Title: Safer Delivery of Surgical Services: a Reliable Teamwork Approach
Funder: Department of Health (England)

Abstract: Aim: To facilitate the transformation of surgical service delivery into a high-reliability enterprise in which the risks of patient harm from treatment process are greatly reduced. Background: Modern high technology health care can be extremely effective, but can also be dangerous. Internationally, around 10% of hospital inpatients suffer harm due directly to their care. Reduction of this burden would be a major contribution to the nation’s health. Analysis of treatment related harm suggests that problems arise mainly because healthcare systems and the work culture amongst staff have not kept pace with the complexity of the technologies introduced during the last 50 years and their potential dangers. Surgery is a high risk healthcare activity, carrying risks of wrong site surgery, hospital acquired infection, retained foreign bodies, and complications from technically inadequate surgery. Our research has shown the potential of addressing the systems design, teamwork and technology aspects of the problem, but more work is needed to refine methods, study generalisability and find out how these approaches are best combined. Raised awareness of the problem has generated an urgent need for evidence-based interventions from Trusts anxious to reduce treatment-related harm. Research Plans: • We will develop and evaluate interventions for the three dimensions of our safety model – system, team and technology – in controlled before/after cohort studies. • We will study relative effectiveness, synergy and order of interventions by introduction sequentially (in either the theoretically optimal or the inverse order), and in parallel. • We will study both wards and theatres in three contrasting hospitals to examine contextual differences in effectiveness. • To understand mechanisms and applicability, we will develop qualitative and statistical models to guide implementation of successful interventions. We propose 5 workstreams: Workstream 1. A 6 month preliminary phase for literature review, co-ordination, measure development and detailed planning. Workstream 2 will study the value of teamwork training in reducing error and harm. Workstream 3 will study the value of “lean” systems redesign directed at improved safety and reliability. Workstream 4 will study IT applications and process standardisation for information transfer, patient monitoring, and decision support. Workstream 5 will use statistical modelling and qualitative knowledge management approaches to derive models for (a) the major sources of patient harm and (b) the barriers to improvements in healthcare systems The studies in Workstream 2 are: Project 2.1 Teamwork in the operating theatre Project 2.2: Teamwork in the surgical ward The studies in Workstream 3 are: Project 3.1 “Lean” for Safety on Acute Wards. Project 3.2 “Lean” for Safety in the Operating Theatre The studies in Workstream 4 are: Project 4.1 Evidence-based computer decision support in postoperative care. Project 4.2 Computerized monitoring for surgical patients Project 4.3 Standardised Communications Processes in surgery The studies in Workstream 5 are: Project 5.1 A statistical model of patient harm in surgery. Project 5.2 Knowledge translation for adoption of safety interventions. Research Team: The Oxford QRSTU team has established an international reputation for pioneering studies of safety improvement innovations. The other team members add expertise of the highest quality in the relevant fields of Healthcare IT, systems transformation, “lean” quality improvement, knowledge translation, statistics and patient-centred outcome evaluation. Research Environment: The Heart of England Trust is a leading first wave Foundation Trust with a strong commitment to patient safety as a strategic goal. The Nuffield Department of Surgery was one of few surgical departments rated 5* in the last RAE. The collaborative research environment at the Division of Medicine at Oxford ensures that it is near the top of all ranking scales for UK medical research institutions. Anticipated Outputs, Outcomes and Impact: The programme goal is a context-sensitive model of surgical systems safety to guide development of intervention strategies. This will provide a basis for future definitive research on the different components. The specific outputs expected include: (a) A refined method for delivering teamwork training to clinical groups (b) Validated measures for theatre teamwork, and process-based measures for patient safety on wards. (c) A context–sensitive description of the effects of “lean” quality improvement on patient safety (d) A method for earlier detection of patient deterioration using high-tech systems (e) A system for improving postoperative care via computer-aided decision support. Public Involvement: Patient-centred outcome measures are central to our measurement strategy, and patient involvement will be integrated into the “lean” programme on wards.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE