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Safer Surgery 84 entire operating theatre team in real time. OTAS © aims to be such a comprehensive and robust measure of teamwork in surgery. We report, in detail, the conceptual background, initial development and empirical application, revision and further testing of the OTAS © . We conclude with an outline of ongoing empirical work and future directions in OTAS © -related research. Conceptual Background Components of Teamwork Systematic study of teamworking started in the 1950s and 1960s, with an emphasis on military teams. The focus of this work was military teams functioning in demanding, stressful conditions and the ultimate aim was to understand the constituents of an effective team and to feed this understanding into team training (Paris et al. 2000). Subsequently, empirical study of teamwork extended to high risk industries outside the military (e.g., commercial aviation, nuclear industry) and, soon the conclusion was reached that effective teamwork is fundamental to safety and efciency in high-risk environments (Helmreich and Foushee 1993). Team communication emerged as a particularly critical aspect of teamwork, which allows the fullment of other dimensions of teamwork, such as team coordination. Numerous studies on teamwork were eventually reviewed and organized in a conceptual framework or model of teamwork by Dickinson and McIntyre (1997). These authors proposed that, from the existing literature, seven components of teamwork can be identied: team orientation, team leadership, communication, monitoring, feedback, backup behaviour and coordination. Dickinson and McIntyre’s (1997) model of teamwork and its components was an important step in conceptually clarifying what teamwork consist of (i.e., the sampling domain of the construct). The logical next step is how to best measure and assess the components of teamwork in real-world teams. Measuring Teamwork in Real-World Teams Since, historically, the study of teamwork started from teams of experts carrying out complex tasks in complex work environments it is perhaps not surprising that assessment of teamwork has been traditionally done through observation. Observation might be carried out within the actual work environment in real time, or in a simulated scenario or via recording teams while they are at work and retrospective analysis of video and audio recordings. Various tools have been developed for observation and assessment of teamwork – a sample of them is reviewed below: TARGETS (Targeted Acceptable Responses to Generated Events or Tasks): this method was originally developed to evaluate team performance in • Observing and Assessing Surgical Teams 85 complex environments such as air crew coordination training (Fowlkes et al. 1994). Specic ‘focal’ events are inserted into training scenarios, each one with a range of acceptable behavioural responses as criteria. An observer can then assess observed responses against the preset criteria. This method is ideally suited for assessment of teamwork during training, as focal events can be scored reasonably objectively (Dwyer et al. 1997). Disadvantages of the method include the need for development of large numbers of scenarios and lack of applicability to real-life teamworking, in which there is much less control compared to training. Behavioural markers systems: these are typically used in commercial aviation. A number of teamwork components are dened and observable behaviours are attached to each one of them in the form of behavioural statements. Observers rate team-members depending on whether the relevant behaviours were exhibited or not (or to what extent). Assessment can be done in real time, or retrospectively, using video/audio recordings. Perhaps the most well- known such tool is the Non-Technical Skills (NOTECHS), used to assess cockpit crews (Avermate van 1998, Flin et al. 2003, Klampfer et al. 2001, O’Connor et al. 2002). NOTECHS assesses leadership and management, decision-making, cooperation and situation awareness. A similar tool is the Line Operations Safety Audit (LOSA): this system utilizes trained observers riding in cockpit jump seats to evaluate several aspects of crew performance and collect safety-related data. Observers record threats encountered by aircrew and types of errors committed, and they record how ight crews manage these situations to maintain safety (Helmreich et al. 2002, Klinect et al. 2003). Early Observational Studies of Teamwork and Safety in Surgical Teams At the early stages of OTAS development, we sought to identify empirical studies that had attempted to assess teamwork in operating theatres. Early attempts to empirically assess teamwork in surgical environments were evidently inuenced by the principles of teamwork assessment tools and the relevant research approaches used in the context of (mostly) commercial aviation. Teamwork was assessed via observation and the key working hypothesis was that teamwork is implicated in the safety and quality of surgical care. Roth et al. (2004) studied team performance using a eld notes technique. Two observers, one surgeon and one human factors expert studied ten complex operations in an exploratory study to identify latent factors that could compromise patient safety and potentially lead to adverse events. Two key themes emerged from these observations: (i) multitasking and the ensuing pressure on operating theatre staff’s attention; and (ii) multiple conicting goals that the staff had to achieve. From a methodological perspective, Roth et al. concluded that retrospective analysis of video recordings could be an alternative to real-time observation in the operating theatre (Roth et al. 2004). • • Safer Surgery 86 Carthey (2003) evaluated the role of structured observations in theatre. Data were collected from 173 neonatal arterial switch operations in paediatric cardiac units across 16 centres in the UK. Trained observers noted errors, problems and notable aspects of good performance. The observer’s interpretation was checked with the operating theatre team after each case. Carthey (2003) concluded that structured, well-dened observational measures are needed for rapid training of observers, better inter-observer reliability, and clearer understanding of what should be observed. An observational study of errors during paediatric cardiac surgery was conducted by de Leval et al. (2000). They found that surgeons’ diagnostic skill, knowledge of strategies to correct problems and communication with the rest of the team were important for error compensation. The authors concluded that error recovery strategies are just as important as error prevention measures. In another study of paediatric cardiac operations, Catchpole et al. (2006) used a single observer in the operating theatre, who was making notes as well as recordings of the procedures (to be reviewed at a later stage). Although the study focused primarily on threats and errors associated with surgical failures, communication and coordination did emerge from it as components of teamwork (see Chapters 7 and 19 of this volume). Mackenzie et al. (1996) used video studies to observe emergency intubations. They found that in stressful situations knowledge-based errors were committed (including drug dosage errors) and that not all observed errors were actually reported. The authors concluded that team training might be benecial for improving team communication. In another study, Mackenzie, Xiao and the IPO Group (2003) used recordings of trauma resuscitations to study team performance in emergency medicine. They found that recordings had some advantage over observation in that they could be analysed iteratively and in more depth – however, they were more time consuming (see Chapter 23 in this volume). Helmreich et al. (1995) developed a checklist to assess teamwork in the operating theatre. Their Operating Room Check List is based on behavioural markers developed for aviation and consists of observable behaviours that are divided into three sections: (i) team concerns; (ii) decision-making and communication; and (iii) management of the work situation. These are scored on four-point scales. Initial results using the checklist in a European hospital showed that there was wide variability in the behaviours observed with up to 40 per cent being below standard (Helmreich and Davies 2007). Guerlain et al. (2002, 2005, 2007) developed the Remote Analysis of Team Environments (RATE) tool. RATE is a recording and analysis system that captures communication and team performance in operating theatres. The authors reported a successful application of the RATE in ten laparoscopic cholecystectomies and concluded that RATE has the potential to identify areas for improvement in teamwork (such as pre-operative brieng) (see Chapter 8 in this volume). Finally, Lingard and her colleagues carried out a series of observational studies with a strong focus on communication (Lingard et al. 2002, Lingard et al. 2004a, 2004b, Chapter 17 in this volume). Five core communication themes in the operating theatre emerged from these studies: (i) time; (ii) resources; (iii) roles; (iv) safety Observing and Assessing Surgical Teams 87 and sterility; and (v) situation control. Lingard et al. (2002) recorded between one and four communication events where tension was high, typically between surgeons and nurses. In another study (Lingard 2004a), 421 communication events from 48 operations were analysed for failures and 129 failures (31 per cent) were found. These were related to the occasion of the communication, its content, its purpose, or its audience. They found that 23 of these failures resulted in some inefciency, 16 triggered tension between staff, 10 caused a delay, 3 resulted in the bending of a rule, 2 in the waste of resources, 2 in inconvenience for the patient, and, nally, one failure resulted in a visible operating error. On the whole, 36 per cent of the failures affected teamwork negatively. The empirical work that we reviewed above was or was becoming available at the early stages of OTAS © development. Upon review and evaluation of the ndings and the methods/assessment tools that are reported in these papers, we concluded that: assessment of surgical teamwork is feasible and acceptable to surgical teams; direct observation appears to be a well-suited methodology for such assessment; a theory-driven, robust observational tool that is specic to surgery needs to be developed. This rationale guided the initial development of the OTAS © tool. Initial OTAS © Development and Empirical Piloting (Healey et al. 2004, 2006c, Vincent et al. 2004, Undre et al. 2006a, 2006b, Undre and Healey 2006) 1 We set out to develop OTAS © using real-time observations in the light of the conceptual framework and assessment issues and approaches summarised above. In designing and piloting OTAS © , we aimed for: a surgery-specic tool, based on a sound conceptual framework and appropriate rationale for assessment; a tool that assesses concurrently what surgical teams do and how they do it; a tool that assesses teamwork across the entire surgical team; a generic tool, designed to assess teamwork in routine procedures in real time across surgical specialities (but also amenable to subsequent adaptation for use, for instance, in emergency surgery or for team training purposes). 1 For the sections on OTAS © development, renement and empirical testing, readers are referred to the original publications (cited in the text) for additional detail. 1. 2. 3. • • • • Safer Surgery 88 Surgical teams are usually comprised of four generic disciplinary groups: surgeons, nurses, anaesthetists and Operating Department Practitioners (ODPs: in the UK, they full the role of an anaesthetic nurse/assistant). Depending on the procedure, other specialists can be part of the team (e.g., radiographers). Tasks and behaviours required in the team process might be carried out by individuals, or by several members within a disciplinary subgroup (e.g., anaesthetist and ODP), or, nally, between two or more subgroups, simultaneously or sequentially. We adopted the approach that an observational assessment of teamwork should account for essential routine tasks relating to team process and patient safety. Thus the rst component of the OTAS © is a task checklist. In addition, however, OTAS © also comprises behaviour ratings. The distinction between the checklist and the behaviour ratings is important: we took the stance that elements of team performance that are captured by checklists or very narrowly dened markers are only a part of the level of teamwork achieved by a team. Simply put, teams that carry out similar routine tasks may still appear very different to an external observer – due to signicant differences in their communication and coordination patterns. Hence, in the initial development of OTAS © we chose to supplement the (more objective) task checklist with (more subjective) behaviour ratings, with an open format for recording of eld observations. Assessment Timeline: OTAS © Operative Phases and Stages In order to facilitate the scoring of tasks and the rating of behaviours, OTAS © divides the surgical process into three meaningful phases (see Table 6.1): pre-operative phase: includes everything up to the point of the actual operation; intra-operative phase: from the point of incision (knife to skin) to the point of closure; post-operative phase: from the point of closure to patient being transferred to recovery/ward. 1. 2. 3. Phase Stage 1 Stage 2 Stage 3 1. PRE-OP pre-op planning and preparation patient sent for to anaesthesia given patient set-up to op-readiness 2. INT RA-OP opening/access to contact of target organ op-specic procedure from prepare to close to complete closure 3. POST-OP anaesthetic reversal to exit from theatre transfer to recovery/ recovery to ward feedback and self-assessment Table 6.1 Operative phases and stages of OTAS © Observing and Assessing Surgical Teams 89 Within each phase, there are distinct stages. These are distinguished by concrete events that require teamwork – such as, for instance, patient entering the operating theatre under anaesthesia for transfer to the operating table. Development of Task Checklist The checklist was constructed for each phase/stage of the operation. Existing operating theatre protocols, recommendations for good practice, domain knowledge and expert advice were inputs to the development process. The initial list consisted of 203 tasks – plus checks for presence of staff in theatre. Tasks fall within one of three categories: patient tasks comprise either actions or information associated directly with the patient, such as safe transfer to operating table and patient notes present; equipment/provisions tasks include checking and counting of surgical instruments; communication tasks include information such as conrmation of operative site laterality. Items on the checklist are marked ‘yes/no’. For example, under the category of equipment tasks, diathermy preparation is marked ‘yes’ if the diathermy machine is switched on and tested prior to the operation. Development of Behaviour Rating Scales Choice of behaviours to be observed followed Dickinson and McIntyre’s (1997) model of teamwork. Of their seven dimensions we retained ve, namely: communication refers to the quality and the quantity of the information exchanged among members of the team; coordination refers to the management and to the timing of activities and tasks; cooperation/back-up behaviour refers to assistance provided among members of the team, supporting others and correcting errors; leadership refers to the provision of directions, assertiveness and support among members of the team; monitoring/awareness refers to team observation and awareness of ongoing processes. Team orientation (which refers to the attitudes that team members have towards each other and to the team task) was deemed hard to assess by observation and also closely related to cooperation/back up behaviour – hence we incorporated it into that dimension. Similarly, team feedback (which refers to providing and receiving 1. 2. 3. 1. 2. 3. 4. 5. Safer Surgery 90 information about performance) was viewed as a component of communication. The ve retained behaviours are rated on 0–6 point, behaviourally anchored scales. The OTAS © Assessment Process Two observers (surgeon and psychologist), enter the operating theatre before the patient arrives. Thereafter, both surgeon and psychologist observer record each stage start-time, they conrm stages in the procedure, serving as a double check on times. The surgeon observer begins checking tasks using a PDA (tasks in Excel spreadsheet, arranged by phase/stage). The psychologist observer begins observing and noting teamwork behaviours as they occur using a paper form. Towards the end of each stage, the psychologist observer uses the OTAS behaviour summary scales to provide ratings for the overall impression of each behaviour construct displayed by the team. Initial Empirical Application: General Surgical Cases (Undre et al. 2006a) This study aimed to assess the feasibility and practicality of systematic teamwork observations in real time in real procedures and also to test the OTAS © tool. Prior to data collection, operating theatre staff were informed and notices about the study were displayed inside and outside the operating theatre. We took care to reassure staff that data would be used for research purposes only and not as surveillance of individuals’ performance. Methods Data were collected from 50 general surgery operations (29 open, 21 laparoscopic) in a single operating theatre in our institution (central London teaching hospital). The data were collected from the operating lists of three consultant (attending) surgeons, but the research team did not have control over staff variation between cases (anaesthetists, trainee/assisting surgeons, nurses). Data were collected from procedures that lasted between 30–240 minutes. Tasks and behaviours were assessed from Pre-op Stage 1 to Post-op Stage 2. The last OTAS © stage was not feasible to assess. Results and Comments Task completion Table 6.2 (general surgery columns) presents the task completion rates. Overall, task completion was higher at post-op than in pre- or intra-op phases. Moreover, task completion was higher for patient tasks than for either equipment/ provisions tasks or communications tasks. Some more specic ndings: anaesthetists had not checked their machines themselves in 20 per cent of the cases; • Observing and Assessing Surgical Teams 91 suction was checked prior to the operation in just 37 per cent of cases; procedures were conrmed verbally in 32 per cent of cases; patient notes were absent in 12 per cent of cases; there was no communication regarding readiness to start procedure in 35 per cent of the cases; delays and changes to the case-list occurred in over 70 per cent of cases. Behaviour ratings These were relatively high, with scores of four or higher (on a seven-point scale). Of signicance were the ndings that communication was rated signicantly lower than the other behaviours and it was lower in the pre- and intra-operative phases. The key nding of the study is that team observations in real procedures in real time are feasible. Moreover, we felt that the OTAS © does capture signicant aspects of teamwork and that the format of the tool (task checklist and behaviour ratings) does allow for capturing some of the richness of surgical teamwork in a robust, replicable manner. Furthermore, the ndings were not dissimilar to previous studies that have highlighted communication issues as well as problems with equipment in surgical teams. Importantly, this initial experience of using OTAS © revealed a number of ways in which the tool could be improved. These were addressed by rening and retesting the tool. OTAS © renement and further empirical testing (Healey et al. 2006c, Undre et al. 2006a, 2007b) In the light of the ndings and our experience with the rst 50 observed cases, a number of revision points for OTAS © emerged: There were redundancies in the task checklist. • • • • • • Phase Pre-operative Intra-operative Post-operative T ask type General Surgery Urology General Sur gery Urology General Surgery Urology Equipment/ provisions 56% 61% 82% 91% 89% 95% Communication 61% 71% 55% 57% 90% 84% Patient 90% 94% 93% 93% 97% 92% Overall 69% 77% 77% 80% 92% 90% Table 6.2 Task completion rates in general surgery (rst study) versus urology (second study) Safer Surgery 92 The scoring of behaviours was relatively blunt, in that it did not allow any discrimination between the different sub-teams (anaesthetic, surgical, nursing) that make up a full operating theatre team. In addition, the scoring of the behaviours was too much reliant on the psychologist observer’s impression of the team. Although the relative subjectivity of this part of the tool was intended, it was felt that it should be reduced to allow novice as well as non-psychology trained observers to be trained in using the tool. In what follows, we report in detail how each one of these issues was addressed. Revision of Task Checklist Structured interviews with nine expert operating theatre staff (three anaesthetists, three nurses, three surgeons) were conducted. Participants were given the original checklist and the following criteria: Inclusion criteria (any of the below) Task contributes to patient safety or quality of care. Task contributes to surgical outcome positively or its omission would contribute adversely to surgical outcome. Task is essential for teamwork or enhances teamworking. Task makes an important contribution to the whole system. Exclusion criteria (any of the below) Task which is duplicated or covered by another task. Task which is irrelevant to any of the above inclusion categories. Tasks which are inherent to the procedure. Task which is not clinically important. For each task, participants indicated whether it should be included/excluded, or whether they were not sure. This process of systematically eliciting expert agreement was used as input to the checklist revision. Working in parallel, two surgeons (consultant and trainee) who were blind to the interview ndings prepared a revised version of the list. No perfect agreement was reached for task exclusion or inclusion. We used the following cut off criteria: Tasks where 9/9 respondents agreed should be included (31) were included. Tasks where 8/9 respondents agreed should be included (55) were included. • • 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. Observing and Assessing Surgical Teams 93 Tasks where 6–7/9 respondents agreed should be excluded (15) were excluded. Tasks where 4–5/9 respondents agreed should be excluded (25) were mostly excluded; these decisions were made with input from the consultant and trainee surgeons involved in the checklist revision. The process furnished a revised, easier to use checklist of 115 tasks (signicantly reduced from the original 203). The tasks still corresponded to the three operative phases as originally dened (pre-, intra- and post-operative). Importantly, virtually all tasks that the two blind surgeon reviewers included in their checklist were indeed included in the list (thus suggesting reliability in the reviewing process). Modication of Behavioural Ratings to Assess Sub-Teams In the initial assessment, one rating per behaviour was allocated to the entire surgical team. In the process of allocating ratings, however, it was noted that discrepancies existed at times between sub-teams (nursing, surgical and anaesthetic) and, as a result, single ratings for the entire team did not convey an accurate picture of that team’s teamwork. The rating scheme was, therefore, revised to provide separate ratings for each one of the ve behaviours to each one of the three theatre sub-teams. With this amendment to the rating scheme, the psychologist observer now generates 45 behavioural ratings per procedure (5 behaviours × 3 operative phases × 3 sub-teams). Development of Behavioural Scoring Aids In order to assist the scoring of the behaviours, demonstrative scenarios and behavioural exemplars were developed for each of the ve behaviours. Exemplar behaviours: exemplar behaviours are items that serve to guide the observer in ‘looking for behaviours’ that indicate effective teamwork. Exemplar behaviours may be checked for their occurrence, in support of overall behaviour ratings – thus serving as reminders for the psychologist observer. Exemplar behaviours were constructed for each of the ve behaviours, for each phase of the procedure, and, nally, for each of the three key sub-teams. For example, during the Intra-op Phase, the surgeon asks the team if they are ready and asks the anaesthetist if it is OK to start the procedure. Demonstrative scenarios: scenarios are particularly useful for calibrating the rating of behaviour to a standardized scale. Scenarios provide a context in which behaviours are related to levels of teamwork effectiveness and demonstrate that certain patterns of team behaviour are associated with certain levels of team effectiveness. For example, the anaesthetist gives clear and audible instructions to the team about the latest blood results and that s/he will be transfusing the patient with two units of blood. 3. 4. • • . Safer Surgery 84 entire operating theatre team in real time. OTAS © aims to be such a comprehensive and robust measure of teamwork in surgery. We report, in detail,. detail. 1. 2. 3. • • • • Safer Surgery 88 Surgical teams are usually comprised of four generic disciplinary groups: surgeons, nurses, anaesthetists and Operating Department Practitioners (ODPs:. 69% 77% 77% 80% 92% 90% Table 6.2 Task completion rates in general surgery (rst study) versus urology (second study) Safer Surgery 92 The scoring of behaviours was relatively blunt, in that
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