeon, RCH,
  Truro
• Mr Jon Allard Research Fellow, Peninsula
  Medical School
• Mrs Linda Walsh Theatres Manager, RCH, Truro
• Turning a team of experts into an expert team

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Does the day in your hospital ever start like
this?
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Coffee room brief
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What if this was a high risk industry?
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Why did they change?

• Accidents
• Aviation - 1972 Staines air crash
• Nuclear - 1979 Three Mile Island
• Space - 1986 Challenger space shuttle
• Shipping - 1987 Zeebrugge ferry
• Off-shore oil - 1988 Piper Alpha
• Rail - 1999 Paddington

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They became High Reliability Organisations by

• Changing their cultures
• Increasing organisational transparency
• Introducing
• - human factors education
• - briefing debriefing for all procedures (10
  min overall, 30 sec pre-procedure)
• - confidential near-miss reporting systems
  (feedback, responsive)
• Simulators

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Root cause

• 75-80 of errors are grounded in non-technical
  systems errors, where the basic system is the
  clinical team
• Cognitive skills
• Decision making
• Conflict resolution
• Situational awareness
• Social skills
• Teamworking
• Interpersonal communication
• Leadership followership What is right, not
  who is right

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Why havent we done the same in medicine?

• Drip drip vs. one jumbo every three days
• Blame cultures
• Non-transparent practices
• Traditional hierarchies
• - tribalism / silo mentality
• - stereotyping and simplifying others roles
• - multiprofessional vs. interprofessional

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Average rate per exposure of catastrophes and
associated deaths in various industries and human
activities
Surgery
Amalberti, R. et. al. Ann Intern Med
2005142756-764
Amalberti, R. et. al. Ann Intern Med
2005142756-764
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Components of TTRM

• Human factors (non-technical skills) education
• Team Self-Review (briefing debriefing)
• Close-Call Reporting
• Assessment
• SAQ
• Questionnaires
• In-depth interviews
• Debriefing logs close-call reports
• (Late starts, early finishes, sickness rates not
  used)

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Safety Attitudes Questionnaire
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Time out
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Communication and situational awareness

• Nine utterances.
• Seven statements.
• Two hostile rhetorical questions.
• Team communication is established through
  dialogue not monologue

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Communication site of tension time versus task

• Im off at 5 we dont have time to do the last
  case
• Surgeons - finish the task
• Scrub team - finish the shift (time)
• Anaesthetists - increasingly time oriented
• Result conflict

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Answer Briefing, to establish situational
awareness

• Whos on the team today? (affective/ morale/
  teambuilding) setting a climate for dialogue
  rather than monologue
• 2. Preparation (do we have the kit? Will we have
  the time?)
• 3. Situational awareness (cognitive/ are we all
  singing from the same song sheet?)

Who is in the team? What are we doing? Do we
have the kit? Any outside issues? Time?