Department of Health

Operating Theatre Improvement - Engagement

  • 05 October 2015
  • Duration: 30:56
  • Welcome to this last section, session 3, talking about engagement, I mean the engagement of staff and clinical engagement. I hope the first two sessions have been useful. It’s always better to be actually in the room with everyone and I’d love to be over there with you in Australia. If there's any questions from the first couple of presentations I’ll give my contact details at the end of this presentation, obviously you can get them off Dennis. I'm happy to clarify anything, I’m happy to answer any of your questions.

    The last sort of session is going to be slightly more short, slightly to the point, but engaging staff is absolutely important. You could have the best data, the best information in the world, but if your staff really don't want to get on board and don’t want to change then you’re going to find it really hard to improve things. I always find the best way to engage people is actually to use all of the skills that I'm sure all of you have, emotional intelligence, but also the collaborating, the coercing, the sort of building that collective will to change. They sound quite soft and that they’re sort of the softer parts of change, but I find that way works much better than the more authoritarian sort of whip or stick method in theatres.

    So we’ll just have a look at what we’re going to talk about in this session. Go back to the article, conclusion we spoke about earlier. Key factors, and really when we talk about engagement, we’re talking about the top two. We’re talking about how well you lead the change, how well you facilitate the change, and also the organisational culture, that contextual will and want to change. Those things are vitally important.

    To meet these five sort of key points, I'm sure there are others, but I've just tried to keep it simple. What’s in it for each member of staff? We don't like doing things unless we understand what’s in it for me. That can be quite simple in theatres. It can just be an easy life, less aggravation, no cancellations or I get to finish and go home on time, I don't have to continue staying late. These are quite easy things, but we have to think about what's in it for everyone. If we can find solutions where everyone wins, they’re far more likely to succeed.

    Positive feedback, we’ll talk about this. In operating theatres there’s a lot of beating up of people when we don't finish on time or we overrun, but how many times do we actually thank the staff and say actually we ran to time today, we had a good session, we got all the cases done, we accommodated that extra trauma case, well done, guys, that was really well done. If you look at the sporting environment and coaching, positive praise and positive feedback should outweigh negative by a significant amount, whereas in our healthcare settings quite often the negative feedback when things go wrong outweighs the positive feedback.

    We also need to empower our staff. In order to improve things, we want to engage things, we don't want to tell them what to do, but we need to get them to actually come up with the solutions themselves. Most people know a better way of doing things, but we’ve got to be bold, and we’ve got to have these sort of wider look or wider perspective and say actually that's the problem, why don’t you solve it? But I do say that with a caveat of caution, though. If you empower people to make changes and then they suggest changes that you don’t think are going to work, sometimes you actually have to go with them and let them find that out for themselves and that can be something that is very hard to sort of suppress yourself from quashing their ideas. But if you’re going to empower people, you’ve got to go with it.

    I also think that the manager leading the change or the facilitator or improvement leader has to be accessible along with the lead clinician and executive board member. You have to be on the shop floor, you have to be approachable and you have to be credible. That role is vitally important and I’m sure all of you in the room here, that you all are motivated to do that role and you’re absolutely essential if your hospital is going to make improvements.

    I think the last bit is also important. Make staff proud to be part of a hospital. Often theatres is the forgotten part of a patient journey. The letters will go back to the wards or to outpatients, but the letters and the thank yous and the praise often doesn’t go into theatres or into theatre stores or into sterile services, all of those other areas, because they’re slightly removed from the patient. So if you’re not working in theatres, but you’re relying on theatres to help make your patient pathways improve, it’s very much part of what I do is to ensure that those theatre members of staff also see that patient feedback and experience that patient thanks. Because, let's be honest. We’ve all got into healthcare because we want to improve things for our patients, and actually when we put, when we see that praise and we see those thank yous from patients, it can actually put a lot of other things in perspective and we can actually be a lot more lenient with some of the other aggravating factors of, and the frustrations at work if we know at the end of the day, we’re helping patients and we’re doing a good job for our patients.

    So just a little bit of explanation on those points, so what's in it for them? You’ve got to understand it’s different, depending on your profession, your seniority, experience, stage of career, your involvement, your personality. These may sound obvious things, but just because you want to change everything, it doesn't mean to say that everyone else is going to have the same motivation for that. So you’ve got to be aware of that, you’ve got to understand that and you've got to change your language, you’ve got to change how you present things to people in order to accommodate that. And that adaption of the message is really important, and you’ve got to think how are you going to do this? How are you going to get your surgeons fired up to join in with you against this, and that will be very different perhaps in some of your ODAs or even some of your executive board members. They may be more interested in the pounds, shilling and pence, whereas an ODA actually they just want an easier life with a more organised working pattern, and not having to sort of react to loads of change, the instructions and late additions to an operating list and all of those kind of things.

    We did some staff surveys. This was the unit that I managed, and the purple is what the English average feedback was. This was for our hospital and this was my particular orthopaedic unit, and I got all of the staff to fill in the staff satisfaction survey, and this included theatre staff, and this included all of the ward staff, and all of the staff involved in patient pathway, and as you can see in our orthopaedic unit, everyone either agreed or strongly agreed that they were empowered or able to deliver the patient care they aspired to. And what of this came out in some of the qualitative stuff, this was an interesting comment from a scrub nurse who, the theatres for a long time had more flexibility with their working, workforce, and so therefore they said that no one could be specialised in certain procedures, because they all had to be able to do all of those. But this went against actually what the surgeons wanted, because they wanted a settled team with scrub staff that knew what they were doing. And actually it went across what the scrub nurses want, because they actually wanted to be good at something. It’s very hard to be good at something if you’re doing something different each week. And that affected those scrub nurses because they didn't feel that they were able to provide the service and the care they could aspire to.

    So, one of the key changes that we made to make things more efficient was to get settled teams working in dedicated theatres with dedicated surgeons. This means you get more slick, you get more efficient, you get more highly trained and more highly skilled. The surgeons like it, and the scrub staff like it, and it means that they’re more happy in their workplace.

    Another thing was, I showed you this earlier, finish times. What was in for them? Well what was in it for this ODA was that we finished on time, we changed the shift pattern so that people started slightly earlier in the mornings and then there was a second shift that started slightly later. I’m only talking half an hour, an hour’s difference. Then that provided an overlap and a staggered nature of when we finished, so that meant that there was always, if one list was going over we could always provide cross-cover and it meant that this particular ODA, a lot of the hassle for her was that she didn't always know whether she was going to be able to pick her child up from care after school. So therefore knowing that she was always going to finish on time relieved a lot of stress for her, helped her work more efficiently and effectively because she knew that because of all these process redesigns, she was going to finish on time.

    Positive feedback loops: As I said in the opening bit, most feedback in healthcare is negative. It focuses on the minority of things when they go wrong. It’s important that we balance this with positive feedback, because even the most upbeat and motivated member of staff, if the only feedback and the only data you ever see is negative, it will be very hard to continue to be engaged in the process and enjoy your work. So we must include positive feedback. This can be with data, and this is one example of how we did it, and this was, again this was for a dedicated joint replacement unit within the orthopaedic department that I was involved with here in Bournemouth. And each day I used to do a daily update and it was important because the productivity of this joint replacement centre was extremely important for the financials and for the throughput of the hospital. And we had to do a certain number of operations per day and get a certain number of discharges. So at the end of each day you can see the time here was 5:43 that I sent this, and I sent it to all the major stakeholders who were involved in the process and managing the teams in this process.

    Most of the days, as you can see here, there was very little to report. We did the cases and there was no problems. On this particular day, sorry, I’ll just go back, on this particular day you can see that pretty much everything was as normal. The list starts at 8:05, it finished at the right time, average case time was what we expected, anaesthetic time was what we expected, and average surgical time was what was expected. So we’re not waiting till something goes wrong, but every day there’s a discipline of what we’re doing.

    What actually happened on this day was there were six joint replacements, but we also found that on the ward there was one patient with compartment syndrome. Now, this doesn't happen very often in this joint replacement unit, I’m glad to say, but what we did was that we were able to squeeze that in and get that back to theatres without delaying the list, get a good treatment for that patient and continue with the day. That was a big effort there to jig around with the theatre staff who were motivated to make that work. So we wanted to make sure say we say well done to those staff. Now the theatre sister used to print this off every day and put it on the wall in the theatre coffee room.

    You can also see that there’s a graph there, and this graph used to change depending on what we were looking at. Most of the time we were always looking at theatre start times. We knew if we got the list starting well, then it would run smoothly through the day. Again, you should bear this in mind in your improvement projects, start times is such a key element that you should monitor it on an ongoing basis. But again, if we start at the right time, it’s important that you praise the staff, and let them know that they’re doing a good job and they continue to do a good job.

    The positive feedback loops also, as a manager I sort out every opportunity for our department to enter any award. You don’t win them all, but some of them you do. And it’s important that you win an award because it in a small way it thanks staff, it gives them recognition and it motivates them and also enables them to have that positive feeling of self-efficacy and achievement. Again, we had a good unit, but it did take that effort to enter them for that award, to explain it to, in this case the regional health board about what we've done. So as the manager and as the leader, if you do a good bit of improvement work, make sure you, as an individual go that extra mile and spend that day to do that application form and make that case, because that one day, if you’re doing that, allows then for your team to get that positive feedback and positive feedback is more likely to lead them to become engaged and continue the hard work. If they’ve just won an award for an excellent service, then they’re not likely the next day to down tools and not keep that up. They’ll feel a pride in that and they want to keep that going. So it’s really important that as leaders and managers, it sounds like a little thing, but we made the effort to enter our teams into awards.

    I talked about empowering people to make changes. It’s important here that you empower people to make improvements. Again this is, the blue is England, the maroon is our hospital or our group of hospitals and the yellow is the unit that I manage. Now, we had no-one that disagreed or strongly disagreed they weren't able to make improvements. Some were indifferent, but a quarter of our staff, much more than the other, were strongly motivated to make improvements happen. Now as I said, you have to understand that sometimes when they suggest things, they might not be the right improvement, but you've got to have the confidence to allow them to go through that process. And we're not talking about major things here. I showed this example in one of my earlier slides, how this was organised. Actually it took about three goes before the staff cracked the best way of doing it. Now, the first way they came up was better than how we were currently doing it, but because I would motivate these guys, they’re continually looking at better ways of doing it. They’re almost like a pit team in Formula 1. They’re wanting to find all of those marginal gains to make it easier, to make it better and more organised. And all the ideas about how we reorganised our theatres, all came from the staff which worked in them. None of them were any of my ideas. I explained the concept of what we were trying to do, and they got it and they went and ran with it and then made make the changes themselves. And that was because we empowered them do it. We didn’t tell them we know the solution, we've seen this X, Y and Z from hospital X, Y and Z, you’ve got to do it like them. We say come on, you’re experienced, you know this can be better, how should we made it better? And that’s a really important point.

    The next point is manager and lead clinician accessible. This sounds quite heavy, but where is your office? How close are you to where the action is? How accessible are you for people popping in and just having that word or that corridor chat with you? If you’re managing this change, if you’re an improvement team or service development team, make sure you move into theatres. If you’re a theatre manager, make sure your door is always open, make sure you also do a few shifts within the theatres and you understand where everyone is working. So important. The same thing for the lead clinician. If you’re leading this change, you’ve got to make sure this is a hospital that you're not just at once a week, but you’re there for a good proportion of the week and you’re accessible to your colleagues and to those working with you. Walk the floor. Make sure you see it from all angles. Do a day in the life of all of your different members of staff. So if you’re a surgeon to a day in the life of someone in theatre stores. That’s a really good way of understanding process. Go and spend the morning with your admissions team, understand how that happens. If you’re a manager, ask if you can scrub and watch an operation, watch how difficult and how much pressure these surgeons work under. These are things we need to understand where everyone’s coming from.

    The last thing is, be credible and genuine, be consistent, communicate well, communicate openly, talk to anyone who wants to know what you’re doing, be able to explain what you’re trying to do. You’re going to get a lot of knockbacks, you’re going to face a lot barriers, but every time you face a barrier or knockback, don’t take it personally. Change is difficult for anyone and everyone to sort of accept and go with, but just keep coming back, keep wanting to make that change and keep believing in the process and the project that you are doing, and that it’s the right thing for your patients.

    I think the best improvement leaders almost aren’t, don’t have that authoritarian style. It’s almost responsibility without authority. If I’m working as an external facilitator or consultant, I don’t manage these people. I’ve got to persuade them to change. But traditionally nobody takes ownership of the whole process. We manage our sort of section of the process. We say, well, it’s not my fault we started late because I did my bit right, the theatre trays were ready but the anaesthetist or the surgeon wasn’t ready. You need to start getting people to understand that they’re all responsible for the smooth running of theatres, and really this management by persuasion and influence is a really important point. So if you are the improvement leader within your organisation, you need to persuade people to change, not tell them to change, but persuade them to change. You need to influence them with data, with information to show them what’s going wrong and how they could make it better and you need to be responsible for compliance, these new pathways and these new ways of working. This is a really important point.

    I’m going to show you this diagram. This comes from, it’s a concept from lean manufacturing in the car industry, but it shows the different types of leader, and really we want to be here in the right hand side. If you've got this bureaucratic manager kind of style where you just lay down the rules, we’ve got to do it like this, you’re going to clash, especially with your clinicians. If you say you've got to do this, you’ve got to do that, it’s my way or the highway, it’s going to lead to conflict, the long term is not going to work. If you are up here in the sort of, oh, you’re empowered and you’re quite flowery and sort just say well, you know let’s all hold hands and have a hug and a cup of coffee and hope things get better, you’re also not going to get anywhere. You need to provide something compelling to make people change.

    You’ve also got to be aware of being the taskmaster and quite often you can have certain surgical teams who can’t understand why their colleagues can’t do it in the same way and can’t be as good as them. You’ve got to be careful though, because to say well I do it like this, this and this, you want to do it in exactly the same way. You’ve got to be careful, because that again rubs people up the wrong way. This builder of learning an organisation is where you want to be, i.e. here is our purpose and our direction, we want to increase surgical throughputs so we can treat more patients and provide a better service to our community. My role is going to be to guide and to coach. It’s going to be to provide the data to enable you to see the problems that we've got and enable then you to get the solutions that are most appropriate for our patients. Through that process I will help, I will motivate, I will coach, II will help you make these changes. But that’s really where we should see ourselves. Be aware of these bottom two, they’re not going to work in the long run.

    And when we talk about engagement we need this optimal project leadership. This is from Chris Ham, really well-respected improvement leader. I hope in your teams you’ve obviously got the clinical lead, but when I say a clinical lead, let’s just have a name of a clinician, someone there who’s being forced to do it or someone who’s there just because they're the clinical director. You need to ensure that you pick someone who’s motivated to be part of this, motivated to work with his colleagues and sometimes have some difficult conversations with his or her colleagues and the choice of that person is really important. You need a chief executive or executive sponsor involved and you need them sometimes to unlock doors, so if you’ve looked at all of the data and you’ve looked at all of your information, and really whatever you do you're 100% productive and you’re really not going to do any more work, and you’ve proved that and you know that with robust analysis, you need those people to say actually, yeah, I know you’ve gone through this process. What we really need to do is build a new operating theatre, and these are the people that you need on board to be able to say, to make those decisions.

    Now these people in their role, they need to check that you are coming to those decisions having tried to maximise the resources that you’ve currently got. You also lead as project leader or manager, and that person has to be motivated. They have to be a real get up and go kind of person. They’ve got to be enthusiastic for the job, they've got to be able to motivate people, they’ve got to want to put in the hard yards of making this work. So sometimes this is not always the theatre sister or the ward sister currently in the post. There’s sometimes there’s someone from outside, or it may be someone slightly more junior, and again you’ve got to be careful how you manage the politics internally with this. But this person will be absolutely crucial. If you’ve got the wrong person, you're probably not going to succeed with your project. Identifying that person is key. It may well be that it is the theatre manager or theatre sister, but it may be that you actually need someone else who doesn't have to do all the financials and HR stuff that they do, who can just focus on a certain quality improvement projects.

    Here was some of the cards and the positive feedback I was talking about. What we used to do is, we used to send a selection of our thank you cards in the department down to theatre. It’s quite often they would mention all the staff, but theatre staff never see these cards. They’re just in the wards and outpatients. We used to send them down with a note from the ward saying thank you. We also, if we got chocolates and we got biscuits, we used to send them down to theatres as well. Share the love. Make sure theatres, make sure they know that they're appreciated as well. Quite often they’re not, but they've got just as important vital role in the patient pathways than more visible parts in the pathway such as the ward staff.

    That’s about engaging, but we also just want to talk briefly about sustainability because if you’ve got an engaged staff, they’re more likely to be sustainable. I’m going to quickly finish by running through these slides and I'm going to talk about the NHS Institute sustainability audit, or sustainability questionnaire. And this is something that Dennis will have used in his time in the institute, and I'm sure he can talk you through it. But really what it does is, it gets, you give a questionnaire to as many members of your team as possible. They answer the questions and then if you get a certain score, an average or aggregated score across your team that’s above or below a certain number, you could pretty much tell whether the project is going to be successful or not. And I’ll give you a couple of examples. They’re not from theatres but there’s from a number of years ago with my colleague, Rob Middleton’s work at the NHS Institute.

    It is relevant because 33% of improvement projects are not sustained a year after they start, so you work really hard to get your start times right, a year later a third of them will become late starts again. 33% of projects maintain the improvement, but had not been adopted by the others in the organisation, so you want this to spread. So if you start doing this work in a couple of theatres you want it to spread in other theatres. And 33% have maintained the gain and there’s evidence of adoption, so we want to make sure we’re in this bottom third, and to do that we need to have engagement from our staff, and we need to ensure that those sort of markers of engagement and sustainability are there.

    It’s not unique to healthcare. The NHS Institute found that across industry there’s also problems with quality improvement projects and them being sustained. So why do these projects fail? Well, it’s not making the change that’s difficult, it’s maintaining it, and that’s all about staff motivation and engagement. So this model I’m talking about is designed by three guys, well guys and girls, it’s designed to be a simple tool, it was designed to identify and understand the key barriers to sustaining change and maintaining change, and it’s used to monitor progress over time.

    Developed by a panel of experts and then rigorously tested for its theoretical robustness, tested practically and it recommends and it points to where you may want to have a look at changing or addressing certain issues within your organisation before you go any further with your improvement project.

    So, once you do the score, if you’re able to score above 55 it’s positive, and you’re probably going to have a good result with your improvement project. If it’s below 55 there’s probably areas that you need to look at before you start your project, areas that you need to address and change organisationally before you start doing any work. If your score is below 40, it’s normally advised that you kind of suspend the project and say okay, before we go any further, we need to sort these areas out with our staff and our systems before we go any further.

    These are some examples from my colleague, Rob Middleton, when he was working as clinical lead for hip and knee replacement at the NHS Institute. Warrick, I’ve just flipped over a slide there. The first trust he looked at, there’s questions about infrastructure for sustainability, fit with the organisation’s strategic aims and culture, the role of clinical leadership and engagement, senior leadership engagement, staff behaviours towards sustaining the change, staff involvement and training to sustain the process, effectiveness of the system to monitor progress, adaptability of the improved process, credibility of the evidence of benefit beyond and helping your patients. Potential total is red, so each of the different sections of questions have different weighting, so red is the potential top score and blue is the actual average score. And the idea is you give this questionnaire to as many people involved in the improvement effort as possible and service change. And these are the averages of this particular trust here.

    So in this first trust we saw that their total score was 40. So out of a possible average, that’s really down on what we were expecting. This tells us that quality improvement efforts in this particular environment at this time were not likely to succeed. The data also told us that as well. They looked at, this was looking at hip and knee replacement and trying to introduce in hearts recovery some years ago, but basically it showed the baseline and the current, there’ve been no change in length of stay over the six-month period, so a lot of resources have been put in there, a lot of external support, but no change was actually made. That's really interesting because that was predicted because actually the staff at the start told us by means of that questionnaire that themselves or their colleagues didn’t believe in the change, didn't think the other members of staff were going to commit to the change, and actually what we found is the change didn’t happen.

    So talk to Dennis, he’ll be able to put you in the way of that engagement and sustainability talk, and I really recommend it. We’ve used it in a number of different projects now and it always does seem to work. Really useful tool.

    So, some final thoughts, just about data and about engaging people. Collect data about process performance not individuals, don't make it about the anaesthetist or the surgeons or the theatre staff. The more you can make it as a combined multi-professional team the better. Make collection of data part of the job. It shouldn’t be an added bonus. We need to get people taking pride in collecting data, making sure data is entered correctly, we’ve got 100% data completeness, that is the only time we can then get useful information from our data. I’ve shown that in the presentations earlier. Use data to monitor but also to praise our staff. Really important. It’s amazing what a bit of praise can do to people to change their performance. Routinely use and feed back data, makes problems easier to solve, so don’t just show data when things go wrong or there’s an overrun. Make sure it's presented publicly so that people know that they’re doing a good job and they’re starting on time and they’re running their theatres efficiently.

    And the data has to be continually used and fed back. It’s really important for it to be meaningful. You need to get your staff getting used to looking at this data on a weekly basis. If they do that, then they’ll actually start to understand the process better and they’ll start to think about the processes and they’ll start to think of their own ways of improving their theatres and making their operating theatres more efficient.

Tom Wainwright, UK improvement specialist, on how to engage theatre staff.


NSW Agency for Clinical Innovation.

Reviewed 05 October 2015


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