Live blog: Improving Theatre Safety Clinical Community


Welcome to the live event blog from the fifth Improving Theatre Safety Clinical Community event, held on Tuesday 18th September 2018 at Wrightington, Wigan & Leigh NHS Foundation Trust.

Follow us on twitter and use #TheatreSafety to join the conversation.

About Theatre Safety

NHS Quest Trusts strive to have the safest operating theatres in the country and are undertaking a programme of work to develop exceptional safety awareness and healthy departmental cultures in this often high-pressure environment. Members are utilising their strengths as a national network to learn from each other and share new innovative approaches in their mission to ensure patients receive the safest possible surgery, every time.

Using the clinical communities model, member trusts combined their expertise in June 2017 to launch the next stage of this ambitious improvement journey. At the second meeting, a packed agenda was built around the theoretical framework of Deming’s Lens of Profound Knowledge and Rogers Diffusion of Innovation. Watch interviews with members in a short film, capturing the journey so far. The third event was held in February 2018 and is captured in this event blog from Zoe Egerickx, NHS Quest Director. The fourth event was held in June 2018 and you can catch up with what went on through our live blog of the day.

Let’s get started…

Attendees today represent 8 member trusts including Bradford Teaching Hospitals NHSFT, Calderdale & Huddersfield NHSFT, Countess of Chester NHSFT, Royal Surrey County Hospitals NHSFT, Royal United Hospitals Bath NHSFT, Salford Royal NHSFT, Sheffield Teaching Hospitals NHSFT and Wrightington, Wigan & Leigh NHSFT.

In our packed agenda today we will be covering:

  • What have we learnt in the past 3 months?
  • What key principles are emerging in the debrief?
  • How can we refine the key principles of the debrief?
  • How do we know we’re improving culture?

Opening the event, NHS Quest Project Manager, Sarah Snape recaps the last Improving Theatre Safety event from June and gives an overview of the challenges and benefits of undertaking the debrief, alongside evolution and implementation, and human factors that need to be considered. If you missed the last event you can check out the live blog here.

Sarah welcomes familiar and new faces to the community and begins with our Clinical Community Evaluation where attendees can update on their progress and interaction with the community so far. The data collected allows us to evaluate the programme, assess if we’ve achieved our objectives and support the network as we move forward as a community.

After completing their Clinical Community Evaluation, Sarah moves on to the first activity.

Attendees are asked to think of an occasion where the debrief has resulted in a positive outcome in their theatre for the patient, the team, and the individual.  They are then asked to think of a situation where a better outcome may have been achieved if a successful debrief had occurred in their theatre, and what the impact might have been for the patient, the team and the individual.

Beginning a feedback session, attendees note that because the debrief is not yet embedded in the culture it is hard to show outcomes yet. The debrief may also not affect that individual patient, but instead could offer learning opportunities for future patients.

Attendees are now working with a partner that they have not met before to share their reflections. Participants are encouraged to allow their partner to talk, uninterrupted, to elicit the maximum amount of information. Following this, the listener will probe and question their partner to really learn more about their feedback.

Zoe and Sarah lead the feedback session where we hear some great insight about debriefs across our trusts.

It is noted that debriefs mainly occur when there has been an incident, there is a higher level of importance placed on it if something has gone wrong.

The little issues matter as much as the larger ones…

Zoe encourages our participants to share personal stories, positive or negative, to engage people with the debrief. She explains that this is more compelling than discussing an abstract scenario.

Our next session is an overview of the My Q Theatre Safety Collaborative. The project was to develop exceptional safety awareness and healthy departmental cultures. Julie Hall, Paula Aaron and Emma Barker from Wrightington, Wigan and Leigh NHSFT lead this next session.

The project team explain the clinical community challenges, identifying the problems and potential focus areas. They began by capturing an opportunity from a team at Western Sussex, and then used The Model for Improvement as part of their actions.

When pulling it all together they considered what is the improvement toolkit required to get greater engagement?

MyQ (My Quality) was launched on 10th October 2017 as a joint initiative between Leigh Theatres and the Ophthalmology department.

Staff have access to the MyQ system and can add tickets to it, detailing any ideas or suggestions they have for improvement.

The key achievements of MyQ are:

  • Engagement through weekly 15 minute meetings
  • Improved team working
  • Ownership – people recognise that problems can be solved once identified
  • Focus- the group is looking at the root cause of problems through further research

However, the project team did note that there have been some issues in set-up. There has been some reluctance with involvement but this is slowly improving.

The team summarise the MyQ project and what is next.


Lesley Jordan from RUH Bath leads our next session looking at The Debrief: Where are we…

Lesley reinforces the importance of testing and learning before further implementation, and championing the need for a PDSA template.

RUH Bath tested the use of a whiteboard in theatres, in the hope to aid teamwork, capture issues and for debrief to occur. Lesley stresses the importance of planning this test of change thoroughly, to ensure all of the learning is captured effectively. Learning was then put into place for the next test, with further testings planned.

The success of a test lies in what is learned from it, no matter how it turns out.

The project has been a constantly developing process, with increased reliability. They have started to build up standard processes fro when it is spread to other theatres, as well as building up evidence of success.

They have started to establish standard processes of:

  • How to do it
  • How to capture the issues
  • Increase in team working
  • Started to build in the positives
  • Staff empowered and enjoy it

But, has it made a difference?

Lesley goes on to talk about their current test; action and feedback of issues to next day.

They are going to test the issues raised at debrief being fed into morning theatre huddle for theatre leads, and the daily managerial planning meeting.

Their plan encapsulates a review of the issues and themes to be escalated, including staffing and overbooked lists, as well as gathering evidence of what is an overbooked list.

They aim to inform and get buy-in from speciality and theatre managers for issues to be discussed, and also establishing monthly theatre safety meetings.

The project has been progressing and the team at RUH Bath are now looking at the spread of this project; what is in other theatres in terms of whiteboards. There is also scope for this to be spread to other theatres at RUH Bath.

Lesley finishes on a great point about once change has happened…

Don’t expect successes on outcomes before the process has been made truly reliable.

Don’t forget to learn from your testing and adjust process.

Tackle issues as they arise and never stop measuring.

Our final session of the morning is a debrief: feedback and learning session led by Zoe and Sarah.

Sarah begins by identifying the key Tests of Change to come out of the feedback from participants. This feedback was then taken to a panel of experts to ask for their input.

Sarah highlights that we want to understand why a change is effective before this is spread.

A key question arising is how measures are used, these measures need to give us results to add value to a project. This will then encourage willing to engage with wider team members. Measures should have a qualitative focus, to tap in to attitudes, behaviours and feelings of the team, to encourage the development of the debrief going forward.

It has been decided that the Safety Attitude Questionnaire should be used to capture information for this clinical community, and we will be hearing more about this later in the day.

There have been challenges around who owns the debrief and what does a poor debrief look like compared to a good one. Sarah notes that as debriefs are not standardised, each theatre has to find what works best for them.

We are looking at the key components to Success for Spread:

  1. Involving the whole team
  2. Make sure the debrief is discussed at the brief
  3. Having things in the right place so that it is possible to do the right things

Sarah goes on to explain the key components of a successful debrief that have come from the feedback:

  1. Culture
  2. Engagement
  3. Motivation

A great question from the room is raised: have we identified the purpose of a debrief?

Zoe now leads us on to the next part of the session to look at the key principles of the debrief.

We’re now feeding back on the great work in this session. Our trusts have answered the following questions:

What is the purpose of the debrief?

  • To log issues- either large one-off or regular daily issues
  • To say thank you
  • To acknowledge contributions
  • Celebrating success
  • Reviewing previous debriefs and issues
  • Highlighting training needs
  • Ensuring continuous improvement and learning- and sharing this
  • Creating a culture of teamwork and a shared voice

Zoe then asks what the priority should be, and attendees decide it should be to say thank you.

What are the must-dos of a debrief?

  • The debrief time should be allocated in to the list planning
  • Identifying at the pre-list briefing when the debrief should take place and who will lead it?
  • Using a template to structure it- even if this differs across teams
  • Asking what went well (as the first question) and celebrating this
  • Asking what could have gone better, and how?
  • Directly asking individuals opinions of what makes the debrief useful and effective
  • A feedback system for issues

What should we be doing in a debrief…but perhaps need further testing?

  • Identify the small issues- things that have become the norm
  • Reflect back to the team brief- what worked and why?
  • Should we include recovery?
  • Share previous debrief issues
  • Implementing change through the debrief
  • Changing the culture
  • Should there be an Standard Operating Procedure?

Our afternoon is starting off with a session led by Stuart Clough, on how can we refine the key principles?

Stuart starts by asking the group to look at what can you test now?

PDSA is a useful framework to use for change, and Stuart takes the group through his top PDSA tips:

  1. What is the question you are trying to answer?
  2. Make a prediction
  3. Record your data
  4. Make note of anything you didn’t expect
  5. Learn from what you have found
  6. Use that learning to work out whats next

After working in groups to talk about the tests they’re going to do, our teams have come up with some great plans. They have been identifying ideas of what to test.

Some of the great ideas include:

  • Championing the issues log in the debrief
  • Testing staff knowledge around further tests (why we’re doing what we’re doing)
  • Relaunching the debrief
  • Implementation of whiteboards
  • Creating an audit tool
  • Sharing of information on previous debrief issues in briefings and future debriefs

Gary Owen, Culture Lead Theatres at Countess of Chester Hospitals NHSFT is leading our next session on the role of the education, training and culture lead.

The Countess of Chester hospital operates over 10 theatres with over 100 theatre staff. A series of ‘never events’ in theatre within a relatively short time, cultural issues, staff retention problems and a lack of ownership of education and training led to Gary’s new role to be implemented.

Gary’s role is primarily to look at:

  • Highlighting and addressing negative cultures within theatre
  • Establishing an effective education and training plan
  • Taking the lead for scenario teaching with an emphasis on human factors
  • Developing and implementing an effective debrief tool

He outlines how his role aligns with the trust values;

  • Safe- scenario teaching
  • Kind- addressing cultural issues
  • Effective- training and development

From being in post for just over 2 months, Gary has taken some initial steps:

  • Networking – championing the role
  • Site visits to other trusts which have improved their environment (Nottingham University Hospital and Scunthorpe General Hospital)
  • Carry out staff engagement surveys
  • Establishing a small training budget

Gary then goes on to explain what he wants to achieve over the coming months in his role.

  • Analyse and present survey results
  • ‘Audit day’ training programme
  • Encouraging staff engagement with teaching scenarios

In our final session of the day, Stuart is taking us through the Safety Attitudes Questionnaire (SAQ). 

The SAQ, developed from aviation, is a recognised measure of safety culture. It provides a snapshot of the climate within a team and considers 6 interpersonal aspects:

  • Team work
  • Perceptions of management
  • Job satisfaction
  • Working conditions
  • Stress recognition
  • Safety climate

In the first part of Stuart’s session he asks our trusts to review the SAQ form and consider the following:

  • When will staff complete this?
  • How often will they complete it?
  • Can it be tested?
  • How could it be used to improve?

Stuart then goes on to explain how we can use the data gathered from the SAQ; what charts are best used to display the data, and how we can glean the most important information.

After a really informative session by Stuart, it’s over to Sarah to wrap up the day.

We’ve had a busy day and have looked at:

  • a focus on debrief- positive opportunities
  • tests of change- past and future
  • draft of key principles
  • plus great sessions from some of our trusts about their great projects


And that brings another fantastic, energising and reflective session to a close. 

Feedback from member trusts highlighted the great opportunity the event was to network with other colleagues, whilst also learning some great new skills.

We will be meeting again in February 2019 at Bradford Teaching Hospitals NHSFT where we will continue some of these great discussions!