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Synergistic Interventions in Surgical Safety: Understanding Culture and System Enhancements

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21 diapositives · 342 Views · Oct 01, 2014

This presentation by Peter McCulloch from the University of Oxford explores the synergistic effects of culture and system interventions on surgical safety. The discussion highlights research outcomes that demonstrate the efficacy of combined strategies like Lean and Crew Resource Management training. It also addresses the variability in surgical contexts and the importance of robust study design, using controlled studies to measure non-technical skills and clinical outcomes. Through this work, insights into improving surgical performance and fostering a safety-oriented culture are provided.

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  1. Safer Surgical Services: Are system and cultureinterventions synergistic? Peter McCulloch, University of Oxford, England

  2. Conflict of Interest • Paid to give talks: No • Paid for my advice: No • Paid for me to attend Conferences: NIHR • Funded my research: • NIHR (PGfARProgramme) • BUPA Foundation • Health Foundation

  3. 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?

  4. What do safety interventions do? • Improving Systems • Industrial QI engagement and PDCA approaches • SOP/Checklist approaches • IT based solutions • 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, 2011. 11: p. 23-7.

  5. S3 Hypothesis • Fixing CULTURE and SYSTEM provides SYNERGISTIC benefits to team performance

  6. Testing the Hypothesis • Multiple comparisons required • Hugely variable environment/context • Available process measures subjective • Outcome measures very distal/insensitive • Signal/Noise ratio therefore problematic

  7. 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

  8. Study Design • Pre-intervention data collection 3-6/12 • Intervention Period 3-6/12 • Post-intervention data collection 3-6/12 • Control group in SAME TRUST, doing work of SIMILAR NATURE • Observation and Intervention separation • No blinding (Alas..) • Observer pairs watch whole procedure

  9. Measures • Non-technical skills Oxford NOTECHS II • Technical performance Glitch rate • Safety Culture WHO checklist adherence LOS • Clinical Outcome 30 day complications 90 day readmissions • PROMs EQ5D Measure of improvement: comparison of Before: After ratio for Active vs Control group

  10. 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

  11. Studies and Settings • CRM alone: Kettering DGH (Ortho/Vascular) • SOP alone: Nuffield Orthopaedic Centre (Hip/Knee teams) • Lean alone: UHCW Trust (Trauma/Ortho) • CRM & SOP: UHCW Trust (Hip/Knee teams) • CRM & Lean: NOC (Plastics/Hip & Knee)

  12. 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

  13. Change in Oxford NOTECHS II[Change in Active – Change in Control] * P = 0.002 * p=0.058 * p=0.047

  14. Change in Glitch Count * p<0.001

  15. Change in WHO compliance% Relative Improvement * P<0.001 * P<0.001 * P=0.032

  16. Relative Changes in Clinical Outcomes (%)

  17. 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

  18. Importance of Study Design • Control groups essential • Valid standard measures important • Lack of blinding a weakness • Challenges: • Hawthorne effects • Contamination • It CAN be done!

  19. 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?

  20. Radical Change? • Strengthen line management • Clarify Accountability • Abolish professional silos

  21. 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