30 April 2008RCOG/ENTER TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD Leroy Edozien.
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Transcript of 30 April 2008RCOG/ENTER TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD Leroy Edozien.
30 April 2008 RCOG/ENTER
TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD
Leroy Edozien
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
5496 perinatal deaths in 2005
Unexplained antepartum 33%
Congenital abnormality 17%
Prematurity 17%
Intrapartum deaths 11%
2006: Risk of intrapartum stillbirth = 1 in 1486
30 April 2008 RCOG/ENTER
Intrapartum stillbirth
Failure to act on CTGTeamwork/communication
Task saturationLoss of situation awareness
Plan continuation bias
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
Interventions to make childbirth safer, reduce number of intrapartum stillbirths
• ‘Safer Childbirth’
• CNST/NHSLA
• Healthcare Commission
• King’s Fund
• RCOG Service Standards, Obstetrics
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
Making maternity care safer
First order v Second order change change
Transactional v Transformational change change
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
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
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3
/
X
Do you work in a team or teams?
30 April 2008 RCOG/ENTER
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?
30 April 2008 RCOG/ENTER
How do you rate the quality of teamwork in your workplace?
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22
/
X
on your labour ward?Do you have formal briefing/debriefing sessions
30 April 2008 RCOG/ENTER
Do you have formal briefing/debriefing sessions
on your labour ward?
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
Team communication
Communication is central to team work
Handover
Briefing
Debriefing
Minimise parallel processes
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
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….’
30 April 2008 RCOG/ENTER
Flawless execution
‘Businesses rarely see execution as a process and almost never debrief’
Hospitals
30 April 2008 RCOG/ENTER
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’
30 April 2008 RCOG/ENTER
Flawless execution
…is not the pursuit of perfection
…is all about expecting things could go wrong, and managing this risk
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
Mission planning
• Identify threats
• Identify available resources
• Apply lessons learned
• Determine courses of action/tactics
• Plan for contingencies
30 April 2008 RCOG/ENTER
Determine courses of action/tactics
Mandatory to attach a timeline to the mission – who will do what, when?
30 April 2008 RCOG/ENTER
Identify threats
• Internal and external
• Complacency, apathy
• Communication
30 April 2008 RCOG/ENTER
Identify available resources
• Staff
• Training
• Environment
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
Briefing
‘When one walks into a fighter pilot’s briefing room, first impressions are everything’
Sharpening the senses
Standard operating procedures
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
Situation awareness
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
Task saturation – coping mechanisms
• Checklists – memory joggers and actions
• Cross-checks – never channelising, always scanning
• Mutual support – operating as a team
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
30 April 2008 RCOG/ENTER
Effective communication
• Concise, clear; not a lot of filler material
• Extraneous conversation
• S.B.A.R
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
Debrief
• The good, the bad and the ugly
• Open communication
30 April 2008 RCOG/ENTER
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’
30 April 2008 RCOG/ENTER
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
30 April 2008 RCOG/ENTER
The ‘Swiss cheese’ model of accident causation
30 April 2008 RCOG/ENTER
System plus individual
Mental skills
People at the sharp endcan thwart sequence
30 April 2008 RCOG/ENTER
Improving safety in maternity care:focus on strategy as well as tactics
Tactics are rarely decisive; it is strategy that makes the difference
IraqApple
30 April 2008 RCOG/ENTER
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
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