Peter McCulloch

Oxford Mail:

Professor of surgical science and practice at Oxford University

With thousands of surgical operations happening in Oxfordshire alone, even a very low rate of incidents can mean many people fail to get the best possible care.

Previous attempts to improve patient safety in surgery looked at what was done to improve safety in other areas of work.

Two approaches became popular – some people focused on the culture of the workplace and tried to improve teamwork and communication by training team members to interact better, using principles developed in the airline industry.

Others focused on the systems of work and used industrial quality improvement techniques to rationalise these and remove or change steps which carry a higher risk of error.

Each approach had its merits and its advocates but there was no clear evidence for which approach was better.

We all want the best for patients so we want to be using the techniques that are most successful at promoting safer surgery.

With funding from the National Institute for Health Research, our team from the Quality, Reliability, Safety and Teamwork Unit in the Nuffield Department of Surgical Sciences (NDS) at Oxford University spent four years comparing different ways of improving safety.

We believe that it has been the largest direct observational study of surgical team performance during whole procedures ever completed.

We ran five identical studies comparing the airline-style culture approach, two different systems approaches and two approaches that combined both culture and systems methods.

What we found is that it is not enough to just fix the system and it’s not enough to just train the team.

You have to do both.

Our research showed that clinical staff who receive teamwork training become better motivated and more knowledgeable about safety risks, but are not able to change their working practices because they don’t know how.

Those who are only trained and helped to improve their system are not educated or motivated to focus on the changes which will be most beneficial for patients.

Staff who received the combined intervention developed more ambitious projects and demanded more help from the experts – making bigger, better changes that led to greater improvements in safety.

My colleague Lorna Flynn focuses on Human Factors Research – that’s research into how and why people do things. She studied why the integrated approaches worked better than systems or culture improvement alone. Two of her key findings were about the need for staff time and for professional support. Frontline NHS staff have no allocated time for safety improvement, and nor do they have specialist training in the disciplines needed.

While really skilled at their jobs, with in-depth knowledge about their systems and working context, they still require substantial support from experts in human factors, ergonomics and quality improvement to make effective change. The integrated approach seems to have motivated staff to demand more from our expert team, which is part of why they were more successful.

These findings have implications for organisations where frontline clinical staff are often expected to do safety improvement work as part of their everyday clinical job; such an approach is not going to be sufficient to improve patient safety.

Healthcare organisations need to give their medical staff the time to improve, and the back-up that comes from access to the right experts.

Overall, it makes sense that the combined approach works better, and I hope our work may lead to a rethink on how safety programmes are developed here in the UK and elsewhere.

I think we now need a really big study to confirm that this combined approach can be delivered at scale, and is still the best.