towards flawless execution on the labour ward

30 April 2008 RCOG/ENTER

TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD

Leroy Edozien


5496 perinatal deaths in 2005

Unexplained antepartum 33%

Congenital abnormality 17%

Prematurity 17%

Intrapartum deaths 11%

2006: Risk of intrapartum stillbirth = 1 in 1486


Intrapartum stillbirth

Failure to act on CTGTeamwork/communication

Task saturationLoss of situation awareness

Plan continuation bias


Interventions to make childbirth safer, reduce number of intrapartum stillbirths

• ‘Safer Childbirth’

• CNST/NHSLA

• Healthcare Commission

• King’s Fund

• RCOG Service Standards, Obstetrics


Making maternity care safer

First order v Second order change change

Transactional v Transformational change change


Achieving change

Systems resist change

Changing a system by changing its ‘centre of gravity’

It is far better to attack your centres of gravity in parallel – all at once, rapidly


Three themes

No observations made for a prolonged period and therefore changes in a patient’s vital signs

not detected

No recognition of the deterioration and/or no action taken other than recording of

observation

Delay in the patient receiving medical attention, even when deterioration has been

detected and recognised


Contributory factors

• Communication – ‘the biggest problem area’• Work and environment• Task factors• Education and training• Patient factors• Team work and social• Equipment and resources• Individual factors

56

3

/

X

Do you work in a team or teams?


Do you work in a team or teams?

12

26

17

1

Really good

Above average

So-so

Poor

How do you rate the quality of teamwork in your workplace?


How do you rate the quality of teamwork in your workplace?

29

22

/

X

on your labour ward?Do you have formal briefing/debriefing sessions


Do you have formal briefing/debriefing sessions

on your labour ward?


Survey of O&G staff

LTH LWH SMH

% staff working extra hours due to demands of job 93 70 72

% staff saying they work in teams 100 97 95

% staff working in a well structured 29 50 37team environment

Extracted from the National NHS Staff Survey 2005


Team communication

Communication is central to team work

Handover

Briefing

Debriefing

Minimise parallel processes


Flawless execution

‘If I failed to execute my mission properly there was an incredibly good chance I was going to be a smoking hole in the ground. Not a nice day. The pursuit of flawless execution was the dividing line between life and death….’


Flawless execution

‘Businesses rarely see execution as a process and almost never debrief’

Hospitals


Flawless execution

‘There were far too many examples around me that together seemed to say that flawless execution really didn’t matter…..

if you failed to execute your mission properly, there was always another day’


Flawless execution

…is not the pursuit of perfection

…is all about expecting things could go wrong, and managing this risk


Flawless Execution cycle

• Plan – influence destiny by being proactive

• Brief – ‘the brief is the mission, the mission is the brief’

• Execute - we know where we are and what we are going to do next

• Debrief - the enduring step

• Win – start another mission


Mission planning

• Identify threats

• Identify available resources

• Apply lessons learned

• Determine courses of action/tactics

• Plan for contingencies


Determine courses of action/tactics

Mandatory to attach a timeline to the mission – who will do what, when?


Identify threats

• Internal and external

• Complacency, apathy

• Communication


Identify available resources

• Staff

• Training

• Environment


Briefing

‘When one walks into a fighter pilot’s briefing room, first impressions are everything’

Sharpening the senses

Standard operating procedures


Situation awareness


Execution

Task saturation - the biggest stumbling block to flawless execution

Common responses to task saturation: quit – shut down

compartmentalise – time sharing b/w important and

unimportant tasks

channelised attention – fixated on one thing


Task saturation – coping mechanisms

• Checklists – memory joggers and actions

• Cross-checks – never channelising, always scanning

• Mutual support – operating as a team


Effective communication

• Concise, clear; not a lot of filler material

• Extraneous conversation

• S.B.A.R


Debrief

• The good, the bad and the ugly

• Open communication


Rankless debriefs

‘ When they cross the threshold of the briefing room door, they throw away their name and rank. All they bring in is truth, an open mind, and open communication. If there was a mistake they want to admit it in front of their peers, supervisors, or subordinates; if they’ve forgotten a mistake, a fellow pilot is going to point it out to them. A two-star general or a green lieutenant, they’re al on the same side of the table’


Rankless debriefs

• Failure to start at the top will lead to a failed debrief

• Inside outside approach – starting inside reaffirms the importance of rankless debriefs


The ‘Swiss cheese’ model of accident causation


System plus individual

Mental skills

People at the sharp endcan thwart sequence


Improving safety in maternity care:focus on strategy as well as tactics

Tactics are rarely decisive; it is strategy that makes the difference

IraqApple


Conclusion

The concept of flawless execution, borrowed from military aviation, can and should be applied in maternity care.

This concept, in conjunction with other interventions, has potential to improve the safety of maternity care and reduce intrapartum mortality and morbidity.

Royal College ofObstetricians andGynaecologists

Setting standards to improve women’s health

Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting

Please turn off all mobile phones and pagers

towards flawless execution on the labour ward

Documents

pursuit of flawless

intrapartum deaths

rcogenterflawless executionis

rcogenterflawless executionif

team environmentextracted

risk of intrapartum

childbirth safer

deterioration andor