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

56

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

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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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