title: Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program.
abstract: Patient safety improvement interventions usually address either work systems or team culture. We do not know which is more effective, or whether combining approaches is beneficial.
  
  
  
  To compare improvement in surgical team performance after interventions addressing teamwork culture, work systems, or both.
  
  
  
  Suite of 5 identical controlled before-after intervention studies, with preplanned analysis of pooled data for indirect comparisons of strategies.
  
  
  
  Operating theatres in 5 UK hospitals performing elective orthopedic, plastic, or vascular surgery PARTICIPANTS:: All operating theatres staff, including surgeons, nurses, anaesthetists, and others INTERVENTIONS:: 4-month safety improvement interventions, using teamwork training (TT), systems redesign and standardization (SOP), Lean quality improvement, SOP + TT combination, or Lean + TT combination.
  
  
  
  Team technical and nontechnical performance and World Health Organization (WHO) checklist compliance, measured for 3 months before and after intervention using validated scales. Pooled data analysis of before-after change in active and control groups, comparing combined versus single and systems versus teamwork interventions, using 2-way ANOVA.
  
  
  
  We studied 453 operations, (255 intervention, 198 control). TT improved nontechnical skills and WHO compliance (P < 0.001), but not technical performance; systems interventions (Lean & SOP, 2 & 3) improved nontechnical skills and technical performance (P < 0.001) but improved WHO compliance less. Combined interventions (4 & 5) improved all performance measures except WHO time-out attempts, whereas single approaches (1 & 2 & 3) improved WHO compliance less (P < 0.001) and failed to improve technical performance.
  
  
  
  Safety interventions combining teamwork training and systems rationalization are more effective than those adopting either approach alone. This has important implications for safety improvement strategies in hospitals.
authors.affiliation: *Quality, Reliability Safety & Teamwork Unit, Nuffield Department of Surgical Science †Said Business School, University of Oxford, UK ‡Cedars Sinai Medical Center, Los Angeles, CA §Oxford University Hospitals NHS Trust, Oxford ¶Department of Orthopaedic Surgery, University of Warwick ||Centre for Statistics in Medicine, University of Oxford, Oxford, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
authors.forename: Lauren
authors.initials: L
authors.lastname: Morgan
authors.forename: Steve
authors.initials: S
authors.lastname: New
authors.forename: Ken
authors.initials: K
authors.lastname: Catchpole
authors.forename: Eleanor
authors.initials: E
authors.lastname: Roberston
authors.forename: Mohammed
authors.initials: M
authors.lastname: Hadi
authors.forename: Sharon
authors.initials: S
authors.lastname: Pickering
authors.forename: Gary
authors.initials: G
authors.lastname: Collins
authors.forename: Damian
authors.initials: D
authors.lastname: Griffin
mesh_terms: D057189:Checklist; D002983:Clinical Competence; D017558:Elective Surgical Procedures / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D015279:Organizational Culture; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration*; D061214:Patient Safety; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration*; D006113:United Kingdom