100 years of living science

May 1st, 2008 Risk Management and Medico-Legal Issues in Women’s Health; RCOG

Assessing and improving teamwork in the operating theatreDr. Nick Sevdalis Dept. of Bio-Surgery & Surgical Technologyn.sevdalis@imperial.ac.uk

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

FactorsOutcome

Technical skills

… to SURGERY

Patient Risk

Factors

Individual skills (motor, cognitive, etc.)

Teamwork & Teamwork & communicationcommunication

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

Relative order of importance of communication

0

1

2

3

4

5

6

7

8

S-ODA CN-ODA

A-S A-ODA A-SN SN-CN SN-ODA

S-SN

Communicators

Rat

ing

orde

r S

SN

ODA

A

Importance vs. quality

Team rating of quality & relative order of importance to surgical outcome

0

1

2

3

4

5

S-ODA CN-ODA

A-S A-ODA A-SN SN-CN SN-ODA

S-SN

Communicators

Rat

ing

0

1

2

3

4

5

6

7

Ord

er

Team Rating

Importance

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” Observational Teamwork Assessment for Surgery” (OTAS)(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

Phase Stage 1 Stage 2 Stage 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

Mean average time duration for stages of surgical process (n=50)

0

10

20

30

40

50

PRE2 PRE2A PRE3 OP1 OP2 OP3 POST1

Stage

Mean

(m

inu

tes)

Team-members in theatre

Presence in theatre

0

20

40

60

80

100

Pre2 Pre3 Op1 Op2 Op3 Post1

Stage of operation

% p

res

en

t (N

=5

0)

S

SN

CN

A

ODA

Summary of task completion

Summary of tasks completed

0

25

50

75

100

Pre Op Post

Operative phase

Mea

n p

erce

nt

com

ple

ted

Equip

Comm

Patient

Examples…

Yes No

Safe transfer 100% 0

Check for burns 100% 0

Notes with pt 88% 12%

Diathermy checked 62% 38%

Briefing 4% 96%

Anaes logbook 28% 72%

Changes/ delays 70.83% 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-op Intra-op Post-op

Surg Urol Surg Urol Surg Urol

Equip 56% 61% 82% 91% 89% 95%

Comm 61% 71% 55% 57% 90% 84%

Patient 90% 94% 93% 93% 97% 92%

Pre-op behaviours

4

4.5

5

5.5

6

Comm Coord Lead Monitor Coop

pre op Anaes

pre op Surg

pre op Nurse

Urology: Behaviours, pre-operative phase

Intra-op behaviours

4

4.5

5

5.5

6

Comm Coord Lead Monitor Coop

intra op Anaes

intra op Surg

intra op Nurse

Urology: Behaviours, intra-operative phase

Urology: Behaviours, post-operative phase

Post-op behaviours

4

4.5

5

5.5

6

Comm Coord Lead Monitor Coop

Post op Anaes

Post op Surg

Post op Nurse

Behaviours: reliability

Observer 2

Communication

Coordination

Cooperation

Leadership

Monitoring

Obs 1

Communication .35* .29* .43** .39** .42**

Coordination .72*** .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 email

• (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/emails 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)

Phase Stage 1 Stage 2 Stage 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 / Stage Stage 1 Stage 2 Stage 3 Stage 4

pre-op theatre Risk assessment Decision-making

and communication of info/consent

Prep patient and theatre

Transfer to theatre

Intra-op theatrepreparation 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 theatreRecovery for

mother;

care for neonate

Transfer to ward and debriefing

familySelf-assessment and

feedback

Revised phases and stages (draft 2)

Phase / Stage Stage 1 Stage 2 Stage 3

Pre-labour/partum

(tbc)Insert Insert Insert

Intra-labour/partum (tbc)

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Post-labour/partum (tbc)

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