Adaptive strategies used by surgical teams under pressure: an interview study among senior healthcare professionals in four major hospitals in the United Kingdom.

BACKGROUND: Healthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures. METHODS: We conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others. RESULTS: The primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies). CONCLUSIONS: Teams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes.

Participatory Design, Project Clients, and Healthcare User Groups.

AIM: This study is the third in a series of investigations that explored the role of project user groups and how they impact on the design of a healthcare facility. Previous studies focused on a wide range of users, whereas this study sought the views of project clients. BACKGROUND: The "project client" represents the organization responsible for the procurement of a healthcare facility. "Users" will work in or "use" that building. With the input of project clients, this research focused on the user group process required for Australian and New Zealand publicly funded healthcare projects. It sought lessons to improve the process for future projects. METHODS: Previous research findings, and an expanded literature review examining participatory design, were used to develop questions for semistructured interviews with selected project clients. Responses were transcribed and analyzed in terms of themes and subthemes using reflexive thematic analysis to develop a narrative that reports and discusses the findings. RESULTS: Although not all are recognized, many stakeholders influence design decisions. No history, rationale, terms of reference, or evaluations of the user group process were found, suggesting that although it is a "given," the process could be enhanced. Useful suggestions for improving the user group process are offered. CONCLUSIONS: Evaluating the user group process, and learning from alternative approaches, may improve its outcomes. A project charter and terms of reference would support more effective decision making, while best practice guidelines and education for user group participants should be considered.

User Group Consultation: Design Quality and Project Success.

AIM: User group consultation is more effective when participants work toward commonly agreed goals and objectives. To understand how they set these goals, this research explored how "user group" participants from diverse professional discipline backgrounds define the concepts of "design quality" and "project success," and their connection on a healthcare facility design project. BACKGROUND: User group consultation is often time-consuming, frustrating, and expensive. Rarely are design quality or project success clearly defined, nor is the connection between them communicated well either in the literature or by project clients. METHOD: Using an online survey, respondents were asked to rank frameworks of components for design quality and project success in order of importance and to indicate how they believed their project clients would assess the same items. They were asked about the connection between the terms, and how well each was achieved on their healthcare projects, both from their personal and their client's point of view. RESULTS: Design quality and project success were personally valued highly by respondents, with a strong connection seen between the concepts. By contrast, respondents perceived their clients saw the connection as less important. Functionality was essential to all, especially clinicians, but designers and other consultants demonstrated a broader perspective on all design outcomes. CONCLUSIONS: Healthcare designers should take the lead on project teams in defining design quality and its connection to project success as part of setting clear goals and objectives for more effective user group consultation.

Interdisciplinary User Groups and the Design of Healthcare Facilities.

AIM: This Australian research explores how "user group" participants from diverse professional discipline backgrounds understand, define, perform their roles, and assess the outcomes of the healthcare design process. BACKGROUND: Part of the design process in Australia and New Zealand, the purpose of interdisciplinary user group consultation is to design the best healthcare facilities possible within the parameters set by project clients and funding bodies. METHOD: An online survey was used to explore how user group participants viewed the process, including how well informed they felt they were about their role/s in it, its success in achieving specific outcomes for their project, and how they felt their project client, owner, or funding body assessed these same issues. It included both closed and open-ended questions, and data were then analyzed using an interpretative methodology by an architect researcher based in practice. RESULTS: Emergent issues identified include governance of the process, knowledge asymmetries between participants, missed opportunities for innovation, composition and workloads of user groups, and the quality of resources available to guide the process. CONCLUSIONS: The interdisciplinary user group process could be improved, and future research will look at how drawing on participatory design methods used in sectors such as urban planning may support the development of new techniques for conducting user groups.

Patient safety regulation in the NHS: mapping the regulatory landscape of healthcare.

OBJECTIVES: The current research project sought to map out the regulatory landscape for patient safety in the English National Health Service (NHS). METHOD: We used a systematic desk-based search using a variety of sources to identify the total number of organisations with regulatory influence in the NHS; we researched publicly available documents listing external inspection agencies, participated in advisory consultations with NHS regulatory compliance teams and reviewed the websites of all regulatory agencies. RESULTS: Our mapping revealed over 126 organisations who exert some regulatory influence on NHS provider organisations in addition to 211 Clinical Commissioning Groups. The majority of these organisations set standards and collect data from provider organisations and a considerable number carry out investigations. We found a multitude of overlapping functions and activities. The variability in approach and overlapping functions suggest that there is no overall integrated regulatory approach. CONCLUSION: Regulation potentially provides a variety of benefits in terms of maintaining the safety and quality of care by providing an external perspective on the care being delivered. However, the variability, extent and fragmentation of the regulatory system of the NHS make it hard for regulators to act effectively and places a massive burden on NHS provider organisations. Overlapping regulatory requests may distract locally driven initiatives to improve safety and quality. Further research is needed to understand the full extent of regulatory activity and the true benefits and costs incurred.

Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice.

BACKGROUND: The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisations in assessing safety. The Health Foundation funded a large-scale programme to assess the value and impact of applying the Framework in regional and frontline care settings. We explored the experiences and reflections of key participants in the programme. METHODS: The study was conducted in the nine healthcare organisations in England and Scotland testing the Framework (three regional improvement bodies, six frontline settings). Post hoc interviews with clinical and managerial staff were analysed using template analysis. FINDINGS: Participants reported that the Framework promoted a substantial shift in their thinking about how safety is actively managed in their environment. It provided a common language, facilitated a more inquisitive approach and encouraged a more holistic view of the components of safety. These changes in conceptual understanding, however, did not always translate into broader changes in practice, with many sites only addressing some aspects of the Framework. One of the three regions did embrace the Framework in its entirety and achieved wider impact with a range of interventions. This region had committed leaders who took time to fully understand the concepts, who maintained a flexible approach to exploring the utility of the Framework and who worked with frontline staff to translate the concepts for local settings. CONCLUSIONS: The Measuring and Monitoring of Safety Framework has the potential to support a broader and richer approach to organisational safety. Such a conceptually based initiative requires both committed leaders who themselves understand the concepts and more time to establish understanding and aims than might be needed in a standard improvement programme.

Safety analysis over time: seven major changes to adverse event investigation.

BACKGROUND: Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today. MAIN TEXT: The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects. We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations. CONCLUSIONS: Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.

Implementing an integrated in-situ coaching, observational audit, and story-telling intervention to support safe surgery.

This article describes an intervention that combined in-situ coaching, observational audits and story-telling to educate theatre teams at University College London Hospitals about the Five steps to safer surgery (NPSA 2010). Our philosophy was to educate theatre teams about 'what goes right' (good catches, exemplary leadership etc) as well as 'what could be improved'. Results showed improvements on 'behavioural reliability' metrics, a 68% increase in near miss reporting and a reduction in surgical harm incidents.

Republished: creating a safe, reliable hospital at night handover: a case study in implementation science.

BACKGROUND: We developed protocols to handover patients from day to hospital at night (H@N) teams. SETTING: NHS paediatric specialist hospital. METHOD: We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. INTERVENTION: In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). RESULTS: Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours deteriorations (p=0.04 for Phase 3 vs Phase 1 for both measures (CI 1.04 to 4.08; CI 1.03 to 4.33), and for Phase 3 vs Phase 2 (p=0.006 and p=0.001 (CI 1.22 to 5.15; CI 1.62 to 9.0)), respectively). The Phase 1 and 2 handover protocols were effective at identifying patients whose clinical condition warranted review overnight. Performance on both surrogate outcome measures, length of handover and distractions, deteriorated in Phase 3. CONCLUSIONS: A carefully designed prioritisation process within the H@N handover can be effective at flagging acutely unwell patients. However, the protocol we introduced was unsustainable. In a complex healthcare system, sustainable implementation of new processes may be threatened by conflicting goals.

What's in my buckets today? Foreseeing and forestalling patient harm.

Operating theatre teams work in an imperfect system characterised by time pressure, goal conflicts, lack of team stability and steep authority gradients between consultants and other team members. Despite this, they often foresee and forestall errors that could harm patients. The paper discusses the strengths and limitations of using Reason's three buckets model of error prevention as a framework for training operating theatre staff how to foresee and forestall incidents.

Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety.

Patients, clinicians and managers all want to be reassured that their healthcare organisation is safe. But there is no consensus about what we mean when we ask whether a healthcare organisation is safe or how this is achieved. In the UK, the measurement of harm, so important in the evolution of patient safety, has been neglected in favour of incident reporting. The use of softer intelligence for monitoring and anticipation of problems receives little mention in official policy. The Francis Inquiry report into patient treatment at the Mid Staffordshire NHS Foundation Trust set out 29 recommendations on measurement, more than on any other topic, and set the measurement of safety an absolute priority for healthcare organisations. The Berwick review found that most healthcare organisations at present have very little capacity to analyse, monitor or learn from safety and quality information. This paper summarises the findings of a more extensive report and proposes a framework which can guide clinical teams and healthcare organisations in the measurement and monitoring of safety and in reviewing progress against safety objectives. The framework has been used so far to promote self-reflection at both board and clinical team level, to stimulate an organisational check or analysis in the gaps of information and to promote discussion of 'what could we do differently'.

Creating a safe, reliable hospital at night handover: a case study in implementation science.

BACKGROUND: We developed protocols to handover patients from day to hospital at night (H@N) teams. SETTING: NHS paediatric specialist hospital. METHOD: We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. INTERVENTION: In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). RESULTS: Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours deteriorations (p=0.04 for Phase 3 vs Phase 1 for both measures (CI 1.04 to 4.08; CI 1.03 to 4.33), and for Phase 3 vs Phase 2 (p=0.006 and p=0.001 (CI 1.22 to 5.15; CI 1.62 to 9.0)), respectively). The Phase 1 and 2 handover protocols were effective at identifying patients whose clinical condition warranted review overnight. Performance on both surrogate outcome measures, length of handover and distractions, deteriorated in Phase 3. CONCLUSIONS: A carefully designed prioritisation process within the H@N handover can be effective at flagging acutely unwell patients. However, the protocol we introduced was unsustainable. In a complex healthcare system, sustainable implementation of new processes may be threatened by conflicting goals.

Understanding safety in healthcare: the system evolution, erosion and enhancement model.

The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety. Significance for public healthThe article identifies lessons from previous theories of human error and accident causation, foresight, resilience engineering and system migration and introduces a new framework for understanding patient safety in healthcare; the System Evolution, Erosion and Enhancement (SEEE) model. The article is significant for public health because healthcare organizations around the world need to understand how safety evolves and erodes to develop and implement interventions to reduce patient harm.

Flexibility: beyond the buzzword-practical findings from a systematic literature review.

OBJECTIVE: The goal was to identify practical, cost-effective, design-related strategies for "future-proofing" the buildings of a major Australian health department. BACKGROUND: Many health buildings become obsolete before the end of their effective physical lives, requiring extensive reconfiguration or replacement. This study sought to move beyond the oft-used buzzword flexibility to seek effective strategies to accommodate future change (future-proofing) that could be further explored in Australia and other developed countries. METHODS: A systematic literature review compiled definitions of flexibility and adaptability from a range of sources. Nineteen case studies were identified that illustrated various future-proofing strategies. A matrix was developed to classify different approaches to flexibility and then used to assess the case studies. RESULTS: Analysis was hampered by inconsistent use of terminology and limited availability of quantifiable methods for assessing the long-term success of approaches to future-proofing. Several key strategies were identified, classified, and discussed in terms of their relevance and application. CONCLUSIONS: More rigorous definitions of flexibility, adaptability, and related terms are needed to enable more useful comparisons of the strategies implemented to future-proof health projects. Local conditions often affect both the strategies adopted and the degree to which they can be considered successful. Many of the case studies analyzed in this research were not operational long enough to enable assessment of their claims of being future-proofed. Therefore, review of lifetime facility costs, including the service life periods of major facility components, should be considered, and some older projects should be evaluated in terms of these criteria.

Reinterpreting the hospital corridor: "wasted space" or essential for quality multidisciplinary clinical care?

The planning of New South Wales (NSW) and other Australian health facilities is guided by the Australasian Health Facility Guidelines (AHFG), which prescribe allowances for circulation (corridors and similar areas for movement between spaces) of between 10% and 40% of functional floor areas. A further allowance of up to 28% for Travel and Engineering is then assumed (University of NSW & Health Capital Asset Managers' Consortium, 2005). Therefore the "circulation" and "travel" space manifested as the corridors and similar movement spaces within health facilities is both extensive and expensive. Consequently, such space often becomes regarded as a necessary evil and, in the name of efficiency, is often minimized wherever possible. This paper revisits the view that corridor space allocations (circulation) must always be minimized to achieve design or functional efficiencies. Minimizing circulation or travel inevitably assumes that the realized space savings will then be reallocated to "more important" areas of the facility. Yet the corridors and other movement spaces also are very important to the functioning of multidisciplinary clinical teams and the quality of care delivery. Ultimately, inflexibly reducing the space allocated to such spaces may be regarded as a false economy.