Assessing and improving teamwork in cardiac surgery

Obiective Paediatric cardiac surgery {PCS) has a low enor tolerance, is dependent upon sophisticated organisational structures and demands high levels of cognitive and technical performance. The aim of the study was to assess the role of intraoperat¡ve non-routine events (NBEs) and team performance on paediatric cardiac surgery outcomes. The current paper focuses on improving methods for studying teamwork; a companion paper will report 0n the empirical results. Methods The authors trained human factors observers to observe and code the NRE's and teamwork from time of anival of the patient into the operating room (0R) to the patient handover in the intensive care unit. The observers undenruent an immersive training period in which each observer attended 1 0 operations, learnt in detail about the technical procedures and clinical tasks and received practice in coding teamwork. Two observers were used interchangeably to observe 0R teamwork The authors instigated a rigorous training and assessment protocol, with independent assessment of their performance by both senior medical and human factors experts using video-based assessment. Beal-time teamwork observations were supplemented with questionnaires on safety culture, level of preparedness by the team, difficulty of the operation and outcome measures. Results 19 PCS cases were observed. Our observers observed a total of 255 h of operations, including the first 1 0 training cases. Because of the complexity of the PCS environment, the authors found that 68% of events were observed by one observer but only 32olo of all events were observed by both observers. lf an event was coded by both observers, 76% was coded in the same way, resulting in high levels of inter-rater agreement. The inter rater reliability of the four main teamwork categories was g1% with Cohen kappa of 0.77. Based on our experience, recommendations were developed for observing teamwork in the operating r00m, for instance 'train observers on video recordings of real operations (not scripted performance), preferably of at least 1-2 h in duration' and 'Bate teamwork in real time and not aftenruards.' Gonclusions PCS is an ideal model to explore the methodological challenges of observing performance of team members in a complex organisational structure. A challenge for the future is to make observations of teamwork in healthcare settings more efficient and robust.