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Lessons in Teamwork from the Killing Fields

06/02/08

Lessons in Teamwork from the Killing Fields
Would you allow your children, partner or parents to be admitted to a hospital with a record of killing 10% of the patients who undergo major surgery?
Dr Ken Catchpole who specialises in understanding how people act in stressful situations was shocked to discover that the error rate in patient care after medical operations had been successfully completed was up to 10%. He compared this to other high risk industries and the military experiencing an error rate of 0.001%.
He reported that “On an aircraft carrier you have hundreds of people, technology, explosives, fuel, and planes landing every couple of minutes – yet they rarely have accidents. Apply healthcare statistics and one in ten planes would be falling into the sea!”
Research at 21 hospitals across the U.K. revealed that surgeons and their colleagues in the operating theatre and the nursing staff in the intensive care wards to which the patients were admitted to recover were highly skilled. There were however no standardised procedures for the handover of the patient between surgery and ICU.
Sometimes the ICU was not informed that a patient was arriving and were not prepared. As the handover took place there might be three or four people giving instructions in the same room simultaneously resulting in high noise levels and it could take up to half an hour to get around to untangling and plugging in all the wires and tubes.
ICU professionals were forgetting basic things such as omitting to switch vital equipment from the portable battery system used during the transfer to mains power on reaching ICU.
The major problem identified was a lack of an interlocking team design for the entire procedure.
Dr Allan Goldman and heart surgeon Professor Martin Elliott at Great Ormond Street Hospital in London are both keen Formula 1 fans and while watching a race together witnessed a 20 member pit-stop team change tyres, fill the tank, clean the air intakes and send the car roaring off – all in less than seven seconds.
It was then that they recruited the expertise of the McLaren team manager Dave Ryan and Ferrari’s technical manager Nigel Stepney to review their handover procedures.
Dave and Nigel were amazed to discover that throughout the handover from surgery to ICU nobody was responsible for leadership, that there were no standardised procedures, that everyone did what they thought was needed to be done and that the medical teams had no briefing on what to do if things did go wrong.
Pit-stop crews, by contrast, knew exactly what to do. If for example a wheel nut rolled away, they would take a spare wheel nut out of their right hand pocket.
A hospital protocol was designed which appointed the anaesthetist as the leader and a step-by-step list checklist designed which team members tick off as each task is completed. There is even a diagram of the patient surrounded by staff so that everyone knows their exact position and task. Silence is observed throughout.
Operation Pit Stop has been adapted to other areas of medicine and has been adopted by hospitals around the world.
Our research indicates that although most organisations hire good – even outstanding - people, they lack the strategies, structure, handover protocols and the ‘political will’ of their management which would ensure interlocking teams work together to optimise their combined energy and experience.
Sadly, teams throughout the organisation often compete for resources and people, and the systems within the organisation work directly to ‘protect’ their division from other divisions. For them, the ‘enemy’ is not their competition, complacency, lack of product visibility or acceptability, but people within their organisation.
This was eloquently demonstrated by one CEO who in his briefing prior to a strategic planning workshop told to us “My Division is characterised by a very complex strategic dilemma, a management group of outstanding individuals without a team ethos and a less than satisfactory forward order book.”
Lack of internal cohesion costs organisations around the world millions if not billions of dollars each year.
For 30 years we have assisted our clients to become future winners. Read what our clients say.
The major problems we regularly identify include:
  • Most organisations are not designed from the board room to the back room to ensure that all interlocking teams have the protocols, checklists or a culture which ensures effective team work
  • Highly successful practices and habits of one team are seldom replicated throughout the organisation
  • People are hired for having the right skills to undertake their job but little account is taken of their abilities as a team player
  • Communications, work flows and ideas while appearing to run seamlessly from one department to the next seldom do.
  • The energies of people in many departments are diverted to fixing botch-ups resulting from system failures as work flows from department to department
  •  The tyranny of the strategic business unit culture destroys every attempt by the CEO to optimise synergies and learning throughout the organisation
  • Many division leaders are given budgets and targets for their division which they are expected to optimise
  •  Many division leaders are incentivised for the success of their division rather than the success of the organisation and some would rather resign than share their best people, resources and winning tactics and practices
  • Companies which claim to be strategically aligned may use scorecards to ensure each departmental manager and employee focuses on corporate goals and strategies. These organisations are unfortunately consistently frustrated by the lack of interlocking mechanisms and a culture which consistently ensures that teams within each organisation work together to optimise company results.
We at Future Winners International have assisted many organisations to develop a cohesive team spirit across the organisation together with global best practice structures, strategies and systems to ensure that team activities fully interlock.
“PCP has ignited our goal of working together as a 'passionate team' by drawing on each other strengths, aiding in areas of weakness and focusing on the end result".    Trent T. Gathright, Houston, USA
"I cannot say enough good things about your program. Your "Passion Creates Profit" profit improvement program has helped us to be more customer oriented and establish a great 'CAN DO' attitude...” Kaveh Someah, Salt Lake City, USA
“We are radically shortening the time from order to delivery. Teamwork, passion and commitment of all are the key”. Allan Whithers, Stourbridge.
Before you hire one of the big five consulting firms or decide to DIY your next strategic planning workshop, why not give us a ring to assist you with new perspectives? We offer a free half hour telephonic consultation to CEOs anywhere in the world.