Presentation on theme: "Safer Surgical Services : Are system and culture interventions synergistic? Peter McCulloch, University of Oxford, England."— Presentation transcript:
Safer Surgical Services : Are system and culture interventions synergistic? Peter McCulloch, University of Oxford, England
Conflict of Interest Paid to give talks: No Paid for my advice: No Paid for me to attend Conferences: NIHR Funded my research: – NIHR (PGfAR Programme) – BUPA Foundation – Health Foundation
Waves of Safety Research Is there a problem? – IoM report How big is it? – Vincent et al, Gawande, What causes it? – Lingard, Sevdalis, Catchpole What works to fix it? Why does it work?
What do safety interventions do? Systems Improving Systems – Industrial QI engagement and PDCA approaches – SOP/Checklist approaches – IT based solutions Culture Enhancing Culture – CRM teamwork training – Supportive policies McCulloch, P. and Catchpole K. A three-dimensional model of error and safety in surgical health care microsystems. Rationale, development and initial testing. BMC Surg, : p
S3 Hypothesis Fixing CULTURE and SYSTEM provides SYNERGISTIC benefits to team performance
Testing the Hypothesis Multiple comparisons required Hugely variable environment/context Available process measures subjective Outcome measures very distal/insensitive Signal/Noise ratio therefore problematic
Programme Design Suite of identical CONTROLLED prospective studies Standardised, validated process and outcome measures used throughout. Planned meta-analysis to allow evaluation of over-arching questions
Study Design Pre-intervention data collection 3-6/12 Intervention Period 3- 6/12 Post-intervention data collection 3-6/12 Control group Control group in SAME TRUST, doing work of SIMILAR NATURE Observation and Intervention separation No blinding (Alas..) Observer pairs watch whole procedure
Measures Non-technical skillsOxford NOTECHS II Non-technical skillsOxford NOTECHS II Technical performanceGlitch rate Technical performanceGlitch rate Safety CultureWHO checklist adherence Safety CultureWHO checklist adherence LOS Clinical Outcome30 day complications 90 day readmissions PROMsEQ5D Measure of improvement: comparison of Before: After ratio for Active vs Control group
Interventions “Lean” Approach (System) – 1 day course plus coaching support during intervention period – Emphasised staff engagement and freedom to set agenda – Used 5S, process mapping, PDCA cycles, poka yoke etc Standardisation Approach (System) – 1 day course on standards and principles plus coaching support – Emphasised staff engagement and freedom to set agenda – Aimed to standardise and visualise work process Crew Resource Management training (Culture) – Based on previous study – 1 day course plus 6 weeks coaching – Partner with Atrainability
Results Orthopaedic, Trauma, Plastic and Vascular surgery observed 5 Hospital sites in 3 Trusts 453 operations observed >2,000 hours observer time in theatre 5,124 patient clinical outcomes analysed
Change in Oxford NOTECHS II [Change in Active – Change in Control] * p=0.047 * P = * p=0.058
Change in Glitch Count * p<0.001
Change in WHO compliance % Relative Improvement * P<0.001 * P=0.032
Relative Changes in Clinical Outcomes (%)
Conclusions & Reflections Single intervention modalities do what you would expect – but weakly Dual intervention increased both BREADTH and STRENGTH of response CULTURE Motivation Understanding of aims Focus Buy-in SYSTEM Understanding of systems Confidence Ability to Make change
Importance of Study Design Control groups essential Valid standard measures important Lack of blinding a weakness Challenges: – Hawthorne effects – Contamination It CAN be done!
Barriers & Future Research Compartments LACK: – TIME for IMPROVEMENT – KNOWLEDGE – SUPPORT – MOTIVATION Nurses & PAMS Junior Doctors Senior Doctors Middle Management RESEARCH IMPLICATIONS How to Upscale? Measuring Resistance Trialling Implementation plans Step-Wedge trial OR?
Radical Change? Strengthen line management Clarify Accountability Abolish professional silos
Thank You Captain Trevor Dale Dr Karen Barker Prof Renee Lyons Prof Damian Griffin Surgical Staff at: Oxford University Hospitals University Hospitals Coventry & Warwick Kettering District General Hospital Dr Steve New Dr Ken Catchpole Dr Lauren Morgan Sharon Pickering Mohammed Hadi Eleanor Robertson Laura Blakely