External and internal drivers made Great Ormond Street Hospital for Children (GOSH) aware of dangers in handover procedures. In the mid-1990s, Bristol, England, saw very high mortality for surgery in congenital heart disease, followed by contentious public inquiry. One of the important findings of a subsequent study was that the journey from the operating room to the intensive care unit (ICU) was high risk.
This external environment impetus to change was followed by an internal driver for change. Interest in human factors led staff physician Professor Marc de Leval to question whether staff-related factors, such as exhaustion, were more important than patient-related factors, such as the position of the coronary arteries. De Leval reviewed all the arterial switch procedures done in the United Kingdom over a two-year period with a psychologist watching the operation. Once again, the journey from the operating room to the ICU was demonstrated to be a high risk factor. Staff came to accept that there was an element of danger associated with what they were doing, so they were receptive to change.
In Formula One motor racing, the pit stop team completes the complex task of changing tires and fueling the car in about seven seconds. The doctors saw this as analogous to the team effort of surgeons, anesthetist, and ICU staff to transfer the patient, equipment, and information safely and quickly from operating room to ICU.
GOSH doctors visited and observed the pit crew handoff in Italy, noting the value of process mapping, process description, and trying to work out what people’s tasks should be. Following their trip, the GOSH team videotaped the handover in the surgery unit and sent it to be reviewed by the Formula One team. From the analysis came a new handover protocol with more sophisticated procedures and better choreographed teamwork.
The GOSH researchers also noted the importance of the role of the lollipop man, the one who waves the car in and coordinates the pit stop. Under the new handover process, the anesthetist was given overall responsibility for coordinating the team until it was transferred to the intensivist at the termination of the handover. These same two individuals were charged with the responsibility of periodically stepping back to look at the big picture and to make safety checks of the handover.
The real gain for patients was safety. Results showed that the new handover procedure had broken a link between technical and informational errors. Before the new handover protocol, approximately 30 percent of patient errors occurred in both equipment and information. Afterward, only 10 percent occurred in both areas.
This case study is excerpted from chapter 10 of Benchmarking for Hospitals: Achieving Best-in-Class Performance Without Having to Reinvent the Wheel, by Victor E. Sower, Jo Ann Duffy, and Gerald Kohers.
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