title: Quality Improvement in Surgery Combining Lean Improvement Methods with Teamwork Training: A Controlled Before-After Study.
abstract: BACKGROUND
  To investigate the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. We conducted a controlled interrupted time series study in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control.
  
  
  METHODS
  We used a 3 month intervention with 3 months data collection period before and after it. A combined teamwork training and lean process improvement intervention was delivered by an experienced specialist team. Before and after the intervention we evaluated team non-technical skills using NOTECHS II, technical performance using the glitch rate and WHO checklist compliance using a simple 3 point scale. We recorded complication rate, readmission rate and length of hospital stay data for 6 months before and after the intervention.
  
  
  RESULTS
  In the active group, but not the control group, full compliance with WHO Time Out (T/O) increased from 14 to 71% (p = 0.032), Sign Out attempt rate (S/O) increased from 0% to 50% (p<0.001) and Oxford NOTECHS II scores increased after the intervention (P = 0.058). Glitch rate decreased in the active group and increased in the control group (p = 0.001). Complications and length of stay appeared to rise in the control group and fall in the active group.
  
  
  CONCLUSIONS
  Combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. We suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients.
authors.affiliation: Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Robertson
authors.affiliation: Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Lauren
authors.initials: L
authors.lastname: Morgan
authors.affiliation: Saïd Business School, University of Oxford, Oxford, United Kingdom.
authors.forename: Steve
authors.initials: S
authors.lastname: New
authors.affiliation: Warwick Medical School, University of Coventry and Warwick, Warwick, United Kingdom.
authors.forename: Sharon
authors.initials: S
authors.lastname: Pickering
authors.affiliation: Warwick Medical School, University of Coventry and Warwick, Warwick, United Kingdom.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Hadi
authors.affiliation: Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.
authors.forename: Gary
authors.initials: G
authors.lastname: Collins
authors.affiliation: Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Red de Investigación de Servicios Sanitarios en Cronicidad (REDISSEC), Madrid, Spain.
authors.forename: Oliver
authors.initials: O
authors.lastname: Rivero Arias
authors.affiliation: Warwick Medical School, University of Coventry and Warwick, Warwick, United Kingdom.
authors.forename: Damian
authors.initials: D
authors.lastname: Griffin
authors.affiliation: Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D065187:Controlled Before-After Studies; D006801:Humans; D007902:Length of Stay; D009985:Orthopedics / Q000592:standards*; D010348:Patient Care Team; D058996:Quality Improvement; D013518:Surgery, Plastic / Q000592:standards*