100 years of living science May 1 st, 2008 Risk Management and Medico-Legal Issues in Women’s Health; RCOG Assessing and improving teamwork in the operating theatre Dr. Nick Sevdalis Dept. of Bio-Surgery & Surgical Technology

Workshop aims (i) To present a tool that assesses teamwork in the context of surgery (30mins) Observational Teamwork Assessment for Surgery (OTAS) © Initial conceptual and empirical work Familiarisation with tool (ii) To systematically modify OTAS for use in obstetric teams context (90mins)

Why assessment of teams Adverse events in surgery Much research devoted to investigation of team training and performance in other high risk industries… …but not in healthcare and surgery Adopting “systems approach” to safety

Surgical performance: from THE surgeon… Patient Risk Factors Outcome Technical skills

… to SURGERY Patient Risk Factors Individual skills (motor, cognitive, etc.) Teamwork & communication Operative environment & procedures Outcome National regulations

Outline of the empirical work Pilot study Current perceptions Observational studies (2) Observational Teamwork Assessment for Surgery (OTAS)

Pilot study Aim: To explore the perceptions and beliefs that operating theatre staff have of teams and teamwork in theatre Methods: 24 semi-structured interviews with members from the main groups in theatre Surgeons, Anaesthetists, Nurses, ODPs

Role understanding

Importance of communication

Importance vs. quality

Summary Team-members tends to overrate their understanding of others’ roles (especially surgeons) Communication between A-S is considered of high importance but the data suggests the quality falls short No agreement regarding current team structure Dissatisfaction with current structure

First observational study Aim: to develop an observational assessment tool for teamwork in surgery “Observational Teamwork Assessment for Surgery” (OTAS) Methods: Phases and stages for observations with 2 observers (surgeon & psychologist) Develop observation tool 50 procedures in general surgery

Teamwork as part of the operative process

Phases and stages PhaseStage 1Stage 2Stage 3 Pre-Op Pre Op planning & preparation Patient ‘sent for’ to Anaesthesia Patient set up to Op readiness Intra-Op Incision to reaching target organ Op specific procedure Prep to close to closure complete Post-Op Reversal of anaesthesia to exit Recovery and transfer Feedback and self assessment

Operationalising these ideas Literature review on teamworking in other industries Observational approach in real operating theatres 3 operative stages (pre, intra-, and post-operative) 2 observers (surgeon & psychologist) 2 arms in the observation Teamwork-related tasks Teamwork-related behaviours

Observers and observation tools SURGEON: TASK CHECK-LIST (yes/no) Equipment/provisions Patient Communication PSYCHOLOGIST: BEHAVIOURS (0-6, anchors, exemplars, scenarios) Communication Coordination Cooperation/Back-up behaviour Leadership Monitoring/Awareness

The 5 behaviours Communication: it refers to the quality and to the quantity of the information exchanged among members of the team Coordination: it refers to the management and to the timing of activities and tasks Cooperation/Back-up behaviour: it refers to assistance provided among members of the team, supporting others, and correcting errors Leadership: it refers to the provision of directions, assertiveness, and support among members of the team Monitoring/Awareness: it refers to team observation and awareness of on-going processes

Stage duration

Team-members in theatre

Summary of task completion

Examples… YesNo Safe transfer100%0 Check for burns100%0 Notes with pt88%12% Diathermy checked62%38% Briefing4%96% Anaes logbook28%72% Changes/ delays70.83%29.17%

Behaviours

Summary Team observations are feasible Team performance can be broken down to measurable simpler parts Both observers rated Communication lower than other tasks and other behaviours Different patterns were observed across operative stages

Second observational study Modifications In the task-list: shorter In the behaviours: included exemplars and demonstrative scenarios Assessment of different sub-teams Surgeons; Anaesthetists; Nurses Reliability analysis Split sites; 50 Urology cases

Results: task completion (comparative) Pre-opIntra-opPost-op SurgUrolSurgUrolSurgUrol Equip56%61%82%91%89%95% Comm61%71%55%57%90%84% Patient90%94%93% 97%92%

Urology: Behaviours, pre-operative phase

Urology: Behaviours, intra-operative phase

Urology: Behaviours, post-operative phase

Behaviours: reliability Observer 2 Communicat ion Coordina tion Cooper ation Leader ship Monitori ng Obs 1 Communication.35 *.29 *.43 **.39 **.42 ** Coordination.72 ***.82 ***.75 ***.81 *** Cooperation.57 ***.49 ***.64 ***.52 ***.55 *** Leadership.59 ***.53 ***.69 ***.62 ***.58 *** Monitoring.43 **.42 **.56 ***.46 **.53 ***

Behaviours: summary Nurses: High on Cooperation, followed by Monitoring and Coordination Low on Communication and Leadership Anaesthetists & Surgeons: Highest on Cooperation Lowest on Communication

Summary Task completion: similar patterns across specialities Behaviours: lowest in communication OTAS can be used to observe and assess team-working in real time It can also be used in other contexts (e.g., simulation for training) to structure feedback/debriefing sessions

The rest of today Moving fields: team-working in obstetric teams Similar and dissimilar aspects in the clinical environment and team-working aspects Second key aim of the workshop: Adapting/modifying OTAS for use in obstetric teams

Revision steps Step 1: revise “phases and stages” (i.e., process) Step 2: revise task checklist Step 3: revise exemplar behaviours

Revision sequence Steps 1 & 2 to be achieved today and followed up via (Could start on Step 3, depending on time) Possibly pilot locally (volunteer sites?) Publish revised tool with this Expert Group as a collective author

Revision process (i) 2 groups (30mins total) Round 1: Revise “phases & stages” separately (15mins) Round 2: get together, swap documents, compare, and agree (15mins) Possibly 4 groups (60mins) Round 1: Groups 1 & 2: revise pre-op 1 to intra-op 1 (35mins) Round 1: Groups 3 & 4: revise intra-op 2 to post-op 2 (35mins) Round 2: get together, swap documents, compare, and agree (25mins)

Revision process (ii) One person in each group to record: Names/ s of participants Specialities Round of revision (1 or 2) (Whether each task is in/out/possibility) Optional: for each task (existing or new) record: Definitely in Definitely out Possibly in/out

Phases and stages (original to be revised) PhaseStage 1Stage 2Stage 3 Pre-Op Pre Op planning & preparation Patient ‘sent for’ to Anaesthesia Patient set up to Op readiness Intra-Op Incision to reaching target organ Op specific procedure Prep to close to closure complete Post-Op Reversal of anaesthesia to exit Recovery and transfer Feedback and self assessment

Revised phases and stages (draft 1) Phase / StageStage 1Stage 2Stage 3Stage 4 pre-op theatreRisk assessment Decision-making and communication of info/consent Prep patient and theatre Transfer to theatre Intra-op theatre preparation in theatre, incl anesthetic prep Knife to skin to delivery Up to skin closure; Complete surgery: anesthetic reversal; mother; neonate assessed and received transfer off table; care for neonate Post-op theatre Recovery for mother; care for neonate Transfer to ward and debriefing family Self-assessment and feedback

Revised phases and stages (draft 2) Phase / StageStage 1Stage 2Stage 3 Pre- labour/partum (tbc) Insert Intra- labour/partum (tbc) Insert Post- labour/partum (tbc) Insert