Operating Theatre Management Conference

Professional collaboration in and outside of the Operating Theatre Room

Prof Owen A UngChair RACS Queensland Regional Committee

University of QueenslandRoyal Brisbane and Women’s Hospital

Wesley and St Andrews Hospital

! !

Hills Private Hospital, Sydney 2003

Declaration

•  No conflicts of interest

WestmeadPrivateHospital,Sydney2004

•  A Multicenter Study – 7 hospitals–  OR median raw utilization differed 94% - 85%

•  Radboud University Medical Center (UMC Netherlands) redesigned their operating room (OR) scheduling method by implementing cross-functional teams (CFTs)–  headed by dedicated anesthesiologist + surgeon, scheduler, OR,

anesthesia, recovery room & ward nurse–  The team meets once a week to discuss the OR schedule of the next

week–  evaluate the OR performance for previous week–  Examines OR program day by day and inform colleagues about all

relevant issues needed for optimal planning and safety–  given a full mandate by the Department Head Operating Rooms &

Anesthesiology to make operational decisions about OR schedule and to make alterations as required

Multidisciplinary Teamwork Improves Use of the Operating Room

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vanVeen-BerkxJAmCollSurgVol.220,No.6,June2015

Multidisciplinary Teamwork Improves Use of the Operating Room

•  A total of 30,203 OR days

•  KPI - raw utilization calculated on 63,607 inpatient surgical procedures

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vanVeen-BerkxJAmCollSurgVol.220,No.6,June2015

Teamwork – St Joseph’s Hospital Moshi Tanzania

•  Paucity of literature on willingness to engage in collaborative practice, trust, respect, societal factors, and cultural factors

collaboration in the operating room

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•  World Health Organisation (WHO) Surgical Safety Checklist•  UK teaching hospital - Identify any changes in safety culture

associated with the introduction of the 5 Steps to Surgical Safety in orthopaedic operating theatres–  pre-list briefings, the three steps of the WHO Surgical

Safety Checklist (SSC) and post-list debriefings in one framework

•  OR Safety Attitude Questionaire - pre-post intervention changes in the six safety culture domains

•  The SAQ-OR survey response rate was 80% (60/75) at baseline and 74% (53/72) one year later.

Safety culture and the 5 steps to safer surgery: an intervention study

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HillM.BriHshJofAnaes114(6):958–62(2015)

Safety culture and the 5 steps to safer surgery: an intervention study

9HillM.BriHshJofAnaes114(6):958–62(2015)

Conclusions:significantimprovementsinsafetyculture

Traditional model - top-down or hierarchical, control focusing upon technical expertise and neglecting the non-technical capability central in inter-professional work (such as good communication and awareness of others)

Promoting inter‐professional teamwork and learning – surgical operating theatre

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CollinK.JEducWorkVol.23,No.1,February2010,43–63

Weallrelyonoursurgicalteams.Whenweshowthemrespect,webringouttheirbestperformance.

Let’s Operate with Respect

Prof Marianne VonauPast Treasurer

12CollinK.JEducWorkVol.23,No.1,February2010,43–63

St Joseph’s Hospital, Moshi, Tanzania 2013

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•  60 hospitals - Safety Attitudes Questionnaire–  Surgeons, anesthesiologists, certified registered nurse

anesthetists, and operating room nurses–  Rated each other using a 5-point Likert scale

•  Response 77.1% (2,135 of 2,769).•  Perceived collaboration and communication:

–  surgeons rated other surgeons “high” or “very high” 85% of the time–  nurses rated their collaboration with surgeons “high” or “very high”

only 48% of the time.•  Physicians rating the teamwork of others as good, but at the same

time, nurses perceive teamwork as mediocre

Operating Room Teamworkamong Physicians and Nurses:

Teamwork in the Eye of the Beholder

14Makary,MJAmCollSurgVol.202,No.5,May2006

•  Hierarchical–  Traditionally surgeon leads and dictates pace–  Not always ideal

•  Communication vital•  Promote teamwork

–  No specific tools–  Doctors and non doctors perception of teamwork varies–  Hesitancy to voice concerns – individual dissatisfaction and

potentially poorer patient outcomes

Perceptions of Teamwork in the OR:Roles and Expectations

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“nursesoXendescribegoodcollaboraHonashavingtheirinputrespected,andphysiciansoXendescribegoodcollaboraHonashavingnurseswhoanHcipatetheirneedsandfollowinstrucHons”

Makary,MJAmCollSurgVol.202,No.5,May2006

SaferAustralianSurgicalTeamwork(SAST)Raisingawarenessofnon-technicalskills

ParHcipantsdevelopknowledge,skillsanda\tudestoimprovetheirperformanceintheoperaHngtheatreinrelaHonto:•  CommunicaHon/teamwork,•  Decisionmaking,•  Taskmanagement/leadership,•  SituaHonalawarenessUHlisesthreeframeworksdevelopedbyTheUniversityofAberdeen,RoyalCollegeofSurgeonsofEdinburghandtheNaHonalHealthService:•  Non-TechnicalSkillsforSurgeons(NOTSS)•  AnaestheHstsNon-TechnicalSkills(ANTS)•  ScrubPracHHoners'ListofIntra-operaHveNon-TechnicalSkills(SPLINTS)

TheRoyalAustralasianCollegeofSurgeons(RACS),theAustralianandNewZealandCollegeofAnaestheGsts(ANZCA),theAustralianCollegeofNursing(ACN)andAustralianCollegeofOperaGngRoomNurses(ACORN)Aninter-professionalworkshopforsurgeons,anaestheGstsandscrubpracGGonersworkinginAustralia.

•  Importance of leadership is recognized in surgery•  Theory proposes - transactional (task-focused) leaders

achieve minimum standards and transformational (team-oriented) leaders inspire performance beyond expectations–  Videorecorded 5 surgeons performing complex operations–  Multifactor Leadership Questionnaire–  Independent coders

Surgeons’ Leadership Styles and Team Behavior in the Operating Room

17Yue-YungHu,JAmCollSurgVol.222,No.1,January2016

Results•  Similarly on transactional leadership (range 2.38 to 2.69)•  Varied transformational leadership (range 1.98 to 3.60)•  Each 1-point increase in transformational score corresponded to

–  3 times more information-sharing behaviors (p < 0.0001)–  5.4 times more voice behaviors (p . 0.0005) among the team–  10 times more supportive behaviors (p < 0.0001)–  displayed poor behaviors 12.5 times less frequently (p < 0.0001)

Conclusions•  Teams led by transformational surgeons demonstrate a statistically

significant increase in information sharing and voice behaviors, which can improve both safety and efficiency in the OR

Surgeons’ Leadership Styles and Team Behavior in the Operating Room

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Yue-YungHu,JAmCollSurgVol.222,No.1,January2016

Chonburi Hospital, Thailand 2015

•  Cultural change in surgery relies on leadership:–  At work, in our roles–  Leading by example–  Through advocacy

Leadership: passing the baton

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Stressispartofourwork,butisnoexcuseforunacceptablebehaviour.

Let’s Operate with Respect

Laurie MalisanoChair Professional Standards

Leadership.It’saboutdoingthe

rightthing.

Let’s Operate with Respect

John BattenChair Court of Examiners

Censor in Chief

RACS Action Plan

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•  Cultural Change and Leadership

•  Education•  Complaint Handling

•  Two core principles :–  Respect–  Collaboration

•  Eight goals and supporting actions

•  20 discrete projects

23 projects addressing:

•  Strengthening complaints

CULTURE CHANGE & LEADERSHIP

Goal 1

Build a culture of respect and collaboration in surgical practice and education

Engagement and Collaboration Communication: Campaign Leadership Development Diversity & RACS Updating Policies / Procedures

1. Code of Conduct 2. Sanctions Policy 3. Accreditation of Hospital Training Posts 4. Selection of Supervisors 5. IMG oversight 6. Hospital Appointments 7. Appointment process for members of

Training Boards

Goal 2

Respecting the rich history of the surgical profession, advance the culture of surgical practice so there is no place for discrimination, bullying and sexual harassment (DBSH)

Goal 3

Build and foster relationships of trust, confidence and cooperation on DBSH issues with employers, governments and their agencies in all jurisdictions

Goal 4

Embrace diversity and foster gender equity

Goal 5

Increase transparency, independent scrutiny and external accountability in College activities

Let’s Operate with Respect Campaign

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•  Campaign: Phase one:–  Information – posters,

web fact sheets etc•  Campaign: Phase two:

–  Supporting action–  How do I ‘Call it out?’

•  Knowledge + skills needed:–  E-Learning module–  Face to face training–  Tips on website–  Ongoing challenge

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Whenweseebadbehaviour,it’suptoustocallitout.

Let’s Operate With Respect

Richard LanderExecutive Director Surgical Affairs NZ

Bullyingandharassment.Whenteams

suffer,paGentssuffer.

Let’s Operate with Respect

Dr Cathy FergusonChair Professional Standards

Education

•  Mandatory component of CPD and in Surgical Education and Training by 2017 – on line module for all FRACS

•  Training for all members of Training Boards, surgical, IMG and research supervisors/ assessors

•  Foundation Skills for Surgical Educators–  Increasing capacity. 800 per year

Campaign Approach

•  Positive positioning that resonates with health workforce•  “Building Respect, Improving Patient Safety”•  Co-badging and co-branding with organisations in

collaborative model•  Campaign communication & material – posters, joint press

releases, social media

Work with hospitals on initiatives

•  aligned approaches to dealing with DBSH and information sharing in the public interest, within the law

•  improve accreditation arrangements with hospitals to better deal with issues of DBSH

•  identifying effective strategies and progressively extending successful models to other hospitals and employers

•  ensuring surgical appointments are merit based •  develop criteria for selection of heads of departments

and other senior positions, incorporating leadership on DBSH

•  Intense media focus–  old case of alleged sexual misconduct–  new allegations of bullying

•  RACS said to be–  Misogynist–  old boys club–  perpetrator of bullying–  condoner of bullying

March 2015

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Establish Expert Advisory Group

•  Literature review•  Online survey•  Narrative collection•  Online discussion forums•  Invited responses (hospital and other)•  Uninvited responses•  Draft report•  Final report

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Key Findings

•  Results consistent across each review method •  49% of surgeons have experienced DBSH•  63% of trainees have experienced DBSH•  30% of women have experienced sexual

harassment•  71% of hospitals experienced DBSH by

surgeons•  Many IMGs report discrimination•  No difference across regions & NZ

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Summary of Material•  DBSH is widespread in healthcare, including

surgery•  There are profound, negative impacts for

individuals, including patients•  There is NO confidence in handling by employer,

College or regulator•  Medical education is outdated and teaching by

humiliation is widespread•  There has been a profound lack of leadership and

ownership of the problem

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Find out more: www.surgeons.org/respect

NowistheGmetodealwithdiscriminaGon,bullyingandsexualharassmentandhowitaffectsthesurgicalprofession.

Let’s Operate With Respect

Prof. David WattersPast President RACS

Bullyingisarealproblemforourprofession.Most

ofushaveseenorexperiencedit.

Let’s Operate with Respect

Phil TruskettPresident RACS

Beingasurgeontakesmorethantechnicalexcellence.Howwebehaveshapesourcultureandprofession.

Let’s Operate with Respect

Spencer BeasleyVice President RACS

Wesley Hospital, Brisbane, Aug 2016

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