Michael Puntis and team – St George’s University Hospitals NHS Foundation Trust

Theatre Team Training

What the judges said:

Team safety huddles and discussion of scenarios promote reflection and learning and empower teams to design their own improvement ideas and plans. What was impressive about the submission from St George’s University Hospitals NHS Foundation Trust was how the teams engaged in the process, and how the development of an inter-professional and flattened hierarchy can lead to transformational leadership, improved communication and shared learning.

A new initiative at St George’s University Hospital Trust has improved safety in operating theatres by creating a basis for shared teamwork, even when the members of the theatre team are constantly changing from day to day.

Despite introducing changes such as the WHO checklist, a number of serious incidents and near misses were still happening occasionally in operating theatres at St George’s hospital. Analysis of incidents indicated that ‘poor teamwork’ was a factor in 21% of these. Poor teamwork is a known factor in safety incidents in the wider literature on patient safety, but it is difficult to discern an established form of good practice to address it.

Part of the challenge lies in the ways in which theatres are staffed. On any given day at St George’s, perhaps thirty theatres may be in action at any one time across a number of locations. Each may be working through a list and handle emergency admissions. The mix of nursing staff, auxiliary staff, anaesthesia staff and surgical staff may be different every day, depending on shift patterns, rotas and rotating specialities. And, while everyone has to introduce themselves at the start of a procedure, little else drives teamwork apart from a shared desire to do their best for the patient. This can mean that communication problems can happen, or shared ways of working don't align, or even the ways in which different tasks are allocated – or assumed to be allocated - between theatre team members can vary day by day.

Research by Michael Puntis and colleagues showed that teamworking may be enhanced through an interprofessional education programme, delivered in-situ (in the theatre) and using practical, immediately relevant material and facilitated by team members themselves, not an external leader. This contrasts with most professional training, which tends to be delivered outside the theatre, by an external facilitator, using generic material to siloed groups of specialists.

Ten years of local Datix records were analysed to identify relevant cases, and to determine appropriate themes and learning objectives, established around ensuring that such events do not recur. Scenarios based on these real cases were designed, structured around a clear sequence of steps of increasing complexity. Towards the end, the team reviews their experience and reflects on what they have learned before the session ends and surgery begins.

Once a month, theatre teams take an hour before surgery to work through a theatre scenario tailored for the whole team. Teams working in orthopaedic surgery use a scenario that describes a potential problem with an orthopaedic patient; vascular teams have vascular scenarios; neurological teams have neuro cases and so on, for twelve surgical specialities. The content, structure and format for delivery are all drafted by Michael Puntis – which ensures consistency but also represents a demanding workload!

Research indicated that initial take-up of such exercises was always a significant challenge. To overcome this, staff were engaged early to help develop the programme. Content and the nature of the programme were discussed in local meetings, a communication programme rolled out before launch and senior leadership engaged. The programme was piloted using two scenarios and adapted in response to feedback.

At the time of writing, about 180 surgical staff were engaging with a new scenario each month and 32 scenarios had been developed. Formal feedback is taken. Recorded response of staff to training has been excellent. The operational effect of the training has, by and large, been less visible but still tangible. Because the training requires that adverse events are discussed across the team in a non-adversarial way, staff report feeling more able to raise and address issues during theatre, and less constrained by hierarchical norms. The training also seeks to capture ideas for improvement that are prompted by the training scenario or the team’s response: an example is a new protocol to ensure that areas are marked for surgery so that they remain visible after the patient is positioned and draped for surgery, thus minimising the risk of a surgical intervention at the wrong spot.

This programme is a prime example of Patient Safety Learning. Using research and hard data about patient safety, it addresses one of the more challenging yet critical factors in improving patient safety – how teams work together when the make-up of the team is fluid. By having teams work together to address patient safety events in a psychologically safe way, this programme enables a trust to start to establish new, better ways of working safely for patients.

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