Escalating obstetrical situations: an organizational approach
Isis Amer-Wåhlin1, Johan Bergström, Eric Wahren, Sidney Dekker2
1Department of Women and Child Health, Karolinska Institute, Stockholm 2Lund University: Leonardo da Vinci Laboratory for Complexity and Systems Thinking, Lund
SFOG 2010
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Background
• Understanding resilience in organizations instead of focusing on accidents (Hollnagel E, Cook R)
• Research on organizational coordination in escalating situations conducted at Lund University. Need for generic rather than specific or procedural competencies to handle low-probability/high consequence events (S. Dekker et al 2008)
• Invited by a mid-size Swedish hospital to initiate a project on escalating labor situations. The organization felt uneasiness about the emergency caesarian sections.
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
An issue of communication?
• “We cannot communicate in healthcare” [attending anesthesiologist] • “It is all about communication” [midwife] • “The obstetricians have no good instruments to tell us that the situation is
critical” [anesthesiologist]
• Communication problems reported to be contributing factors in 60% of the cases reported
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Communication
…what we try to do when we speak to those near us….
Thought – idea, information, feelings Encoding – message sent Decoding – message received and translated into information. Two parties needed!!
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Communication
No one would talk much in society if they knew how often they misunderstood others.
Johann Wolfgang Von Goethe
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Non-technical communication barriers
• Language
• Culture
• Knowledge
• Formality
• Prestige
• Conflicts
• Hearing problems
• Reduced mental capacity, emotionally preoccupied
• Keeping your thoughts to yourself, not showing your intentions
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Sender responsibilities
• Clear, short and simple
• Open and honest
• One idea at the time
• Correct ”voice” for the situation
• Correct terminology
• Repeat if necessary
• Give and take feedback
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Receiver responsibilities
Listen actively (two-way)
Watch actively
Rephrase the content of the message
Repeat the message
Use nonverbal communication to reinforce mutual understanding
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Aoccdrnig to a rscheearch at an Elingsh uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht frist and lsat ltteer is at the rghit pclae.
The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae we do not raed ervey lteter by it slef but the wrod as a wlohe.
Written communication
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
But is it really all about communication?
• But what would happen if we instead approached the problem with an organizational approach, involving:
– The midwifes – The obstetricians (from residents to attendings) – The operation ward (anesthesiologists, anesthesiology nurses, operation nurses) – The neonatal care
• Focus on generic competencies in relation to previous experiments on the effect of training in other organizations (MS Antwerpen) comparison with training in obstetrics (ALSO)
• Specific interest in intervention decisions/actions – e.g. calling for help
“It ain’t so much the things we don’t know that get us into trouble.
It’s the things we know that just ain’t so.”
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Communication? What about team work?
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Material
• Mid-size Swedish hospital to initiate a project on escalating labor situations
• Labour ward • Operation room • All involved personnel, different levels • Elective and emergency activities
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Method
• Semistructured interviews • Observations
Klein, Calderwood & Macgregor. Critical Decision Method for
Eliciting Knowledge, IEEE Transactions on Systems, Man and Cybernetics. 1989;19: 462-472
Charles L. Bosk. Forgive and remember. 1993
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Kvalitativa datainsamlingstekniker
Observation – kan vara det enda sättet att samla in vissa data (om man ej frågar om det man är intresserad av eller det ej går att mäta)
– planerad och medveten process – materialet analyseras på strukturerat sätt Deltagande/icke-deltagande Strukturerad/semistrukturerad/ostrukturerad
Intervjuer strukturerad semistrukturerad ostrukturerad
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Resultat
Mycket sällan adresserad information Aldrig kontroll av att en information uppfattats korrekt av
mottagaren Parallella samtal vanligt Vanligt att man avbryter varandra
1. Överrapportering från opererande läkare till narkosjouren 2. Överrapportering från narkosjour till ansvarig narkosläk på
salen 3. Kommunikationen på Op-salen 4. Överrapportering till barnläkare
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Descision
Previous studies have shown that comparing different industries can generate qualitative information that can be used in explaining generic competencies ( Vaughan 1999)
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Acc
iden
t fre
quen
cy
Time
Improved technology
Improved skill training, use of simulators
Human Factors training
Quality systems, Organization Culture
Counteracting accidents
Technical oriented
Human oriented
Background
Non Technical Skills
Technical Skills
Norms
Work related knowledge
Theoretical knowledge
”Know-how”
Rules
Procedures
Combination of Skills
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Contingency theory
• Could we instead of a problem of communication look at escalating obstetric situations using organizational contingency theory?
• The more dynamic the environment, the more organic the organizational structure
• Examples are military and so called High Reliability Organizations
• Decentralization of decision-making authority concerning safety issues permit rapid and appropriate responses to dangers by the people closest to the problems at hand
• “Decentralized anticipation” – Emphasizing the superiority of entrepreneurial efforts to improve safety over
centralized and restrictive top-down policies or structures
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Contingency theory and obstetric interventions
• Contingency theory seems to predict wrongly
• Obstetrics (and healthcare in general) seems to appeal to hierarchy and structure in response to developing emergencies
– “As a midwife I am responsible for managing the normal pregnancy and the normal labour” [told by many midwifes]
– “But the boundary when it is not normal anymore is fluid” [midwife]
• As the situation is judged to be non-normal more layers are added to the organization
– Resident obstetrician – attending obstetrician – anesthesiologist – neonatologist
• And that can limit diversity
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Constructing obstetric interventions as an organizational problem reveals:
Structures of power and knowledge • “When the physician arrives he/she takes the responsibility/accountability of the situation” [midwife] • “As a midwife I become an assistant. At least if the obstetrician is experienced. But they have
different levels of experience” [midwife]
Structures of identity • “If you walk in unannounced at a labour room the midwifes will have a go at you” [obstetrician] • “I don’t call for help as much as for someone to share my view of the situation” [midwife] • “It is the resident who calls the attending, we don’t.” [midwife] • “I got a call to come and stay outside a specific labour room.” [Pediatrician]
Novice/expert relationships • “What we often face is the feeling that the resident does not dare to bring in the attending” [midwife]
The construction of contingency • “We try to keep the patient at home for as long as possible, because if we have them here the risk is
greater that we will start to intervene in the labour process” [obstetrician] • “Sometimes the midwifes rather increases the infusion rate than calls the resident” [resident]
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
USA pilots 1988
USA pilots 1989
USA pilots 1991
USA pilots 1994
Medical 1994
“Even when fatigued, I perform effectively during critical times of flight”
42 % 33 %
28 % 24 %
60 %
CRM
Agree
Disagree
Attitude changes
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
"The definition of insanity is continuing to do the same thing over and over again and expecting a different result." Albert Einstein
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Possibilities?
• Escalation is a dynamic process which depends on the situation and the management
• Increased cognitive activity required along with escalation • Increased coordination required along with escalation • Are “non-technical skills” independent of context? • Kan such skills be trained? • Can specific scenarios be developed to train such skills? • What are the characteristics of a resilient organisation?
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Training?
• Situation awareness • Leadership / Teambuilding • Communication • Problemlsolving • Descision • Critical analysis
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Safety culture
• ”Informed”
• Reporting
• Just
• Flexible
• Learning
Amer-Wåhlin, Bergström, Wahren, Dekker. Escalating obstetric situations: an organizational approach
Varför?
www.leonardo.lth.se
