In November this year I wrote about Paul Barach‘s work in developing team work in health care. I have been thinking about his insights since my encounter with his work.
I have found this paper (Barach et al, 2008) subsequently and note from its conclusion that:

Pediatric cardiac surgery is an ideal model to study the coordinated efforts of team members in a complex organizational structure. Adverse events occurred routinely during pediatric cardiac surgery and were mostly compensated. Case complexity was a significant predictor of major adverse events. The number of major adverse events per patient correlated with clinical outcomes.

A more recent paper (Schraagen et al, 2010) provides details about observation protocols for recording intraoperative non-routine events (NREs). The paper has some interesting points to make about inter-observer agreement and the training required:

The authors trained human factors observers to observe and code the NRE’s and teamwork from time of arrival of the patient into the operating room (OR) to the patient handover in the intensive care unit. The observers underwent immersive training in which each observer attended 10 operations, learnt in detail about the technical procedures and clinical tasks and received practice in coding teamwork. Two observers were used interchangeably to observe OR 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. Real-time teamwork observations were supplemented with process mapping, questionnaires on safety culture, level of preparedness by the team, difficulty of the operation and outcome measures.

I have have been thinking a great deal about error, harm and care in the last month and have shared Paul’s insights with a number of people working in team contexts. My original contact with his work was through his interview with Norman Swan (link to podcast) on Radio National’s Health Report.

More Examples of Care

Yesterday (20 December) I learned of the release of the ANZASM 2009 Annual Report by the Australian and New Zealand Audit of Surgical Mortality (ANZASM). This report is based on the activities and outcomes during 2009. The announcement of the report’s availability notes that:

The primary objective of the audit is peer review of all deaths associated with surgical care. The audit process is designed to highlight system and process errors and trends associated with surgical mortality.

I learned yesterday too about the work of Anna Tharyan (Professor of Psychiatry, Christian Medical College,
Vellore, Southern India) and Prathap Tharyan (Professor of Psychiatry, Christian Medical College, Vellore,
Southern India). I found out about Cochrane Collaborations and in passing the work of Clive Adams (Professor of Mental Health Services Research,University of Nottingham, UK). What fascinated me about their work was their sense of caring and the use of a collaborative approach to care. A transcript of the Health Report program about their work can be found here.

In the program Anna starts the interview with this observation:

After 26 years of working within the confines of a large teaching department of psychiatry I was invited by a man who had organised a not for profit organisation to just, as he said, do rounds on the street. He says doctor, you’re going round and round your hospital wards, would you care to come with me down the street and see how many of your patients sit by the roadside? And this man who hasn’t completed a school education opened my eyes to the vast section of the people who need professional psychiatric help who were not existing as far as we were concerned.

Prathap discusses evidence-based medicine in his interview and shares his insights into low cost, clinic-based research design involving real life patients and the kind of working conditions found:

This was a real world trial and we didn’t exclude large numbers of people because most trials tend to exclude somebody with this condition or that condition. But a clinician doesn’t have that luxury, you’ve got to treat everybody who comes so a lot of that evidence isn’t applicable to us. So we decided to create our own evidence using our own patients using our usual clinical practice.

With Clive Adams he has been investigating effective medication for violent patients. Their work exemplified for me the possibilities created by collaborative caring.

Collaborating to Care

I was fascinated to learn about Cochrane Centres in the Health Report and was attracted immediately to the democratic potential of such collaboration.  I have discovered that the Cochrane Collaborative is made up of contributors and entities based all around the world. The majority of the Collaborative’s work is conducted online.

Each entity is a ‘mini-organisation’ in itself, with its own funding, website and workload. Contributors affiliate themselves to an entity, or in some cases several entities, based on their interests, expertise and/or geographical location.

The Collaborative produces Cochrane Reviews which are systematic reviews of primary research in human health care and health policy:

They investigate the effects of interventions (literally meaning to intervene to modify an outcome) for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. (For information about the structure of these reviews see here.)

I was interested to read about the impact these Reviews have on practice in the UK National Health Service.


Paul Barach’s work has taken me on a journey of discovery. I was attracted intuitively to his approach to systematic observation and how teams might use observation to enhance performance and promote trust. The link between Paul, Anna, Prathap and Clive was made for me by Norman Swan. The Cochrane Collaborative is a real bonus in this wayfinding.
I am hopeful that by exploring a range of contexts for caring that my understanding and practice of care is developed. I am looking forward to exploring inter-professional learning in much more depth in 2011.
Photo Credits
Baby in Hand
PS Asleep on a Bench


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