A Hospital RacesTo Learn LessonsOf Ferrari Pit Stop Auto Crew Teaches SurgeonsSmall Errors Can Add UpOn the Track, or in the ICU
Dr. McEwan as 'Lollipop Man'
By GAUTAM NAIK, WSJ November 14, 2006; Page A1
Our Driving Organic Growth executive education class was a great success! The participants again marveled of how we integrated Kellogg’s intellectual capital with the market proven process Market Driven Growth. They reinforced the power of coming to the class in teams from the same company as they developed their own Growth Initiative Journal, a tool designed to apply the class lessons to their own, immediate growth challenges. The class in May (14 to 17th) is starting to fill up!
As a pure marketing effort to the KIN members who have not attended the course, here are a few quotes that we were given permission to replicate...
“At last, a practical approach to growing innovation cultures within our organizations! Real tools coupled with keen insights presented by world-class practitioners. This is a high-water mark in executive education!” – Director of Strategic Planning, Raytheon
“This was an excellent program that married the rich experience of a world class practitioner with the intellectual power of top notch academics. A winning combination.” -- Partner, RPOptions Management Consultants
“This class helped create a process by which to identify, prioritize, develop and grow new business opportunities in a way more likely to integrate into my company.” -- GM & DVP, Automatic Data Processing
One of the students pointed out this article that is a great example of getting ideas from very different sources...........
LONDON -- After surgeons completed a six-hour operation to fix the hole in a boy's heart, Angus McEwan supervised one of the more dangerous phases of the procedure: transferring the fragile three-year-old from surgery to the intensive care unit.
Thousands of such "handoffs" occur in hospitals every day, and devastating mistakes can happen during them. This one went off without a hitch, thanks to pit-stop techniques of the Ferrari race-car team.
"It was smooth. We didn't miss anything," said Dr. McEwan, a senior anesthesiologist at Great Ormond Street Hospital for Children. His role as leader of the handoff was partly modeled after Ferrari's "lollipop man," who uses a large paddle to direct drivers to the pit.
In one of the more unlikely collaborations of modern medicine, Britain's largest children's hospital has revamped its patient handoff techniques by copying the choreographed pit stops of Italy's Formula One Ferrari racing team. The hospital project has been in place for two years and has already helped reduce the number of mishaps.
The challenge of moving a patient to another unit, or to a new team during a shift change, is an old one. In 1995, one man in Florida had the wrong leg amputated after a flubbed handoff. "If you transfer a patient to the ICU after surgery and the ventilator isn't ready, you're really riding on the edge" of patient safety, says Allan Goldman, head of the pediatric intensive care unit at Great Ormond Street Hospital and a chief architect of the hospital's collaboration with Ferrari.
A 2005 study found that nearly 70% of preventable hospital mishaps occurred because of communication problems, and other studies have shown that at least half of such breakdowns occur during handoffs………….
One Sunday in 2003, after a particularly tough day in the operating theater, Dr. Goldman and surgeon Martin Elliot slumped before a TV set and watched a Formula One race unfold. Both were racing fans, and they noticed striking similarities between patient handovers at their hospital and the interchange of tasks at a racing pit stop. But while a 20-member crew could switch a car's tires, adjust its front wing, clean the air vents and send the car roaring off in seven seconds, hospital handovers seemed downright clunky by comparison.
The duo invited members of McLaren, a British team that fields race cars in Formula One contests, to provide insights into pit-stop maneuvers. Armed with videos and slides, the racing team described how they used a human-factors expert to study the way their pit crews performed. They also explained how their system for recording errors stressed the small ones that might go unnoticed, not the big ones that everyone knew about.
That point struck a chord with Dr. de Leval. He immediately saw that pit-stop handovers were successful precisely because of an obsession with tiny mistakes, a conclusion similar to the one he had reached in his 2000 paper about arterial-switch operations…………..
In early 2005, Dr. Elliot, Dr. Goldman and Mr. Catchpole traveled to Ferrari's headquarters in Maranello, Italy, and sat down with Nigel Stepney, the racing team's technical director. As a test car roared around a nearby track, the visitors played a video of a hospital handover and described the process in pictures.
The Ferrari man wasn't impressed. "In fact, he was amazed" at how clumsy and informal the hospital handover process appeared to be, recalls Mr. Catchpole, now a researcher at Oxford University.
In that meeting, Mr. Stepney described how each member of the Ferrari crew is required to do a specific job, in a specific sequence, and usually in silence. By contrast, he noted, the hospital handover was often chaotic. Several conversations between nurses and doctors went on at once. Meanwhile, different members of the team disconnected or reconnected equipment to a patient, but in no particular order.
In a Formula One race, the "lollipop man" with a paddle ushers the car in and signals the driver when it's safe to go. But in the hospital setting, it wasn't always clear who was in charge. Though the anesthesiologist had nominal responsibility to take the lead during a handover, sometimes the surgeon assumed that role -- or no one at all.
The crew at Ferrari trained for the worst contingencies. "If Michael Schumacher comes in five laps early because it's raining and he wants wet-weather tires, they're prepared," says Mr. Catchpole, referring to the Ferrari driver and seven-time world champion, who recently retired. The hospital team dealt with problems as they came up…………
Back in London, Dr. Goldman and his colleagues began to incorp
orate Ferrari's lessons, along with advice from two jumbo-jet pilots, into the hospital handover process. They wrote up a seven-page protocol describing every step in the procedure. Between December 2003 and December 2005, they also did a careful study to see if those changes made any real difference to patient safety………
After the changes, the average number of technical errors per handover fell 42% and "information handover omissions" fell 49%. It also took slightly less time to execute each handover, though, unlike the Ferrari team, the doctors weren't trying to speed up their process.