Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program

Ann Surg. 2017 Jan;265(1):90-96. doi: 10.1097/SLA.0000000000001589.


Importance: Patient safety improvement interventions usually address either work systems or team culture. We do not know which is more effective, or whether combining approaches is beneficial.

Objective: To compare improvement in surgical team performance after interventions addressing teamwork culture, work systems, or both.

Design: Suite of 5 identical controlled before-after intervention studies, with preplanned analysis of pooled data for indirect comparisons of strategies.

Setting: Operating theatres in 5 UK hospitals performing elective orthopedic, plastic, or vascular surgery PARTICIPANTS:: All operating theatres staff, including surgeons, nurses, anaesthetists, and others INTERVENTIONS:: 4-month safety improvement interventions, using teamwork training (TT), systems redesign and standardization (SOP), Lean quality improvement, SOP + TT combination, or Lean + TT combination.

Main outcomes and measures: Team technical and nontechnical performance and World Health Organization (WHO) checklist compliance, measured for 3 months before and after intervention using validated scales. Pooled data analysis of before-after change in active and control groups, comparing combined versus single and systems versus teamwork interventions, using 2-way ANOVA.

Results: We studied 453 operations, (255 intervention, 198 control). TT improved nontechnical skills and WHO compliance (P < 0.001), but not technical performance; systems interventions (Lean & SOP, 2 & 3) improved nontechnical skills and technical performance (P < 0.001) but improved WHO compliance less. Combined interventions (4 & 5) improved all performance measures except WHO time-out attempts, whereas single approaches (1 & 2 & 3) improved WHO compliance less (P < 0.001) and failed to improve technical performance.

Conclusions & relevance: Safety interventions combining teamwork training and systems rationalization are more effective than those adopting either approach alone. This has important implications for safety improvement strategies in hospitals.

Publication types

  • Clinical Trial
  • Comparative Study

MeSH terms

  • Checklist
  • Clinical Competence*
  • Elective Surgical Procedures / standards*
  • Humans
  • Medical Errors / prevention & control*
  • Organizational Culture*
  • Outcome and Process Assessment, Health Care
  • Patient Care Team / organization & administration*
  • Patient Safety*
  • Prospective Studies
  • Quality Improvement / organization & administration*
  • United Kingdom