VIEWPOINT Thoughts and reflections on issues of interest to perioperative practitioners KEYWORDS Patient safety / Never events / Changing culture Provenance and Peer review: Unsolicited contribution; Not peer reviewed; Accepted for publication October 2013.

The challenge of creating a ‘we’re all in this together’ culture in Addenbrooke’s theatres In the wake of seven consecutive never events in theatres during 2011-2012, senior managers at Addenbrooke’s had a challenge – to raise morale and support staff to fully support the WHO surgical safety checklist process. Theatres operations manager Maggie Ward and the theatres team took some innovative steps to change culture in theatres. Four ‘never events’ took place in a six-week period at Addenbrooke’s in 2011 between September-October 2011, making eight in total during 2011 and 2012. These events generated wide-spread publicity, as well as an unannounced Care Quality Commission (CQC) visit in April 2012, which confirmed that it had moderate concerns for patient safety. The CQC’s report stated: “People are at risk because the use of the surgical safety checklist is not consistent and the system to monitor the quality of this process has not been effective”. The key priority for the Trust was to ensure that a World Health Organisation (WHO) surgical safety checklist was completed for every patient operated on in theatres to minimise the incident of a never event, and staff engagement and communications was key to its success. My personal challenge as operations manager for theatres was to maintain our reputation as a centre of excellence. The bottom line was to assure patients, the Trust and commissioners that we deliver a safe service by living our mission statement that patient safety is at the heart of all we do.

Creating a culture of inclusion in theatres The keystone to this project was inclusion – ‘we’re all in this together’ – and an engagement plan was developed involving 1,000 staff, from nurses to consultants. Our aim was to ensure that every member of the multidisciplinary team in perioperative care clearly understood they had a duty of care to patients in assuring their safety. The success of this would be measured by the adoption of the WHO surgical safety checklist and team brief in a standardised format with no variations. Our mantra was ‘no team brief, no checklist, no operation’. Senior management were committed to creating a ‘we’re all in this together’ culture by breaking down hierarchical barriers so that any member of the operating team could speak up and highlight concerns they had in regards to patient safety. This involved input and engagement from staff of all levels (surgeons and anaesthetists, unit team leaders, operating department practitioners, theatre support workers) across a number of disciplines (surgery, emergency department, women’s and children’s, neurosurgery, Cambridge Eye Unit, the Rosie Maternity Hospital).

May 2014 / Volume 24 / Issue 5 / ISSN 1750-4589

We invested in a communications manager, to establish new channels to promote patient safety messages through a regular e-bulletin and newsletter, as well as weekly patient safety posters displayed on toilet doors. To maintain this engagement, best practice and learning regarding patient safety is shared at monthly audit meetings, and as monthly audit reports. Regular patient safety learning events take place for all staff to learn key messages, for example a team from theatres ran a stand in the hospital reception promoting the most recent National Patient Safety Week.

The power of critical friends We looked outside our four walls to see how other trusts who were in a similar position turned things around. We invited senior clinicians from Plymouth Hospitals as a ‘critical friend’ to audit our processes; we visited Marshall’s Aerospace in Cambridge to learn from their safety systems and invited Cranfield University to lead a workshop on ‘extreme events’ learning. It was clear that every member of staff had a role to play in keeping patients safe, and they needed to have their role clearly defined, from scrub nurse to surgeon. We identified WHO champions to show the

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The challenge of creating a ‘we’re all in this together’ culture in Addenbrooke’s theatres Continued

team how to undertake the new checklist and guide their teams through the changes. Our communications manager assists us in promoting key messages and developing communications channels. A clinical audit lead and two clinical leads were also appointed for theatres. To implement 100% compliance with the checklist, we had a role play session by the senior management team on ‘how to do the WHO’. We held daily audits of the process to highlight pockets of non-compliance and celebrate best practice, and daily 11am meetings with patient safety themes for theatres unit team leaders. We also ran a series of posters relating to the WHO checklist, which were displayed throughout theatres.

TOP TIPS TO CHANGE CULTURE IN THEATRES Walk the floor - be visible and speak to staff so they understand why changes need to happen. Meet the teams - audit mornings are a great opportunity to meet with large groups of medical and theatre staff. Spread the word - Display posters of the WHO checklist in all theatres and important safety messages everywhere (changing rooms, toilets, scrub sink areas). Seek out the sceptics - meet with them outside the theatre environment to understand why they are resistant to change. Accept negativity - when standardising care you can’t please all people all of the time, but do expect compliance. Standardisation - of all perioperative care standards across all theatres and specialities with no variations or exceptions.

We recognised that theatres are a high pressure environment, and so we promoted the power of ‘mindfulness’ for patient safety, encouraging theatre staff to pay attention to the present and de-cluttering the brain to ensure concentration on the task in hand. For the first time, we held regular multidisciplinary meetings, where all staff from surgeons to scrub nurses took advantage of training such as human factors safety mornings.

A very good safety culture In December 2012, nine months after their first visit, the CQC visited Addenbrooke’s again. The report particularly praised staff attitude towards the WHO surgical safety checklist: “We found clear evidence of an improvement in the application of the WHO checklist within operating theatres. We found staff were enthusiastic and focused on maintaining people’s safety through the improved use of the WHO checklist”. It has been almost two years since the last ‘never event’ in Addenbrooke’s theatres took place, but while we are reassured that we have maintained a safety culture in theatres, we remain preoccupied with failure – which is healthy. We remain vigilant for potential actions that could result in a never event, and mindful that we have to sustain this change. Rather than brush the series of never events under the carpet, we remind all new staff the circumstances that led to the events, and the steps we have taken to ensure they do not happen again. 96

An example of one of Addenbrooke’s posters that illustrates the allocation of roles in theatres to promote patient safety. In Addenbrooke’s there is always a person in charge of the theatre – denoted by a red hat.

n Maggie Ward RN (Anaesthetics and Theatres), MPA, PG Dip in Health Services Management Operations Manager for Theatres, Cambridge University Hospitals n Julia Harrison BA (Hons), PG Dip Journalism Communications Manager for divisions of surgery, emergency and perioperative care, Cambridge University Hospitals May 2014 / Volume 24 / Issue 5 / ISSN 1750-4589

Disclaimer The views expressed in articles published by the Association for Perioperative Practice are those of the writers and do not necessarily reflect the policy, opinions or beliefs of AfPP. Manuscripts submitted to the editor for consideration must be the original work of the author(s). © 2014 The Association for Perioperative Practice All legal and moral rights reserved.

The Association for Perioperative Practice Daisy Ayris House 42 Freemans Way Harrogate HG3 1DH United Kingdom Email: [email protected] Telephone: 01423 881300 Fax: 01423 880997 www.afpp.org.uk

The challenge of creating a 'we're all this together' culture in Addenbrooke's theatres.

In the wake of seven consecutive never events in theatres during 2011-2012, senior managers at Addenbrooke's had a challenge--to raise morale and supp...
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