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Surgical Safety Checklist
A story
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2008
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Design Checklists don’t have to be comprehensive – they need to focus on the critical steps Getting the wording right – simple, usable, applicable Pause points – plus briefing and debriefing
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Aim Create a culture of teamwork
Create rigour and discipline in a high risk process Get the ‘dumb stuff’ out the way Reduce harm and save lives
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2009
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I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It is the complexity that science has dropped upon us and the enormous strains we are encountering in making good on its promise. Atul Gawande
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Knowledge has both saved us and burdened us.
The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably. Knowledge has both saved us and burdened us. Atul Gawande
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We need a different strategy for overcoming failure, one that builds on experience …but somehow also makes up for our inevitable human inadequacies. And there is such a strategy, though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist Atul Gawande
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Simplicity Complexity Profound simplicity William Schultz
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Work as imagined versus work as done
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Or in more detail… Work as imagined Work as prescribed Work as done
Potential fantasy – people who don’t know about real work and imagine what should happen set standards or guidelines for others to enforce and wonder why they don’t work Work as prescribed Working ‘by the book’ - work carried out is per the rules or policies because it has to be e.g. radiotherapy Work as done The messy reality – work may not be carried in accordance with policy but this is the way in which people get through their tasks or day Work not as disclosed Work carried out is not in accordance with official policy and others would find it unacceptable so it is not discussed
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Incivility Kindness
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Kindness [the quality of being friendly, generous, and considerate]
To give and receive kindness increases morale Everyday Prosociality in the Workplace: The reinforcing benefits of giving, getting and glimpsing -Chancellor J, Margolis S et al; Emotion 2017 June 5
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[rude or unsociable speech or behaviour]
incivility [rude or unsociable speech or behaviour]
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Recipients of minor incivility
experience an immediate loss of cognitive capacity lose time worrying about the rudeness reduce the quality of their work reduce their time at work take it out on service users Dr Chris Turner References via:
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Incivility shuts people down and silences them Grandstanding Gender Seniority Status Titles Groups
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Patients pay the price of failed conversations
The inability to speak up The inability to listen The failure to respond
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Avoidable or unavoidable
Are you really listening or are you just waiting your turn to talk? Robert Montgomery
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Briefing and debriefing
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Talk Listen Debriefing Briefing
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Essential components What went as planned? What went ok?
What would we like to replicate? What could we do differently? Anything that needs escalating? What has been actioned? What do we need to pass on? What shall we pick up at the briefing tomorrow?
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Essential behaviours Facilitation Kindness Respect Curiosity
Speaking up Listening Responding
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What we now know – checklists…
Help people talk to each other Help people develop relationships however brief Help with interactions and connections Give people identity and names Make the invisible visible Help people have a voice Are never about compliance
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Catalyst Session 1 In the spirit of ‘safety II’.. Discuss the debrief in your organisation…[using trio methodology] What works well? What adjustments do people make to ensure things work? What interpretations are made in order to succeed? How could we replicate good practice?
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Trio methodology 3 people 3 rounds of 20 mins each Story teller
Listener Observer 3 rounds of 20 mins each Story teller shares what happens in their organisation for 10 minutes Listener asks clarifying or probing questions for 5 minutes Observer is the time keeper and feeds back what they have heard and all agree and write down the key messages from the round THEN each person changes roles until all have played each role
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Lunch
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Catalyst Session 2 Step 1 (20 mins) Step 2 (40 mins)
Review notes from catalyst session 1 - across all three stories What were the challenges? What worked well? What adjustments did people make to ensure things work? What interpretations were made in order to succeed? What could we do to replicate good practice? How do we get away from the compliance culture? Create one flip chart / scribble sheet that describes the 3 things you will do when you get back to work Step 2 (40 mins) Feedback session facilitated by Suzette Build on the 3 things together to find partners and ideas
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Behavioural insights Using the findings of the behavioural and social sciences to help people achieve their goals and to improve the effectiveness of policy without requiring anyone to do anything!
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The by now famous example
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We are perpetually bombarded by subtle influences and cues
Fire doors Shop layouts How a form is written Advertising Language
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Examples Supermarkets – full of behavioural engineering
Colours (reds and greens make each other stand out more) Prices – 2 for one, one for £2 or three for £5 Packaging Smells Checkout items Changing the colour of an envelope makes it more attractive Addressing a person by their name can increase the impact of a communication or intervention Providing immediate feedback changes behaviour e.g. smart speed signs
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Easy Attractive Social Timely
EAST Easy Attractive Social Timely
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Make it easy People are much more likely to do something if it is easy and low-hassle Simplify Remove barriers Set defaults that provide the path of least resistance
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Examples Reduce suicide by removing ligature points
Increase pension use by employers who automatically enrol workers into pension plans The opt in or opt out of organ donation The settings of your smart phone Provide prompts or reminders to do something such as diary reminders or computer alerts
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Make it attractive People who are drawn to that which catches their attention Personalise – use people’s names Make it relevant Make a key point stand out Think about the messenger – experts and named individuals beat anonymised or distrusted sources Incentivise Use emotion
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Examples Making something we know we ought to do more appealing
Reward and recognition Awards Air miles Supermarket points Creating a game which incentives different actions Being motivated to ‘doing good’ – recycling, towels in hotel rooms
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Making something attractive by using humour, fun and curiosity
Making healthy food more fun Cutting food into sun shapes Games, video content aimed at encouraging people to exercise more Safety messages on airplanes such as Virgin Atlantic (cartoon with key visuals and music from famous films) or Air New Zealand (delivered by children)
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Make it social People are strongly influenced by what others are doing or have done People are influenced by networks, friends and colleagues Reciprocity and active commitments or promises trigger action
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Reciprocity Someone on the train goes to the toilet leaving their bag and someone tries to steal it Most would not intervene Someone catches your eye and smiles at you as they go to the toilet leaving their bag and someone tries to steal it You are more likely to intervene Someone turns to you and asks you to keep an eye on their bag while they are away and someone tries to steal it Most would intervene
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Social influences Know about what influences the social context you are working in How people influence each other, the body language, the words used, how people follow Understand the social norms, rules, behaviours and values of the people you want to change The power of the group – the diffusion of responsibility e.g. the famous ‘smoke filled room’ The power of the clues
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Social - shock tactics Anti-smoking campaigns
Road traffic accident campaigns Calorie labelling rather than units of alcohol on drinks a glass of wine is equivalent to a slice of cake
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Examples We are 8 times more likely to drop a flyer if others are already on the ground We are more likely to comply with environmental behaviours (not having the sheets changed every day) if we know that is what other people do 7 times more likely to give a donation when a colleague has already done so
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Make it timely Interventions are more effective before habits have formed or the behaviour has been disrupted Examples: We are more likely to give to charity before Christmas People who have suffered a heart attack may desire advice about how they and others in their family might change their behaviour Adults may become more interested in their own learning when their children start going to school People who have moved from being unemployed may be more happy to help someone else in the same situation
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Communication It matters who the messenger is
Role modelling – the behaviours of others shapes and amplifies what we do Tone, style and language Be human, be personal
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