TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD

1. TOWARDS FLAWLESS EXECUTION ON THE LABOUR WARD Leroy Edozien RCOG/ENTER

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3. 5496 perinatal deaths in 2005 Unexplained antepartum 33% Congenital abnormality 17% Prematurity 17% Intrapartum deaths 11% 2006: Risk of intrapartum stillbirth = 1 in 1486 RCOG/ENTER

4. Intrapartum stillbirth Failure to act on CTG Teamwork/communication Task saturation Loss of situation awareness Plan continuation bias RCOG/ENTER

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7. Interventions to make childbirth safer, reduce number of intrapartum stillbirths • ‘Safer Childbirth’ • CNST/NHSLA • Healthcare Commission • King’s Fund • RCOG Service Standards, Obstetrics RCOG/ENTER

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9. Making maternity care safer First order v Second order change changeTransactional v Transformational change change RCOG/ENTER

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11. Achieving change Systems resist change Changing a system by changing its ‘centre of gravity’ It is far better to attack your centres of gravity in parallel – all at once, rapidly RCOG/ENTER

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13. Three themes No observations made for a prolonged period and therefore changes in a patient’s vital signs not detected No recognition of the deterioration and/or no action taken other than recording of observation Delay in the patient receiving medical attention, even when deterioration has been detected and recognised RCOG/ENTER

14. Contributory factors • Communication – ‘the biggest problem area’ • Work and environment • Task factors • Education and training • Patient factors • Team work and social • Equipment and resources • Individual factors RCOG/ENTER

15. Do you work in a team or teams? RCOG/ENTER

16. How do you rate the quality of teamwork in your workplace? RCOG/ENTER

17. Do you have formal briefing/debriefing sessions on your labour ward? RCOG/ENTER

18. Survey of O&G staff LTH LWH SMH % staff working extra hours due to demands of job 93 70 72 % staff saying they work in teams 100 97 95 % staff working in a well structured 29 50 37 team environment Extracted from the National NHS Staff Survey 2005 RCOG/ENTER

19. Team communication Communication is central to team work Handover Briefing Debriefing Minimise parallel processes RCOG/ENTER

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21. Flawless execution ‘If I failed to execute my mission properly there was an incredibly good chance I was going to be a smoking hole in the ground. Not a nice day. The pursuit of flawless execution was the dividing line between life and death….’ RCOG/ENTER

22. Flawless execution ‘Businesses rarely see execution as a process and almost never debrief’ Hospitals RCOG/ENTER

23. Flawless execution ‘There were far too many examples around me that together seemed to say that flawless execution really didn’t matter….. if you failed to execute your mission properly, there was always another day’ RCOG/ENTER

24. Flawless execution …is not the pursuit of perfection …is all about expecting things could go wrong, and managing this risk RCOG/ENTER

25. Flawless Execution cycle • Plan – influence destiny by being proactive • Brief – ‘the brief is the mission, the mission is the brief’ • Execute - we know where we are and what we are going to do next • Debrief - the enduring step • Win – start another mission RCOG/ENTER

26. Mission planning • Identify threats • Identify available resources • Apply lessons learned • Determine courses of action/tactics • Plan for contingencies RCOG/ENTER

27. Determine courses of action/tactics Mandatory to attach a timeline to the mission – who will do what, when? RCOG/ENTER

28. Identify threats • Internal and external • Complacency, apathy • Communication RCOG/ENTER

29. Identify available resources • Staff • Training • Environment RCOG/ENTER

30. Flawless Execution cycle • Plan – influence destiny by being proactive • Brief – ‘the brief is the mission, the mission is the brief’ • Execute - we know where we are and what we are going to do next • Debrief - the enduring step • Win – start another mission RCOG/ENTER

31. Briefing ‘When one walks into a fighter pilot’s briefing room, first impressions are everything’ Sharpening the senses Standard operating procedures RCOG/ENTER

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34. Situation awareness RCOG/ENTER

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37. Flawless Execution cycle • Plan – influence destiny by being proactive • Brief – ‘the brief is the mission, the mission is the brief’ • Execute - we know where we are and what we are going to do next • Debrief - the enduring step • Win – start another mission RCOG/ENTER

38. Execution Task saturation - the biggest stumbling block to flawless execution Common responses to task saturation: quit – shut down compartmentalise – time sharing b/w important and unimportant tasks channelised attention – fixated on one thing RCOG/ENTER

39. Task saturation – coping mechanisms • Checklists –memory joggers and actions • Cross-checks –never channelising, always scanning • Mutual support –operating as a team RCOG/ENTER

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41. CDU WARD ROUND DATE: TIME: 08:30/13:00/17:00/21:30/01:00/05:00 If late: time and reason why - Present on WR RCOG/ENTER

42. Effective communication • Concise, clear; not a lot of filler material • Extraneous conversation • S.B.A.R RCOG/ENTER

43. Flawless Execution cycle • Plan – influence destiny by being proactive • Brief – ‘the brief is the mission, the mission is the brief’ • Execute - we know where we are and what we are going to do next • Debrief - the enduring step • Win – start another mission RCOG/ENTER

44. Debrief • The good, the bad and the ugly • Open communication RCOG/ENTER

45. Rankless debriefs ‘ When they cross the threshold of the briefing room door, they throw away their name and rank. All they bring in is truth, an open mind, and open communication. If there was a mistake they want to admit it in front of their peers, supervisors, or subordinates; if they’ve forgotten a mistake, a fellow pilot is going to point it out to them. A two-star general or a green lieutenant, they’re al on the same side of the table’ RCOG/ENTER

46. Rankless debriefs • Failure to start at the top will lead to a failed debrief • Inside outside approach – starting inside reaffirms the importance of rankless debriefs RCOG/ENTER

47. The ‘Swiss cheese’ model of accident causation RCOG/ENTER

48. System plus individual Mental skills People at the sharp end can thwart sequence RCOG/ENTER

49. Improving safety in maternity care:focus on strategy as well as tactics Tactics are rarely decisive; it is strategy that makes the difference Iraq Apple RCOG/ENTER

50. Conclusion The concept of flawless execution, borrowed from military aviation, can and should be applied in maternity care. This concept, in conjunction with other interventions, has potential to improve the safety of maternity care and reduce intrapartum mortality and morbidity. RCOG/ENTER