1. OR Culture Part II If culture is the problem, what is the solution?
Dr. Mark Fleming

2. Outline Where are we? (Cultural typology) Improvement strategies
Engagement
Spread
Improvement
Assessment and improvement tools
Surveys
Team training

3. Safety Culture
A culture of safety can be defined as an integrated pattern of individual and organizational behavior, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999).

4. Where are you? Generative Improvement Safety mountain Orientated
Proactive
Bureaucratic
Reactive
Pathological
Status Quo

5. What level are you at? Pathological Reactive Bureaucratic Proactive
Toxic environment (shoot the messenger), people actively do not want to improve
Reactive
Passive ignoring of improvement initiatives, until something bad happens
Bureaucratic
Willing adoption of proven safety interventions
Proactive
Active development and evaluation of new safety interventions
Generative

6. Engagement
Identify one (or more) supportive Physician to pilot checklist and promote benefits to colleagues
Highlight need to change by identifying failures that could have been prevented
Conduct team survey to highlight communication problems

7. Spread Track levels of checklist use
Ask those who are not using the checklist why they are not using it
Get current users to present benefits to colleagues (e.g. grand rounds)
Create information sheet promoting benefits
Get supportive dept heads to discuss checklist use with non users

8. Improvement Develop quality audit
Develop checklist of key behaviours (timing, attention of team members etc)
Develop schedule to observe each physician using audit
Provide individual and group feedback
Survey staff groups about how the audit is being used

9. Surveys Modified Stanford Instrument MapSaF ORMAQ
Used by accreditation Canada,
Does not measure team work
MapSaF
Developed for use in NHS, not sure about copyright issues for use in Canada
ORMAQ
Items are published, includes teamwork

10. ORMAQ teamwork items
17. The only people qualified to give me feedback are members of my own profession.
18. It is better to agree with the operating theatre team members than to voice a different opinion.
22. The doctor’s responsibilities include co-ordination between his or her work team and other support areas.
25. Operating theatre team members share responsibilities for prioritizing activities in high workload situations.
31. I enjoy working as part of a team.
44. To resolve conflicts, team members should openly discuss their differences with each other.
48. All members of the operating theatre team are qualified to give me feedback.
54. The concept of all operating theatre personnel working as a team does not work at this hospital.
56. Effective operating theatre team co-ordination requires members to take into account the personalities of other team members.

11. Team Training
Dr. Donald Moorman (Beth Israel Deaconness Hospital in Boston) developed a 3 hour knowledge based team training program, based on CRM
There is some evidence that it is effective
Reduction in errors and adverse events
Increase in teamwork behaviours
Adapted for Canadian teams with permission by:
Mark Taylor, Lesia Yasinski and Mike Rodgers

12. References
Kizer, K. W Large system change and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient Safety Foundation.
Manchester Patient Safety Framework (MaPSaF)
Sexton J, Helmreich RL, Thomas E. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-50
Fleming, M., Smith, S. Slaunwhite, J. & Sullivan, J. (2006). Investigating interpersonal competencies in cardiac surgery teams. Canadian Journal of Surgery, Vol 49 No 1.
Team Training materials files.me.com/markfleming/u3l77t

13. Team training video links
files.me.com/markfleming/4xvafh
files.me.com/markfleming/9pp0b6
files.me.com/markfleming/cm7cfk
files.me.com/markfleming/dwoxeo
files.me.com/markfleming/13b8vo
files.me.com/markfleming/qcu7gr