This document summarizes three case studies conducted by Dr. Brigid Gillespie and her research team examining ways to improve team performance and safety culture in surgical settings. The first case study evaluated a brief team training program and found improvements in non-technical skills and checklist adherence. The second studied changes following a hospital relocation and found increased team performance scores. The third evaluated an intervention called "Pass the Baton" that improved checklist use, teamwork climate, and safety culture through multi-component implementation strategies. The studies demonstrate the impact of training, environmental factors, and tailored implementation approaches on surgical team outcomes.

1. Focusing on Workplace Culture to
Drive Practice Change: An Exemplar
Case Synopsis
Dr Brigid Gillespie
Professor of Patient Safety
Griffith University & Gold Coast University Hospital
b.gillespie@griffith.edu.au

2. Acknowledgements
Research team
Prof Wendy Chaboyer, Prof Andrea Marshall, Evelyn Kang, Emma Harbeck,
Joanne Lavin, Catherine Steel, Tina Nikolic, A/Prof Teresa Withers, Dr Nicole
Fairweather, Therese Gardiner, Dr Mark Sykes, Dr Kyra Hamilton & Dr Dianne
Ball.
Stakeholders
§ Study participants
§ Princess Alexandra & Gold Coast University Hospitals
Funders
§ Australian Research Council (ARC) Discovery Early Career Research
Award (DECRA): 2012-15
§ NHMRC Translation Into Research Practice Fellowship (TRIP), 2014-16
§ National Centre for Research Excellence in Nursing Interventions
(NCREN), Griffith University
§ Australian College of periOperative Nurses (ACORN)
§ Gold Coast University Hospital & Griffith University Collaborative Grant

3. Background
§ Up to 60% of all adverse events occur in surgery, with 33% resulting
in permanent disability, and ≈13% resulting in patient death.
§ High-risk area of surgery more vulnerable to teamwork and
communication failures.
§ Investigating social and cognitive skills that enable or impede team
performance important to identify ways to improve team cohesion in
surgery.
§ Non-technical skills (NTS) = interpersonal (i.e., communication,
teamwork and leadership), and cognitive skills (i.e., decision making
and situational awareness).
§ Impact of work culture on use of NTS.

4. Case Study 1:
Effect of a brief team training program on
surgical teams’ non-technical skills:
An observational study

5. Team training in surgery
Aim
Evaluate the effect of a brief team
training intervention in improving
surgical teams’ observed NTS.
Design
Pretest-posttest interrupted time series
design with repeated measures
analysis to detect longitudinal changes
in surgical teams’ NTS.
Gillespie et al, 2017, J Pat Saf

6. Setting: 550-bed tertiary referral centre with 22 ORs.
Sample: Vascular, Upper GI, Hepatobiliary and Cardiac teams;
elective surgeries
Data collection
§ Single observer, structured observations.
§ Observations weekly, 25 weeks pretest, 20 weeks post test.
Measures
§ Non-technical skill assessment (NOTECHS), 5 factors
(outcome)
§ WHO SSC adherence relative to ‘time out’ and ‘sign out’
observed (yes/no options)
Analysis: SPC charts for longitudinal data (NOTECHS scores)

7. Team training program
TEAMANATOMY
1 hour DVD
§ SA theories-individual and
shared
§ ‘Unpack’ 2 vignettes on
situational awareness (filmed)

8. Results
§ 179 surgical procedures with cardiac, vascular, upper gastro-
intestinal (UGI), and hepatobiliary (HPB) teams were
observed.
§ 20/30 (67%) core team members participated in the program.
§ Notable improvements in posttest use of WHO SSC for sign-
in and timeout (p <.0001).
§ Average posttest NOTECHS scores increased across all
teams, with largest improvements in the vascular and UGI
teams.

9. WHO SSC Usage before-and-after team training
WHO SSC Before
n=99
After
n=80
c 2, p
Check-in 97 (98.0%) 80 (100.0%) 1.6, p=.201
Time-out
18 (18.2%) 68 (85.0%)
79.1, p<.001
Sign-out
9 (9.1%) 27 (33.8%)
16.7, p<.001

10. NTS scores

11. Case Study 2:
Changes in Surgical Team Performance &
Perceptions of Safety Climate following
Expansion of Perioperative Services

12. Background
§ Increased in number of commissioned OR from 11
to 22
§ Affiliated and co-located within a university precinct.
§ On site research facilities
§ Expanded services, e.g., cardiac
§ State of the art equipment in the OR
§ Working towards Magnet Recognition program

13. Hospital relocation
Aim: To observe changes in surgical teams’ work process
following hospital relocation.
Design: Natualistic longitudinal before-and-after study
1. Survey (using Teamwork Climate & Safety Culture)
2. Structured observations NTS (using NOTECHS tool) &
WHO SSC compliance
§ Observations for each phase weekly, 6 months pre-relocation and
12 month post relocation
§ 25 pre, 20 post hospital relocation
§ Specialties observed; orthopaedic, paediatrics, general and thoracic

14. Results
§ 186 surgical procedures with general, paediatric, thoracic and
orthopaedic teams observed.
§ Increased average team and safety climate scores for all teams.
§ Mean post-relocation NOTECHS scores increased across all
teams → significant improvements (p=0.020), with largest
improvements in the paediatric team.
§ TCSC response rate 80% & 90% pre-post relocation
respectively.
§ Non-significant improvements after relocation in perceptions of
teamwork climate and safety culture.

15. Combined team NTS scores

16. Total NTS scores for each specialty, pre & post
hospital relocation

18. Comments
§ First study to examine process changes in surgical team
performance during such a major upheaval.
§ Results suggest a naturally occurring process change over time.
§ Environmental factors (e.g. ergonomic) may support collaborative
work.
§ Increase in staff numbers – i.e., new staff creates a positive
change in work place culture.
§ Communication & teamwork among surgical teams improved in
transient teams [Korkiakangas et al. (2016) & Gillespie et al. (2013)]

19. Case Study 3:
Passing The Baton to ensure Safe Care:
Evaluation of a Knowledge Translation
Intervention to Improve Use of the
Surgical Safety Checklist

20. Checklist implementation
Series of studies using surveys, observations and interviews
involving:
§ Process mapping of workflow & communication patterns
§ Development & implementation strategies to increase SSC use
§ Evaluation of:
• Primary outcomes, i.e., SSC usage, teamwork climate and safety culture
• Secondary outcomes, i.e., day of procedure cancellations, procedural delays,
in OR at to Start of procedure, and finish of procedure to out of OR

21. Implementation of Pass The Baton (PTB)
§ Development of multi-component intervention co-
created with stakeholders
Components included:
1. Social influence (opinion leaders, change champions)
2. Audit & feedback (information, education, knowledge
brokers)
3. Reinforcement (prompts & reminders)

23. Observational Audit Results: Use of SSC
% items completed (0-100%)
SSC
Component
Baseline
(10 teams)
% (SD)
3 months post-
implementation
(35 teams)
% (SD)
12 months post-
implementation
(32 teams)
% (SD) P-value
Sign-in 82.4 (8.1) 93.1 (5.1) 74.7 (20.2) <.001
Time-out 69.4 (6.9) 80.2 (9.8) 79.3 (8.2) <.001
Sign-out 0 79.3% (30.7) 94.5 (8.1) <.001

24. Teamwork & Safety Climate Survey Results
Response rate 59/150 (39.3%)
TSCS Baseline 12 months post-implementation
Doctors Nurses Total n Doctors Nurses Total n
n 10 22 27 11 44 59
Teamwork Climate
Mean
(SD)
64.5
(11.5)
60.3
(17.7)
63.1
(15.6) 70.0 (11.0)
68.2
(14.9)
69.1
(14.4)
Range 39-84 29-91 29-91 52-86 36-98 39-98
Safety Culture
Mean
(SD)
61.5
(19.4)
54.7
(19.6)
59.5
(19.0)
68.2
(15.3)
65.1
(15.5)
66.5
(15.3)
Range 21-88 17-77 17-88 35-92 23-96 23-96
Scores: 1-100, higher scores indicate better safety culture

25. Day of Procedure Cancellations

26. Reasons for Procedure Cancellations

27. Procedural Delays (in minutes)

28. Procedural Delays (minutes) by Specialty

29. In OR to Procedure Start time (minutes)

30. Procedure Finish to Out of OR time (minutes)

31. Comments
§ PTB heightened awareness of importance of
intraoperative communications
§ Some efficiencies dropped in post implementation period
– discrepancies in information possibly picked up earlier
& promptly actioned as a result of more frequent
communications among OR teams
§ Impact of the hospital context influenced uptake of PTB,
which has become ‘normalized’ in practice
§ PTB is now being used at a second hospital site

32. Conclusions
§ Implementation of any new innovation or evidence-
based practice, shaped by macro (organizational),
meso (departmental), and micro (individual) factors.
§ Buy-in of stakeholders at all levels, essential for
successful implementation and ongoing change.
§ Tensions b/ need to meet financial, activity-based
targets and need to maintain safety and quality.

33. Conclusions (2)
§ Success of Pass The Baton – why?
§ Cost-neutral, benefit recognized, addressed
workflow issues, able to be adapted in real time.
§ Barriers analysis (not undertaken when
implementing TEAMANATOMY), taking into account
organizational factors.

34. Conclusions (3)
§ Pragmatic approach to implementation, taking into
account the ‘messiness’ of context.
§ Strong leadership, consistency and audit; necessary
mechanisms to sustain any practice improvement
strategy.

35. Questions or Comments?
Dr Brigid Gillespie
Professor of Patient Safety
b.gillespie@griffith.edu.au