Article 1: In praise of a systems approach for professionals

Our company, Rotamap, aims to help clinical departments, mainly in the NHS, to do their work better.

The focus of our software is the organisation of departmental resources, which in many ways is a crude meter of how well people are managed (in the NHS at least). We explain our collaborative approach to clients in four or six session clumps with members of the department concerned. These comprise very general units of work, and last 2-12 hours each. Yet we have discovered during even these relatively brief periods when unspecific tasks are carried out, that how professionals work together can be as important as the expertise each individual brings to the practice of his or her profession.

This is the first of three articles discussing aspects of team collaboration, particularly in a clinical setting. Each discusses important aspects of how the horizontal approach, as distinct from a highly individualised and professionalised vertical paradigm, can provide benefits to professional teams. This approach can also yield surprising insights that can hold value for the managers of the unit in question.

The articles cover areas outside our direct experience, but are well supported by a number of medical specialists, particularly Dr Atul Gawande in his Second 2014 Reith Lecture entitled "The Century of the System", and his book "The Checklist Manifesto".

At our March 2015 Rotamap event held at the RSA in London, we presented our inter-department benchmarks, as we usually do. The benchmarks (based on a list of criteria, like the number of theatre sessions, as applied to each department using our system) always cause a stir owing to their comparative nature (they are anonymous, but attendees are issued with their department's anonymisation code at the event). However, on this occasion Rotamap's Ollie Fielding presented, in addition to the general benchmarks, a comparison between two departments of similar size. Ollie used a short "Good Department Checklist", to many oohs and aahs from the audience, to help ascertain whether the performance of each was healthy, and if so, which was doing better.

The success of Ollie's presentation depended on the checklist format, which has a now famous medical precursor. In 2001 the anaesthetist and critical care specialist Dr Peter Pronovost created a five-point checklist for changing a central line (the catheter placed in large veins in the chest, groin or neck)in theatre. The five steps comprised well-known directions, for instance to "wash your hands with soap" and "wear a sterile mask, hat, gown and gloves". Yet stating the obvious, and ensuring that the obvious was actually complied with in a systematic way, dropped the ten-day line infection rate at Johns Hopkins' I.C.U. from 11% to zero. After monitoring the project for another 15 months, Pronovost and his colleagues released a study that estimated that this method had saved eight lives and $2 million in costs.

When Pronovost's central line protocol was adopted by the Michigan state hospitals through the "Michigan Keystone Initiative", they reported that in the first 18 months (by 2006), they had saved around $175 million and 1,500 lives. Pronovost went on in 2008 to be lauded by Time magazine as one of the 100 most influential people in the world.

" catch the kinds of problems that even experts will make mistakes at doing...most often basically failures of communications"

Another clinical checklist that has received a lot of publicity is the WHO theatre checklist, which Atul Gawande helped to design. The aim of the checklist is " catch the kinds of problems that even experts will make mistakes at doing...most often basically failures of communications"[1]. The checklist, which occupies a single A4 page, helps the surgical team confirm prosaic matters such as checking that everyone in the team has been introduced, whether they have the right patient and that the pre-operative antibiotic has been administered. The checklist, which has been implemented in several countries in both the developing and developed world, is credited with having saved around 9,000 lives in Scotland alone in the four years to 2014.[2]

"Results from a WHO global pilot study of 'Safe Surgery Saves Lives' (Haynes et al, 2009) "[3} records the outcomes of the intensive efforts made to validate the WHO checklist prior to its general adoption by the NHS. The Scottish results given above follow a subsequent trial at eight participating hospitals in the use of a WHO surgical safety checklist. Both led to Òa reduction in complications and unplanned re-operations"[3]. This was confirmed by the results of further trials carried out at other hospitals.

However, the WHO study yielded an interesting finding: that while 78.6% of clinicians involved in the trial felt that the programme prevented errors, 93.4% would want the checklist used if they were undergoing surgery themselves.[4] This result (the lower number of clinicians likely to use the checklist or consider it effective), compared with the other (that a much larger number desired its use when undergoing operations themselves) is suggestive. It implies that while clinicians are familiar with the tenets of good care, they do not wish to be reminded of these principles: but, when they are, the results improve. The checklist neatly bisects the "vertical" focus of the professional on her of his area of expertise and the "horizontal" concerns of the team. Concomitantly one could argue that the real success of the Keystone and WHO theatre checklist initiatives is in getting clinicians to follow the protocol routinely, and to provide the technical and political support to do so. For instance, at Detroit's Sinai-Grace Hospital Pronovost helped persuade the executive team to become actively involved in the project. New central-line kits, which contained both the required drapes and chlorhexidine soap, were developed, and checklists were used to stimulate cross-team working and problem-solving. Evidence provided by Gwabde also shows that checklists can support memory recall and help embed certain precautions that clinical staff might have either not known about or overlooked.[5]

Our own experience in working specifically with checklists and coordinated care comes from visiting Mr Shane Duffy at the Chelsea and Westminster hospital in London. Duffy is an obstetrician who works part of each year in developing countries in Africa. He has spent several years developing protocols to improve the outcome of maternal emergencies such as haemorrhage, eclampsia, the resuscitation of babies and cardiac arrest. Like Pronovost, Duffy is stripping back these procedures to their component parts, something he calls "de-skilling", to reduce complex requirements to a chain of individual steps. Visiting the unit you can, on occasion, watch a team tackling a plastic dummy suffering a life-threatening eclamptic fit, navigating their way with a tablet running Duffy's MedNav software.

Like Pronovost, Duffy is stripping back these procedures to their component parts, something he calls "de-skilling"

As Duffy points out, maternal deaths in the UK are rare. However, when they do occur, about 70% are attributable to substandard care. Duffy says: "When you define substandard care, it tends to be around communication, escalation, identification and team working. It's not that people haven't got the necessary technical skills, but how people work together".

The MedNav system helps provide a systematic approach, whether a team is dealing with eclampsia or a haemorrhage; the team is encouraged to organise itself appropriately, and one member acts as scribe to record events as they unfold, and to alert the rest of the team when action is required. MedNav provides prompts for the next step, whether this entails administering drugs or positioning the patient appropriately. Crucially it helps the team understand what it must do to execute the necessary steps in the protocol in a sure-footed way.

MedNav is still under development, but the initial results are positive. Duffy believes that the improved flow of communication and situational awareness has provided a performance improvement of about 20%, a reduction that should result in fewer maternal deaths. From our visits to the simulation lab we have noted that there seem to be other benefits too, such as the manner in which working together was analysed and commented upon in a non-combatative way. Even if the team followed the protocol and the dummy died (so to speak), the team felt that they had worked to a plan and done their best, and could work on ways they could do better next time. Trying to coordinate, it seems, can be seen to be more positive and productive than retreating to traditional specialisms.

It is this latter aspect, where clinicians realise they can benefit from improved coordination as a team or department, that has led to our development of the Rotamap project. The apparently mundane rotas that represent the organisation of the whole department's efforts show up, over time, revelatory insights into how the group is working. Not only can one analyse the group's performance against peer departments, but also measure variables and other factors that show how well the department is operating and the nature of the pressures exerted upon it. For instance, a well-run department achieving high consultant productivity may provide exemplary levels of supply of anaesthetists for surgical events, but suffer from inconsistent and variable demand for theatre lists to be covered, with last-minute changes and cancellations by other parties.

At our 2012 forum Dr William Wight, Clinical Director of Anaesthetics at the RVI in Newcastle, showed how he used data from the Rotamap system for anaesthetics, CLWRota, to assess how the department and individuals were performing. Dr Wight showed how he introspected the[1] department's data to ensure that full-time colleagues achieved a rate of 301 sessions a year, took less unplanned leave, and participated more in clinical governance sessions, college tutor duties and administrative work. Data tracking through the system permitted Dr Wight to build up an accurate picture of the likely productivity of the department, and to keep an eye on each individual's performance assessed quarterly. The overview helps Dr Wight to pre-empt potentially serious issues by means of routine maintenance, instead of allowing them to escalate into large-scale problems. This purview also reveals the important degree to which clinicians are involved in helping to run their department, and helps him to manage the training of juniors, amongst other important non-clinical tasks that are often overlooked when assessing performance.

Through coordination systems such as Rotamap, doctors doing too much work and in danger of exhausting themselves can be encouraged to regain balance, and those targeting leave on work days can have the gaps in their clinical delivery pointed out to them. Similarly, trainee supervision rates can be tracked, and the department can peg the rate at which it believes senior trainee "solo" or unsupervised sessions may run. This is a boon both to senior trainees readying themselves to become consultants, and to departmental productivity rates. Perhaps most importantly, it helps the department to understand precisely what it is doing, assists it to model its service in order to improve it, and also puts it in a strong position to defend itself against management initiatives that might be short on facts.

Outside the ambit of the department, CLWRota records the rate at which various specialists in other departments change or cancel theatre sessions. These data can be analysed to help spot troublesome communication with other departments. Dr Geoff Bedford, Dr Wight's colleague at the Freeman Hospital, follows a particularly enlightened approach in the presentation he gave at the Rotamap autumn 2015 event at the Baltic in Newcastle. Dr Bedford described how he had extended the benefits that CLWRota brought to internal departmental communications by using its systematic approach to coordinate theatre Planning meetings. As a result of these efforts the Freeman has a very high Rate of theatre utilisation, well above 90%.

Checklists and coordination grids, which is what our departmental rotas provide, can be seen to govern the intersection of the individual's responsibilities with the wider operation of the group. The grid of sessions in a rota or the checkboxes of a list are undoubtedly mundane, which makes it is easy for experienced professionals to overlook their utility. However, as shown by the results from the Pronovost central line checklist project, the WHO theatre checklist and the departmental improvements made possible by a straightforward rota system, the resultant advantages to the team can be considerable. Such systems provide a counterpoint between the individual and the group that can prove beneficial to the performance of both. Additionally, such coordination tools can help departments to establish their desired and expected patterns of activity, against which changes or anomalies can be discerned and dealt with.

Yet systems such as these, although they can be simply presented, can be difficult to put in place. Professionals often dismiss their banality or dislike the implication that they aren't doing their job well. These techniques can be seen as a threat to the status quo, and yet another thing to remember to do in a busy schedule already brimming with administrative work.

Some of the challenges to the adoption of a systems approach will be discussed in the next article.

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