Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality

A few years ago I was watching one of the learning channels and a story came on about how a formula 1 pit-stop team taught a hospital crew in a London hospital how to improve on their turn over in pediatric intensive care.    The fact that the hospital is saving more children because they have refined their process is great.  I think there is another story hidden here, it is the story of how people in one industry opened their minds to the possibilities and allowed others to help.

Today is Memorial_Day we honor and remember are fallen defenders.   The people who have fought to protect our interests, our values, our morals and our way of life.  The best way to thank them is to continue to protect their families and protect our freedom and our country.   To do this we have to be smarter and think more about what we are doing.  We have to take the time to think .

More often than not we don’t think, we just DO.  We don’t think about the consequences of our actions and we as a society are become more self obsessed and absorbed.   There is less willingness to listen to each other or talk about difficult subjects and work out our talks in ways that are productive.

What I find very interesting today is that people are willing to listen to stories if they read like or sound like something that comes from a TED event.  See Reggie Watts for an example of something that totally makes no sense but it is “an idea worth spreading.”

We aren’t willing to think ourselves but we are compelled to listen to those who appear to think.  This concept applies to every aspect of our lives including our personal lives.  Facebook is a great example, it is potentially worth more than Disney and it gives us individually very little except that immediate feedback that we so desire.

So, today please allow me to inspire some thought in you.  When looking for answers, think about the right questions and if you don’t know the answer or you can’t come up with something that makes sense ask around and extend your reach concerning who you should ask for help.  You may find your answer with Reggie Watts “in the negative space” or whatever, but moreover you may find the right answer in exactly the wrong place.   After all, who knew that a pit crew could save newborns.

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality


Background:  We aimed to improve the quality and safety of handover of patients from surgery to intensive care using the analogy of a Formula 1 pit stop and expertise from aviation.

Methods:  A prospective intervention study measured the change in performance before and after the implementation of a new handover protocol that was developed through detailed discussions with a Formula 1 racing team and aviation training captains. Fifty (23 before and 27 after) postsurgery patient handovers were observed. Technical errors and information omissions were measured using checklists, and teamwork was scored using a Likert scale. Duration of the handover was also measured.

Results:  The mean number of technical errors was reduced from 5.42 (95% CI ±1.24) to 3.15 (95% CI ±0.71), the mean number of information handover omissions was reduced from 2.09 (95% CI ±1.14) to 1.07 (95% CI ±0.55), and duration of handover was reduced from 10.8 min (95% CI ±1.6) to 9.4 min (95% CI ±1.29). Nine out of twenty-three (39%) precondition patients had more than one error in both technical and information handover prior to the new protocol, compared with three out of twenty-seven (11.5%) with the new handover. Regression analysis showed that the number of technical errors were significantly reduced with the new handover (t = −3.63,P < 0.001), and an interaction suggested that teamwork (t = 3.04, P = 0.004) had a different effect with the new handover protocol.

Conclusions:  The introduction of the new handover protocol lead to improvements in all aspects of the handover. Expertise from other industries can be extrapolated to improve patient safety, and in particular, areas of medicine involving the handover of patients or information.

More SLA Questions..

Can my words have footnotes, please? – Amy Harbottle

This past week I was interviewed for the upcoming this year.  I always take every opportunity to speak or teach because it forces me to really focus on the areas that I am exploring with others.  One of the most popular subjects in recent times is the SLA, that is why I have chosen to spend a lot of time on it.

We have a problem and it is a serious one, consumers are not controlling the market.   I understand that the idea of this doesn’t make much sense but it is the reality and we need to know what we can do about it, if anything.   We also need to know what questions we should ask from the boardroom to the lab.

How much do you pay for gas today?  When you go to the doctor’s office are the prices on the wall like McDonalds?  How about your dentist?

How many times have you installed a piece of software and scrolled down through 60+ pages (like Apple) to use install it or use the product?

Lets get this straight… you go someplace or purchase something and you have NO SAY in the conditions of the exchange other than if you don’t like it you don’t accept.  What if your husband or wife agreed and you didn’t know?  What about your children?  They click faster than you.

I remember when you could go into a store and negotiate a price on an item and the conditions of sale.   You can still do that!  We just have either forgotten or our children don’t know.  This is very important because it directly correlates to your ability to make choices on what you are willing to purchase and what you aren’t.  If I told you that somewhere in the agreement that you didn’t read it says “If finds out that you have died, has the right to recover software sold under licensing and any hardware or media that software resides on”  Would that be ok?   Read some of these agreements.

This applies to the service level agreement as well.   This is critical because lawyers are not making these agreements on your behalf but they are making these agreements on behalf of the service provider.   It is like going to court without representation against the legal mafia.

Last year Amazon had a service outage that put companies down hard but it didn’t violate any SLA and further there was no remedy for these companies (

Ray Wang writes:

As calmer heads prevail, most CIOs, business leaders, and analysts realize that:

  • Cloud outages are rare but can happen. While most organizations can not deliver 99.5% up time let alone 90% performance, disruptions can and will happen.  The massive impact to so many organizations last week highlights potential vulnerabilities of betting 100% of capacity in the cloud.  More importantly, it showed that broad adoption does not equate with bullet-proof reliability.  Most organizations lacked a contingency plan.
  • Cost benefit ratios still favor cloud deployments. For most organizations, the cost of deploying in the cloud remains a factor of 10 cheaper than moving back to the traditional data center or even a private cloud.  Capital costs for equipment, labor for managing the data center, excess software capacity, and the deployment time required to stand up a server create significant cost advantages for cloud deployments.
  • Current service level agreements lack teeth and should be improved.Most organizations lack teeth in the cloud/saas contracts to address service level agreement failure.  Despite all backups and contingency plans, clients should consider scenarios where core business systems go down. What remedies are appropriate? What contingencies for system back up are in place.   Who is responsible for disaster recovery? Will the vendor provide  liability and for what?

The Bottom Line: Proactively Account For Breaches In Service Level Agreements In SaaS/Cloud Contracts

Organizations should protect themselves from future breaches through a combination of contract provisions and contingency plans.  Here are some suggestions recommended to clients:

  • Apply provision from the SaaS/Cloud bill of rights.  Though written in late 2009, this document remains a best practices guide to SaaS contracting.  Key provisions to apply include: Quality guarantees and remuneration, stipulate data management requirements, on-going performance metrics
  • Include service level agreements with teeth. Credits for free licenses for down time sound good on paper. In reality, down time when critical systems fail could result in massive financial losses.  Contracts should apply risk on the potential business loss.  Some clients include a provision that identifies compensation for a percentage of average daily business revenue during the time period of down time.
  • Reevaluate your Amazon deployment strategy. Believe it or not, Amazon technically did not violate its service agreements.  To deploy a true backup strategy, organizations should add copies of their server instance in multiple regions and data centers as an added layer of protection.  This ensures that a proper fail over occurs even if multiple regions experience outages.
  • Implement a real disaster recovery strategy. The Amazon outage exposed that many start ups failed to have a disaster recovery strategy.  A number of solution providers now provide cloud disaster recovery.  More importantly, these providers can recover physical or virtual machines in a cloud within minutes.  Whether organizations can fire up a backup server in time remains the open question.

Think about this! 

Your business is YOUR responsibility.  How many organizations are responsible for more than just themselves?  Local, state and federal government are moving into cloud strategies, banks and financial institutions are making groundbreaking moves on cloud computing and finally medical communities are moving “to the cloud.”

My doctor is a really cool guy and I trust him when he tells me that I should eat right and exercise but I don’t want him putting my medical records in cloud services that he doesn’t understand.

Cloud SLA (Government / Defense)

I teach a cloud computing course for Thomas Erl @ Arcitura from time to time and the question that always comes up is the one about service level agreements.   It is a complicated subject that does not get enough attention in our industry.  I am presenting some of the discussions that we have had in class and some of the questions asked all relative to cloud computing and mostly aligned to the defense industry.    This is part of an SLA series of blogs to get people thinking about their requirements and to understand what an SLA can do or not do for a business.

Today I will share a short story .

It was 5:00 PM on a monday afternoon,  a routine procedure on a patient in London turned into a catastrophic challenge requiring expertise from across the pond.    Dr.  Jack Ash is a leading Gastroenterologist living in Ontario, Canada.   Dr. Ash received a call asking if he could help the patient in London.   Dr. Ash has extensive experience with remote surgery a relatively new practice taking shape using cloud oriented services.   Dr. Ash is using IT services provided by the hospital in Ontario.  The services in London are with a different hospital and a different IT service provider.   The configuration of the services look very similar to this (see figure 2)

The SLA looks something like this IT_Service_Level_Agreement_Publish_To_Customers.   Dr. Ash didn’t have much time, he needed to act fast.   He ran down to the office and coordinated all of the requirements with the remote team in London.   This situation had been discussed before and the staff had practice with dummies and cadavers.  Fortunately for Dr. Ash he routinely performs procedures like this in Ontario between hospitals often.

The stage was set, the anesthesiologist had the patient stable and all of the supporting staff acted as planned.   Due to the situation and set backs some time had gone by and the procedure took place closer to 8:00 PM .

Dr. Ash started the robotic services and invoked various commands over the network.  At first the procedure was going well, there were some minor fluctuations with bandwidth but nothing major.  In order to make sure that the network connectivity was consistent Dr. Ash asked a staff member to call over to his local IT and make sure QoS was turned on.   The helpdesk reported back quickly that all available resources and network traffic managing the robotic services had priority on the network.   The procedure continued and Dr. Ash was noticing severe latency through his video stream.   He had to act fast to finish the procedure and just as he was finishing the final maneuvers, the robotic arms lost connection.  Luckily the original staff working on patient x were in the room for Dr. Ash to talk through the final moments.

What happened?  Why did the arm lose connectivity?  How did the SLA help?  How could the SLA have helped?

Although this story was not real, the technology is real and the fact is that medical practitioners are doing something like this today.   Why did the arm lose connectivity?  I’ll give you a hint, there was a soccer game at Chelsea and there were a lot of people in London very interested in that game.

There are various reasons for the potential failure of service.   The problem is that most people focus on what technology can do as opposed to understanding where it make sense to use services like this and where it makes sense not to use these services.   There are plenty of business cases that could have created a more stable environment but more often than not businesses choose to go head first into situations like this.   It seems like a great idea and they even had an SLA!  I wonder what that would have done for patient x had this person died.

These are some of the concepts that we will need to explore further.  I will put together some defense oriented generic scenarios for thought.