Introduction This paper expands the analogy between motor racing team pit stops and patient handovers. Previous studies demonstrated how the handover of patients following surgery could be improved by learning from a motor racing team. This has been extended to include contributions from several motor racing teams, and by examining transfers at several different interfaces at a non-specialist UK teaching hospital.
Methods Letters of invitation were sent to the technical managers of nine Formula 1 motor racing teams. Semistructured interviews were carried out at a UK teaching hospital with 10 clinical staff involved in the handover of patients from surgery to recovery and intensive care.
Results Three themes emerged from the motor racing responses; (1) proactive learning with briefings and checklists to prevent errors; (2) active management using technology to transfer information, and (3) post hoc learning from the storage and analysis of electronic data records. The eight healthcare themes were: historical working practice; problems during transfer; poor awareness of handover protocols; poor team coordination; time pressure; lack of consistency in handover practice; poor communication of important information; and awareness that handover was a potential threat to patient safety.
Conclusions The lessons from motor racing can be applied to healthcare for proactive planning, active management and post hoc learning. Other high-risk industries see standardisation of working practices, interpersonal communication, consistency and continuous development as fundamental for success. The application of these concepts would result in improvements in the quality and safety of the patient handover process.
- Human factors
- qualitative research
- information technology
- high-risk industries
- motor racing
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- Human factors
- qualitative research
- information technology
- high-risk industries
- motor racing
As part of progressive efforts to identify and address threats to safety in surgery1–3 and ward care,4 5 previous studies have looked at the interface between these and recovery,6 team interfaces7 and handovers between care teams.8 9 The transfer of patients between hospital areas may be a particular source of potential harm since the combination of equipment and information transfer increases the potential for error.10 We have previously demonstrated how improvements in the time-critical transfer process of vulnerable patients from paediatric cardiac surgery to intensive care11 could be made by learning about pit stops from a single Formula 1 (F1) motor racing team.12
In the current study, we sought to expand our understanding of this analogy and examine how our previously successful protocol might be developed for application in a broader range of contexts by inviting contributions from other F1 motor racing teams and investigating a wider range of clinical practitioners and within-hospital patient transfers.
A qualitative design was used to address a range of topics, practitioners and different patient transfers. Letters of invitation were sent to the technical managers of nine Formula 1 (F1) motor racing teams in Europe. Responses were invited by letter (three), telephone or personal interview (two) based on the preference of the responder, since this industry has carefully guarded commercial sensitivities.13 One team declined to participate, and three failed to respond. Information was requested about (1) the processes used to encourage teamwork and briefings, (2) threat and error management and (3) task design (table 1).9 12–14 The topic areas were developed from previous work with F1 teams12 13 and other high-reliability organisations. These topics were then used to explore within-hospital patient transfers at a major UK teaching hospital (table 1). Following pilot studies to ensure working practice was not disrupted, a human factors researcher without previous clinical experience (RS) interviewed 10 clinical expert participants regularly involved in patient transfers. Participants were chosen using mixed purposive sampling to ensure the dimensions of interest (location, people) were represented.15 16 Staff from each of the key team interfaces of interest were invited to participate, resulting in two consultant anaesthetists, two scrub nurses, two postanaesthetic recovery unit (PACU) nurses, two surgical ward nurses and two intensive care unit (ICU) nurses. Their professional experience ranged from 8 months to 37 years (mean: 18.7 years). Each participant gave consent prior to the interview. To avoid bias,17 the researcher avoided prompting the participants other than to respond openly. Ethical approval for this study was provided by Milton Keynes LREC (Ref no 04/Q1603/35).
The data from the F1 teams were collated and analysed into key themes for comparison with previous research.12 These data, together with previous studies of handover, and other literature describing high-reliability processes in healthcare,18–22 formed the conceptual framework for the analysis of the hospital data. The clinical interviews were recorded digitally, transcribed and imported into NVivo2, a qualitative data-management software tool. In NVivo2, iterative thematic coding resulted in emergent and repeated themes being coded by the researcher and, where appropriate, linked to other transcripts, establishing patterns of relationships to form an understanding of the current deficiencies in patient transfers. This type of approach for analysing qualitative data has been successfully used in previous studies of attitudes and perception of processes in medicine.23 24 These were then compared with the themes identified as essential to high-performance handover by F1 teams.
From the nine invited teams, three provided written responses, two invited telephone interviews, one declined to participate, and the remaining three failed to respond. Responses were received over a period of 6 months, and are summarised in table 2. Although there was a varying degree of information provided, all five teams mentioned that they have a briefing and debriefing procedure for both racing and testing, with four out of five teams stating such briefings included the driver and all relevant departments. All teams mentioned using checklists in the configuration of the car, and for fault management and ensuring the reliability of components.
We do have a fixed procedure and schedule for briefings and debriefings at race and test events. Especially for debriefings after every session we have a checklist, which gets ‘ticked-off’ and filled in by the driver together with the race engineer. (F1 Team E)
Four of five teams recorded data electronically and transferred information to the factory for analysis. Several mentioned that these data included the recording of dialogue from headsets worn by team personnel during a race. Less frequently noted, but also of potential importance, were electronic systems to log and resolve fault issues (mentioned by two out of five teams), and the use of external standards (ISO9000) for maintaining quality during the manufacturing process within the team and with external suppliers (mentioned by two out of five teams).
There are three or four mechanisms for passing on information depending on what that information is. If it is a fault (ie, car failure) then it will be logged into a faults system that then sends the message to the factory for solving. If it is a mechanics job list to change the car specification this is handled directly by the race engineer and passed to the mechanics. Everything is done electronically. (F1 Team A)
Overall, three themes emerged; first, briefings & checklists as methods for preventing errors; second, the use of technology to log and transfer information reliably between locations and team members, and third, the analysis of electronic data records as a method for identifying existing and future problems (table 3).
Patient transfer process
The 10 healthcare practitioner interview transcripts were analysed iteratively. The initial analysis by RS resulted in 22 themes, with eight higher-level codes: historical working practice; problems during transfer; poor awareness of handover protocols; poor team coordination; time pressure; lack of consistency in handover practice; poor communication of important information; and awareness that handover was a potential threat to patient safety. The eight codes were discussed with, and reanalysed by, KC and SH, resulting in three final themes. These have been mapped to the three themes from the F1 data as (1) proactive prevention; (2) active management; and (3) learning from analysis (table 3).
There was a reported lack of proactive prevention, and all participants described at least one instance where procedures were unclear. The lack of clarity was often considered to be due to historical working practices (‘it's quite an obvious sequence of events as it were, and it tends to happen up and down the country pretty much the same really;’ hospital participant 8) and personal methods of working (‘everyone's got their own way of doing it;’ hospital participant 1). Seven participants stated they were unaware of any written or formal specification for a within-hospital patient transfer. Where checklists were used, they were for children rather than for adults: ‘RQC (Reported Questionnaire on Children)’ (hospital participant 5).
Although clearly defined roles were reported (eg, sequencing of events in either receiving or collecting a patient), there were also comments about the hierarchy (‘I think it's generally acknowledged that the anaesthetist is in charge anyway, depending upon the ego of the surgeon, but it's generally acknowledged that the anaesthetist is in charge, so if the anaesthetist says “stop,” we stop’ (hospital participant 10)), and the ownership of paperwork (‘it's a matter of ownership; is it a medical responsibility or is it a nursing responsibility which is where the difficulty lies unfortunately’ (hospital participant 6)).
The type of training varied; for example, with supervision rather than formal training used in for medical staff:
We don't formally practice it internally, but what you do along the line in your training and over the years, is that you've seen the consultants doing it, you've seen your colleagues doing it, then you supervise your colleagues doing it when you're senior enough and that's how most of the things have been learned in NHS. (hospital participant 4)
The eight nursing participants indicated that they received professionally based training rather than task-specific, multidisciplinary team training.
The active management of handover was mostly based on verbal information (‘as in written format—not to my knowledge, no, it's all done verbally’ (hospital participant 2)). Many of the theatre-based participants reported that the anaesthetic documentation and patient records formed the basis of the transferred information. These were later used to form the basis of the formal patient record
the op sheet, where they have to write everything that was done in the operation and everything that's happened in recovery. And then that comes back up here and will stay on the patents notes, so you can refer to it if you need to see if they were given anything downstairs or anything like that. But it's all in their notes really and on our ward, the doctor's notes and the nurse's notes are all kept together, so it's just one big folder going backwards and forwards. (hospital participant 9)
The use of technology to transfer information ranged from examples for patient movement within Theatres ‘we have a theatre info system, so we can just flush it up on screen and it will say ‘op finished’ so we know that Mr so and so is coming from theatre 4’ (hospital participant 10). An electronic system (Theatre Information Management system) was mentioned but with a lack of knowledge about the level and extent of application and use.
Typical problems when communicating with other wards/departments during the patient handover included omitted information, unclear verbal or written communication, and failure to supply a sufficient level of detail. Time pressures were cited as a reason for failing to detail ‘will be the occasion when the patient doesn't get formally handed over because you'll be aware there is constant pressure on us to get the next patient in and because they don't want to cancel anybody at the end of the day or run late, so sometimes physically we just haven't got time’ (hospital participant 7).
The lack of consistency in both the information and staff was cited by nine participants: ‘I think it's very hit and miss. I think it depends on the person you are handing over to and their level of experience and I think it also depends on the theatre staff themselves’ (hospital participant 7). There was concern that this lack of consistency could contribute to patient safety risks (hospital participant 6).
To explore how processes could be improved (in an analogy to learning from analysis by reviewing the electronic data records from F1), the hospital staff were asked ‘What would you say are the key elements which would improve the process of transferring a patient?’ None of the participants suggested using audits or evaluations. There were suggestions that checklists and team training might offer benefits, but there was a general feeling that experience replaced the need for reflective practice ‘I suppose you could have a checklist but to be honest, people wouldn't use it that have been doing it more than a while because they're used to doing it, and they wouldn't need it anymore’ (hospital participant 9).
As with earlier studies8 12 19 24 we found that a lack of protocols, formal guidance or procedural training was associated with inconsistencies in the handover process, communication and coordination problems, and threats to patient safety. The responses from the five participating F1 teams confirmed the value of the working practices identified in our previous studies.12 They reinforced the importance of these methods in this type of high-risk industry, where there is a relentless search for performance gains encompassing the technology of the cars, human factors and human performance.13 F1 motor racing organisations place considerable importance on the use of checklists, briefing and debriefing, and have formal procedures for ensuring the highest level of consistency. In comparison, patient transfers do not use checklists, have no clear procedures, have ad hoc approaches to briefing and unsurprisingly were reported to be inconsistent and a potential source of patient safety problems. Previous studies have identified that hospital workers tend to take a `quick fix' approach to support short-term productivity25 26 rather than the type of learning from analysis seen in F1 to identify existing and future problems.
The procedure of recording dialogue by F1 teams allows personnel to refresh their recollection of complex information provided at track sessions and briefings, much as tape-recorded handovers have been used with some success in clinical handovers.27 28 Indeed, the practice of logging a vast array of data as a record, as a communication medium and as a method for fast fault diagnosis and resolution features frequently in the F1 responses. The healthcare analogy includes incident-reporting systems and monitoring of clinical data29 where, although not focusing specifically on handover tasks, responses might be possible with immediate local benefits for the patient. For example, access to information showing operating time might immediately flag up patients whose surgery was difficult and thus who were at greater risk during their postoperative care. However, instead of the large amounts of data produced by a single F1 car, healthcare might benefit from access to smaller amounts of data from a large number of patients. This study has highlighted professional differences in the acceptance and implementation of checklists and training, as has been found in other research.30 31 McDonald et al30 identified a dichotomy in safety culture between nurses (advocates of standardisation) and doctors (adhering to unwritten rules of acceptable behaviour). As handover is a critical interface between professional groups, it is important to understand these differences but also to challenge practice to seek improvements in safety and efficiency. Technology should be seen as a tool for improving performance, and not a direct solution itself.32 33 The potential of electronic information sharing between units in a hospital would benefit from further attention to how it could be used,34 rather than just the platform on which it might occur.
It has been suggested that unsafe practice in surgical teams persists because it is a functional response to psychological factors, professional values and organisational pressures.25 The vast differences in workload volumes, organisational goals and funding mechanisms means we should take care not to extrapolate too far from F1 to direct recommendations for adoption of practice. The limited responses from the F1 teams, and bias in questions that invited criticism in healthcare, but not in F1 practices, were also methodological limitations. Nevertheless, our studies have demonstrated that lessons can be learnt from F1 for the benefit of handovers in healthcare. The lessons from motor racing can be applied for proactive planning, active management and post hoc learning from analysis. In healthcare, working practices can be lacking in the standardisation, interpersonal communication, consistency and continuous development seen as fundamental to success in other high-risk industries. Addressing these issues with such a framework within healthcare organisations would result in improvements in quality and safety of care.
Thanks to all staff for their time and for allowing us to interview them, and to the F1 teams for their help.
Funding This project was part-funded by the BUPA Foundation, with KC gratefully supported by a Leverhulme Trust Early Career Fellowship.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.