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Surgery is getting safer thanks to NIHR-funded research by an Oxford University team that has brought together two previously competing theories about how best to protect patients.

Previous attempts to improve patient safety in surgery used one of two approaches. Some investigators tried to improve teamwork and communication by training team members to interact better, using principles developed in the aviation industry. Others have focused on the systems of work and used industrial quality improvement techniques to rationalise these and remove or modify steps which carry a high risk of error.

The work was carried out over four years by the Department of Surgical Sciences (NDS) at Oxford University under an NIHR Programme Grant for Applied Research. It is believed to be the largest, direct observational study of surgical team performance during whole procedures ever completed.

The team ran five identical studies comparing the culture approach, two different systems approaches and two combined culture/system approaches. They found that the combined system/culture approaches were clearly better than either of the single approaches. This is an important idea which may change practice internationally.

Two new papers, published in the journal Annals of Surgery, outline the results of their research.

It is not enough to just fix the system and it's not enough to just train the team. You have to do both. - Professor Peter McCulloch

Professor Peter McCulloch, Principal Investigator of the programme and head of the Quality, Reliability, Safety and Teamwork Unit (QRSTU) at NDS, said: ‘One set of interventions tried to modify the culture of the team and the other tried to improve the system of work. No one had asked which of these was better, or whether combining the approaches would be more effective. It is not enough to just fix the system and it’s not enough to just train the team. You have to do both. 

‘It makes sense that this 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.’

The 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.

Lorna Flynn, Human Factors Research Assistant within QRSTU and first author of the second, qualitative paper, commented: ‘In addition to telling us that integrated approaches targeting systems and culture produce the best outcomes; our research has highlighted the fact that frontline staff do not have the time or means to address patient safety issues alone. Whilst they possess local in-depth knowledge about their systems and working context, effective improvement work still requires substantial support from experts in Human Factors/Ergonomics and Quality Improvement. These findings have implications for practice in organisations where frontline clinical staff are often expected to do this work as part of their everyday clinical job; such an approach is not going to be sufficient to improve patient safety unless healthcare organisations engage properly with experts in these fields.’

The papers, Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) and The Safer Delivery of Surgical Services Programme (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems, are published in the journal Annals of Surgery.

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