Capturing the crisis 'golden moment' - A leadership opportunity for overcoming institutional inertia in safety-critical situations

Surgical leadership in a culture of safety: An inter-professional study of metrics and tools for improving clinical practice

BACKGROUND

Leadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aims to identify a framework, metrics and tools to improve surgical leadership and safety outcomes.

METHODS

Qualitative interviews were performed with leadership experts from safety-critical professions. Non-probability-based sampling was undertaken in major international airlines. Data underwent thematic analysis and clinical adaptation by multiple surgeon-analysts using the framework method.

RESULTS

583 codes were synthesised into 10 themes. Leaders were identified as 'threat and error managers' who placed safety first. Their core attribute was humble confidence. This allowed them to set the tone for high standards of practice, whilst empowering individuals to speak up about safety issues. Safety-oriented leaders assumed complete responsibility and applied their authority discerningly to obtain optimal outcomes. Finally, effective leaders rallied support for their mission by instilling confidence, building collaborations and managing conflict.

CONCLUSIONS

Surgical leadership requires the ability to manage risk, opportunity and people. The study provides an assessment matrix and deliverable tools for improving surgical safety.

How crises work: A model of error cause and effect in surgical practice

INTRODUCTION

Surgical crises have major consequences for patients, staff and healthcare institutions. Nevertheless, their aetiology and evolution are poorly understood outside the remit of root-cause analyses.

AIMS

To develop a crisis model in surgery in order to aid the reporting and management of safety critical events.

METHODS

A narrative review surveyed the safety literature on failure causes, mechanisms and effects in the context of surgical crises. Sources were identified using non-probability sampling, with selection and inclusion being determined by author panel consensus. The data underwent thematic analysis and reporting followed the recommendation of the SALSA framework.

RESULTS

Data from 133 sources derived five principal themes. Analysis suggested that surgical care processes become destabilized in a step-wise manner. This crisis chain is initiated by four categories of threat or risk: (i) the systems in which surgeons operate; (ii) surgeons' technical, cognitive and behavioural skills; (iii) surgeons' physiological and psychological state (operational condition); and (iv) professional culture. Once triggered, the crisis chain is driven by only three types of errors: Type I. Performance errors consist of failures to diagnose, plan or execute tasks; Type II. Awareness errors are failures to recognise, comprehend or extrapolate the impact of performance failures; Type III. Rescue errors represent failures to correct faulty performance. The co-occurrence of all three error types gives rise to harm, which can lead to a crisis in the absence of mitigating actions.

CONCLUSION

Surgical crises may be triggered by four categories of threat and driven by only three types of error. These may represent universal targets for safety interventions that create new opportunities for crisis management.

Avoid, Trap, and Mitigate: Development of an Evidence-Based Crisis Management Framework in Surgery

BACKGROUND

Increasingly, surgeons are adopting broader roles in emergency response, on both clinical and executive levels. These have highlighted the need to develop healthcare-specific crisis management systems. Cross-professional research between safety-critical industries is a valuable method for learning crisis control. Commercial aviation, in particular, has been used to drive innovation in surgical safety. This study aimed to identify, adapt, and operationalize a surgical crisis management framework based on current practice in commercial aviation.

STUDY DESIGN

A multimethod qualitative study interrogated safety experts in commercial aviation and healthcare. Stage I used immersive observational fieldwork in commercial aviation practice. Stage II performed semi-structured interviews with senior airline pilots. "Snowball" sampling targeted professional networks, recruiting 17 pilots from 4 airlines. Thematic analysis was used to derive a model of crisis management. Stage III undertook 3 focus groups with 5 pilots and 5 healthcare safety specialists. Expert consensus methods were used to adapt the model to clinical practice.

RESULTS

Interview data provided 2,698 verbatim quotes on crisis management from aviation experts with a combined flying experience of 188,000 hours. Aviation crisis management was structured in 3 phases: avoid, trap, and mitigate. Adapted to clinical practice, these translated to crisis preparedness, recovery, and containment interventions. Additionally, the study identified 7 types of implementation tools and 9 crisis management skills that could be used to operationalize this framework in surgical practice.

CONCLUSIONS

Surgical crisis management can follow the avoid, trap, and mitigate framework used in commercial aviation. Implementation relies on the combined use of crisis skills and performance tools. Crisis management should be delivered as part of a systems-based approach that relies on well-integrated failure management models. Simulation and in-situ validation of this framework is needed.