TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD

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TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD

• Leroy Edozien

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5496 perinatal deaths in 2005

• Unexplained antepartum 33
• Congenital abnormality 17
• Prematurity 17
• Intrapartum deaths 11
• 2006 Risk of intrapartum stillbirth 1 in 1486

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Intrapartum stillbirth

• Failure to act on CTG
• Teamwork/communication
• Task saturation
• Loss of situation awareness
• Plan continuation bias

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Interventions to make childbirth safer, reduce
number of intrapartum stillbirths

• Safer Childbirth
• CNST/NHSLA
• Healthcare Commission
• Kings Fund
• RCOG Service Standards, Obstetrics

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Making maternity care safer

• First order v Second order
  change changeTransactional v
  Transformational change change

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Achieving change

• Systems resist change
• Changing a system by changing its centre of
  gravity
• It is far better to attack your centres of
  gravity in parallel all at once, rapidly

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Three themes

• No observations made for a prolonged period and
  therefore changes in a patients vital signs not
  detected
• No recognition of the deterioration and/or no
  action taken other than recording of observation
• Delay in the patient receiving medical attention,
  even when deterioration has been detected and
  recognised

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Contributory factors

• Communication the biggest problem area
• Work and environment
• Task factors
• Education and training
• Patient factors
• Team work and social
• Equipment and resources
• Individual factors

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Do you work in a team or teams?
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How do you rate the quality of teamwork in your
workplace?
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Do you have formal briefing/debriefing sessions
on your labour ward?
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Survey of OG staff

• LTH LWH SMH
• staff working extra hours
• due to demands of job 93 70 72
• staff saying they work in teams 100 97 95
• staff working in a well structured 29 50 37
• team environment
• Extracted from the National NHS Staff Survey
  2005

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Team communication

• Communication is central to team work
• Handover
• Briefing
• Debriefing
• Minimise parallel processes

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Flawless execution

• If I failed to execute my mission properly
  there was an incredibly good chance I was going
  to be a smoking hole in the ground. Not a nice
  day. The pursuit of flawless execution was the
  dividing line between life and death.

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Flawless execution
Hospitals

• Businesses rarely see execution as a process
  and almost never debrief

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Flawless execution

• There were far too many examples around me that
  together seemed to say that flawless execution
  really didnt matter..
• if you failed to execute your mission
  properly, there was always another day

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Flawless execution

• is not the pursuit of perfection
• is all about expecting things could go wrong,
  and managing this risk

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Flawless Execution cycle

• Plan influence destiny by being proactive
• Brief the brief is the mission, the mission is
  the brief
• Execute - we know where we are and what we are
  going to do next
• Debrief - the enduring step
• Win start another mission

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Mission planning

• Identify threats
• Identify available resources
• Apply lessons learned
• Determine courses of action/tactics
• Plan for contingencies

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Determine courses of action/tactics

• Mandatory to attach a timeline to the mission
  who will do what, when?

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Identify threats

• Internal and external
• Complacency, apathy
• Communication

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Identify available resources

• Staff
• Training
• Environment

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Flawless Execution cycle

• Plan influence destiny by being proactive
• Brief the brief is the mission, the mission is
  the brief
• Execute - we know where we are and what we are
  going to do next
• Debrief - the enduring step
• Win start another mission

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Briefing

• When one walks into a fighter pilots briefing
  room, first impressions are everything
• Sharpening the senses
• Standard operating procedures

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Situation awareness
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Flawless Execution cycle

• Plan influence destiny by being proactive
• Brief the brief is the mission, the mission is
  the brief
• Execute - we know where we are and what we are
  going to do next
• Debrief - the enduring step
• Win start another mission

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Execution

• Task saturation - the biggest stumbling block to
  flawless execution
• Common responses to task saturation
• quit shut down
• compartmentalise time sharing b/w important
  and
• unimportant tasks
• channelised attention fixated on one thing

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Task saturation coping mechanisms

• Checklists memory joggers and actions
• Cross-checks never channelising, always
  scanning
• Mutual support operating as a team

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CDU WARD ROUND DATE TIME 0830/1300/1700/21
30/0100/0500 If late time and reason why -
Present on WR
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Effective communication

• Concise, clear not a lot of filler material
• Extraneous conversation
• S.B.A.R

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Flawless Execution cycle

• Plan influence destiny by being proactive
• Brief the brief is the mission, the mission is
  the brief
• Execute - we know where we are and what we are
  going to do next
• Debrief - the enduring step
• Win start another mission

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Debrief

• The good, the bad and the ugly
• Open communication

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Rankless debriefs

• When they cross the threshold of the briefing
  room door, they throw away their name and rank.
  All they bring in is truth, an open mind, and
  open communication. If there was a mistake they
  want to admit it in front of their peers,
  supervisors, or subordinates if theyve
  forgotten a mistake, a fellow pilot is going to
  point it out to them. A two-star general or a
  green lieutenant, theyre al on the same side of
  the table

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Rankless debriefs

• Failure to start at the top will lead to a failed
  debrief
• Inside outside approach starting inside
  reaffirms the importance of rankless debriefs

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The Swiss cheese model of accident causation


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System plus individual
Mental skills
People at the sharp end can thwart sequence
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Improving safety in maternity carefocus on
strategy as well as tactics

• Tactics are rarely decisive
• it is strategy that makes the difference
• Iraq
• Apple

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Conclusion

• The concept of flawless execution, borrowed from
  military aviation, can and should be applied in
  maternity care.
• This concept, in conjunction with other
  interventions, has potential to improve the
  safety of maternity care and reduce intrapartum
  mortality and morbidity.

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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
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