Safer Surgery 254 knowledge of anaesthetic practice. Expertise in anaesthesia, as in other elds of practice, rests on the successful relationship between these different forms of knowledge. There is ‘explicit’ knowledge, which is capable of being written down, codied and communicated in textbooks and journals and set out in examination syllabuses. There is also ‘tacit’ knowledge, dened as ‘knowledge that has not been (and perhaps cannot be) formulated explicitly and therefore cannot be stored or transferred entirely by impersonal means’ (MacKenzie and Spinardi 1995, p. 45). It is typically acquired via demonstration followed by practice. Our work has begun to unravel the relationship between formal knowledge and the knowledge born of experience in expert anaesthetic practice. Formal training in communication skills is to be welcomed but we would suggest that a substantial amount of teaching and learning of these skills goes on almost unrecognized during the kinds of interactions we have documented. The danger of course is that if safe, effective care depends on the understanding of informal, idiosyncratic procedures and communicative devices, then staff who are not familiar with them pose a threat. These may include locum and agency staff and those from overseas or otherwise different working cultures. There does not seem to be a great deal in the research literature on how relationships between members of the interprofessional team are negotiated. In the context of handovers, there is a substantial body of research on nurse-to-nurse handovers (Kerr 2002, Manias and Street 2000, Sherlock 1995), and some recent interest in handovers between doctors (Horn et al. 2004, Solet et al. 2005), but little work exploring interprofessional handover. Our data suggest that nurses may sometimes be manoeuvred into taking the responsibility for setting the boundaries of doctors’ safe practice – for instance in saying when they consider the anaesthetist can safely leave the patient and return to the operating theatre – and this may prevent them from effectively voicing concerns about safety. Paradoxically, they do appear to inuence medical practice, though not in the explicit fashion one would expect in a fully developed ‘safety culture’, but instead in variable, informal, and less visible ways. Handovers provide an opportunity to check progress and review care. Manias and Street (2000) have suggested that nurse-to-nurse handovers (observed in an intensive care unit) act to maintain conformity of practice, as a nurse’s work during the previous shift is under scrutiny by the colleague relieving her or him. Typically, intraoperative problems were underplayed in the handovers we observed. This may simply be because few of them lead to problems in the recovery room, but we suggest that anaesthetists’ practice may be similarly exposed to the recovery nurses’ subtle and implicit judgement of what constitutes an acceptable clinical standard. Whatever the circumstances, the handover process must still be conducted to the satisfaction of both parties, and take place in such a way that neither party ‘loses face’ so that future encounters are not jeopardized (Goffman 1967). One characteristic of safety-sensitive organizations is that everyone, no matter how junior they are, feels free to voice concerns about safety (Sexton et al. 2000, Smith et al. 2006b). In the context of anaesthetic practice this has to be done using coded language and without confrontation. This informal, Teams, Talk and Transitions 255 implicit approach goes against the standardized approaches to handover in safety critical industries (Arora and Johnson 2006, Patterson et al. 2004). Conclusion Approaches to improving care relying on protocol and standardization are widely promoted as ways of enhancing patient safety. We argue that, unless the tacit and implicit cultural factors underlying interprofessional working and communication in the operating theatre are taken into account, such approaches will not achieve their potential. In research terms, future work might usefully explore the effect of different styles of communication on patient anxiety, patient satisfaction, anaesthetic team performance and markers of patient safety. Key to Extended Transcript Extracts A Anaesthetist O Orderly or porter ODP Operating department assistant RN Recovery room nurse N Surgical nurse S Surgeon LM/LMA Laryngeal mask airway (airway management device) PCA Patient-controlled analgesia machine Names, where given, have been changed. References Arora, V. and Johnson, J. (2006) A model for building a standardized hand-off protocol. Joint Commission Journal on Quality and Patient Safety 32, 646– 55. Atkinson, P., Coffey, A., Delamont, S., Loand, J. and Loand, L. (eds) (2001) Handbook of Ethnography. London: Sage Publications. Goffman, E. (1967) Interaction Ritual: Essays on Face to Face Behavior. New York: Doubleday. Goodwin, D., Pope, C., Mort, M., and Smith, A. (2005) Access, boundaries and their effects: Legitimate participation in anaesthesia. Sociology of Health and Illness 27, 855–71. Harms, C., Young, J.R., Amsler, F., Zettler, C., Scheidegger, D. and Kindler, C.H. (2004) Improving anesthesiologists’ communication skills. Anaesthesia 59, 166–72. Safer Surgery 256 Hindmarsh, J. and Pilnick, A. (2002) The tacit order of teamwork: Collaboration and embodied conduct in anaesthesia. Sociological Quarterly 43, 139–64. Horn, J., Bell, M.D.D. and Moss, E. (2004) Handover of responsibility for the anaesthetised patient – opinion and practice. Anaesthesia 59, 658–63. Kerr, M.P. 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London: Sage Publications. Smith, A.F. (2007) Reaching the parts that are hard to reach: Expanding the scope of professional education in anaesthesia. British Journal of Anaesthesia 99, 453–6. Smith, A.F. and Shelly, M.P. (1999) Communication skills for anesthesiologists. Canadian Journal of Anesthesia 46, 1082–8. Smith, A.F., Goodwin, D., Mort, M. and Pope, C. (2003a) Expertise in practice: An ethnographic study exploring acquisition and use of knowledge in anaesthesia. British Journal of Anaesthesia 91, 319–28. Teams, Talk and Transitions 257 Smith, A., Mort, M., Goodwin, D. and Pope, C. (2003b) Making monitoring ‘work’: Human-machine interaction and patient safety in anaesthesia. Anaesthesia 58, 1070–8. Smith, A.F., Pope, C., Goodwin, D. and Mort, M. (2005) Communication between anesthesiologists, patients and the anesthesia team: A descriptive study of induction and emergence. Canadian Journal of Anesthesia 52, 915–20. Smith, A.F., Goodwin, D., Mort, M. and Pope, C. 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This page has been left blank intentionally PART III Observation of Theatre Teams This page has been left blank intentionally Chapter 16 An Empiric Study of Surgical Team Behaviours, Patient Outcomes, and a Programme Based on its Result s Eric Thomas, Karen Mazzocco, Suzanne Graham, Diana Petitti, Kenneth Fong, Doug Bonacum, John Brookey, Robert Lasky and Bryan Sexton Introduction As one of ve principles for creating safe systems of healthcare delivery, the Institute of Medicine (IOM) report on medical error (Kohn et al. 2000) concluded that healthcare organizations need to ‘promote effective team functioning.’ Their recommendation for promoting team behaviour was based primarily upon qualitative research methodologies and approaches such as root cause analyses. In the airline industry, research linking effective team functioning to ight safety led to specic training in teamwork that was subsequently associated with improvements in safety. Healthcare settings involving high risk of harm such as labour and delivery (Sexton et al. 2006b), critical care (Pronovost et al. forthcoming) and especially surgery (Makary et al. 2006a, Sexton et al. 2006c) share many of the same fundamental elements of the airline industry, where people are working with other people in a high-tech and high risk work environment. Research suggests the need for improved teamwork and communication in neonatal intensive care (Falck et al. 2003, Halamek et al. 2000, Thomas et al. 2006) emergency departments (Morey et al. 2002) the operating room (Carthey et al. 2003, Makary et al. 2006b), trauma resuscitation (Santora et al. 1996, Sugrue et al. 1995, Xiao et al. 1996) and among residents of all disciplines (Sutcliffe et al. 2004). Nevertheless, very little quantitative research has assessed the relationship between team behaviours and outcomes in healthcare. Despite a signicant amount of rhetoric around teamwork, team training and the impact of communication breakdowns, the evidence that directly links the interpersonal interactions of caregivers to the outcomes of their patients has not been well documented. For example, two recent reviews concluded that no studies have shown that team training can improve teamwork and the quality of care (Baker et al. 2005, Salas et al. 2006) and a cluster randomized trial of team training for labour and delivery teams did not nd signicant changes in process of care or outcome measures (Nielsen et al. 2007). Knowledge about how to improve team behaviour appears Safer Surgery 262 to be in its infancy. We conducted and have published the results of study to determine whether patients of surgical teams who exhibited good teamwork had better outcomes than patients of teams with poor teamwork (Mazzocco et al. 2008). We summarize this study’s methods and ndings and go on to describe how the data from the study were used to develop and implement a multi-institutional programme to improve surgical teamwork. Methods This study was conducted in the operating rooms of two medical centres and two ambulatory surgical centres afliated with the Kaiser Foundation Health Plan in the USA. It involved structured observation of personnel (surgeons, anaesthesiology providers, nurses, technicians and others) doing surgical procedures at the four sites during the period from March to August, 2005 and assessment of 30-day post-surgical outcomes (by retrospective chart review) of patients whose surgical team had been observed. Observed providers consented in writing to be observed. We approached 149 physicians, registered nurses, operating room technicians and nurse anaesthetists; 19 (12.7 percent) declined to participate. Provider consent was rst sought after presentation of information about the project at a regular meeting of the provider group. Some provider groups (surgeons, MD anaesthesiologists and Certied Registered Nurse Anaesthetists) voted at the information meeting to participate universally, although 2 of 44 of the physicians attending the informational meeting declined in spite of this group vote. Seventeen of 69 (25 percent) nurses and technicians attending the informational meeting initially declined to participate in the study but some of these providers consented to have specic procedures observed when they were asked at the time the procedure was selected. Providers who did not attend the informational meetings were asked whether or not they consented to participate in having specic procedures observed but the consent rate by provider was not tracked for these individuals. Patients were observed if they did not opt out of observation after being informed of the study during their pre-operative visit (29 patients opted out of the study). The study sample size of 300 surgical cases was chosen based on resource and time availability. A statistical power analysis done a priori based on the sample size showed that the study had a power of 0.95 to detect a correlation of 0.20 or more between a rating of team behaviour on a four-point scale and rating of outcome on a ve-point scale using a two-tailed statistical test. The study was reviewed and approved by the Kaiser Permanente Institutional Review Board for protection of human subjects. Observers and Training Observers of the surgical procedures were all registered nurses. Standardization of observations and calibration between observers was achieved in a training session An Empiric Study of Surgical Team Behaviours and Patient Outcomes 263 given at the Johns Hopkins University Quality and Safety Research Group. Training of four registered nurse observers included an overview of behavioural observation and peri-operative teamwork, and a series of calibration exercises whereby observers watched video clips of team behaviours, rated the frequency with which the behaviours occurred on the data collection form used in the study, and then debriefed the exercise to discuss discrepancies and verbally justify their ratings. This iterative process involved observing, rating and debrieng ve videos, during which time the real-time calibration level of the observers was calculated and shared with the observers using a within group measure of inter- rater agreement (RWG) (James et al. 1984), requiring a .70 cut-off for acceptable agreement. Behavioural Markers The study dened team function based on behavioural markers (Klampfer et al. 2001). Behavioural markers are observable, non-technical behaviours that have been demonstrated empirically to contribute to performance in work environments, including the airline industry (Sexton et al. 2000) and healthcare (Thomas et al. 2004). Behavioural marker data were collected using a standard instrument adapted for this study (Thomas et al. 2006). The instrument used in this study assessed the following six behaviour domains: brieng, information sharing, inquiry, assertion, vigilance and awareness, and contingency management. Operational denitions for behaviours in each domain are given in Table 16.1 (Mazzocco et al. 2008). For each domain, the observer gave the surgical team a score from 0 to 4 on how often the specied behaviours related to that domain were observed. A score of 0 was given if the behaviours were never observed; 1 if the behaviours were observed rarely; 2 if there were isolated examples of the behaviour; 3 if the behaviours were observed intermittently; and 4 if behaviours were observed frequently throughout the observation period. For each domain, separate team scores were assigned for the induction, intra-operative and hand-off (transition to the next level of care) phases of the procedure. Selection of Procedures for Observation Procedures were selected for observation on the morning of the surgery based on consent of all team members to be observed, compatibility with the operational needs of the surgical suite, anticipated length of the procedure and availability of the observer. Each selected procedure was observed by one observer, who joined the team to begin observation when the patient was brought to the operating room. Observation ended when the patient was taken out of the operating room and handed off to the next level of care. . Safer Surgery 254 knowledge of anaesthetic practice. Expertise in anaesthesia, as in other elds of. handover process must still be conducted to the satisfaction of both parties, and take place in such a way that neither party ‘loses face’ so that future encounters are not jeopardized (Goffman. Kindler, C.H. (2004) Improving anesthesiologists’ communication skills. Anaesthesia 59, 166–72. Safer Surgery 256 Hindmarsh, J. and Pilnick, A. (2002) The tacit order of teamwork: Collaboration and