NHS Sustainable Operating Theatres Project Report
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Contents
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1.
Executive Summary
2.
Our Project Brief and Approach
3. Sense-making 4.
Project Challenges
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Outcomes and Impacts
6. Conclusion 3
Executive Summary Operating theatres account for up to 20-30% of hospital waste (Babu, Dalenberg et al. 2018) and anaesthetic gases represent 5% of the carbon footprint for all acute NHS organisations (Charlesworth and Swinton 2017). The perioperative environment is dominated by single use, disposable items- from the multiple syringes and swabs used on every patient through to laparoscopic instruments worth thousands of pounds that are incinerated following a single procedure. The products and processes that have been developed to address health risk and infection concerns undoubtedly benefit the individual patient, but they are damaging the planet, and directly contributing to current and future public health concerns. While other intensively polluting industries- air travel, farming, fashion- are under the spotlight, the operating theatre has escaped close public scrutiny. Perhaps this is because so few of us witness what goes on? Perhaps it is because we trust doctors implicitly to do the right thing for us? Perhaps waste has become normalised for clinicians? Perhaps big pharma has locked healthcare practice into a loop where ongoing consumption is the only option? Our three month project with the Centre for Sustainable Healthcare and Newcastle Hospitals Trust focused on co-creative working with anaesthetists and perioperative staff at The Freeman Hospital, helping them to apply design-thinking to build a path towards a more sustainable future. 4
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Meet the Team
Our team was made up of four Multidisciplinary Innovation postgraduate students with the following backgrounds: Mairi Bell - Consulting and Business Development Jack Fitt - Business Management Kai Hsu - Industrial Design and Computer Science Hannah Pickard - Children’s Physiotherapist
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Our Project Brief and Approach
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Our Brief and Clients
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We were presented with an interesting yet challenging brief around Sustainable Operating Theatres, which included two main stakeholders-
• ●The Centre for Sustainable Healthcare, represented in this project by Dr Cathy Lawson; and • ●Newcastle Hospitals NHS Foundations Trust, primarily the Freeman Hospital and Dr Ian Baxter, Consultant Anaesthetist
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Set-up
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The initial weeks in the set-up phase of the project included desk research and a visit to Northumbria University’s perioperative simulator to understand: the situation of practice; change initiatives in the NHS; how other facilities and countries are tackling the problem; empathising with key actors; and, build our credibility as a team.
Set-up
Given our limited time on the project, we had clear objectives for our first meeting with our client at the end of week 4:
We presented four separate briefs as avenues we might go down. We were aware that the project scope, outcomes and approach would vary considerably depending on which level of intervention we targeted. Together we agreed a local level brief around waste reduction.
• ●Agree which opportunities to take forward • ●Identify stakeholders for each opportunity and agree access protocols • ●Agree methods for co-creation and engagement during the problem/ solution phase 13
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We focused on three sub-projects that met both Dr Lawson’s brief and, critically, our own. We knew that we were only coming in for a limited time and the majority of the work would happen beyond our exit. We recognised that the healthcare model could only be reframed to incorporate sustainability from within. Therefore our value as MDI students was as catalysts for change, to build capacity and appetite for new ways of thinking and participatory action research. Our three sub-projects, A, B and C aligned with this value scaffold.
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Project Summaries - revised to reflect meeting outcomes (21/06/19) Project ATrack Waste across the Patient Journey 1. 2. 3.
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Validate opportunities from workshop Identify additional opportunities Prepare a high level feasibility and benefits summary for all opportunities Visualise the ‘old vs new’ journey as a stakeholder communication Socialise opportunities at next audit day 18th July
Project BLeaning the Central Line Kit
Project C 18-24 Month Plan
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• Write up mini-briefs for all ideas in scope • Cathy to write up existing projects • Meet on 28th○ Plot by complexity and stakeholders ○ Go/no-go decision and onto 18-24 month plan • Render plan in visual format
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Approach paediatric cardiothoracic team Deliver workshop with a ‘provocation’ brief Summarise outputs and key themes Paediatric cardiothoracic team to take forward findings and insights as appropriate
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Project A originally set out to deliver a modified design sprint (Knapp 2016) both remotely and through a workshop, but we encountered challenges early on. The plan was adapted to gather ‘pain points’ from clinicians and observe these in an end-to-end ‘patient journey’ from the ward, anaesthetic room, operating theatre and recovery. We had the opportunity to validate information in surgical visits where we followed patients through a surgical procedure observing the entire perioperative environment, its tools and procedures. Validated information was fed back to a wider audience of Department staff during an Audit Day and data was gathered.
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Project B focused on making a pre-packaged central line kit used by paediatric cardiothoracic anaesthetists more lean. Staff had already started to make comments about changes, therefore our client hypothesised this would be a good place to start. What began as a survey morphed into the idea of a more provocative workshop to assess what items might come out of the existing kit. Sadly, a date for the workshop never materialised, however, we gave our client draft work we’d developed including possible questions and activities that could be run in the future.
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Project C involved working jointly with Dr Lawson and Dr Baxter to map out a plan for the next three years which included a clear vision and milestones for various projects already underway or pending within the Trust. We were careful to deliver this in a simple format that was easily editable to enable changes to this live document as the plan evolves over time.
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2019
2020
2021
Department Sustainability Audit
Look at systems to move opened drugs with patient
Scope and initiate research project about pharmaceutical waste alternatives & recycling
Reusable Clinician attire starts to appear in regular use
Sustainability module launches on Newcastle Medical School undergrad curriculum
Plastic patients effects bag replaced with sustainable alternative Collaboration on new Anaesthesia curriculum with Newcastle Medical School
Secure future of Fellowship in Environmentally Sustainable Anaesthesia
Analysis of TSSU waste handling identifies opportunities
Collaboration on revised ODP curriculum with Northumbria
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Scope and prepare for system changes from ‘patient journey’ work
New behaviours about ‘non-OR’ scrubs to reduce unnecessary laundering
Patient Box in place for single patient use of disposables New BSc for ODPs launches at Northumbria
Education initiatives to train all department staff regarding new sustainable procedures
Non-essential laundry minimised through small, practical changes Energy reduction measures in place across OR environment
Pilot single patient use initiatives reducing plastic waste across patient journey
Pilot Gas Capture Technology
Start replacing disposables in coffee room with reusables
REUSE
2022
Natural light in staff areas
SUSTAINABLE OPERATING THEATRES ROADMAP Newcastle Trust is modelling sustainable operating theatre practices, ready for first cohort of Medical Students under revised curriculum
Transformation Map
Lights on motion sensors
Carbon footprint from volatile gases reduced by 40% across Trust in line with NHS LTP Capture volatiles for processing and reuse scavenging systems
Waste streams scaled to set behaviour expectations Specialist recycling streams for single use plastic and metal
Environment optimised to make correct disposal the easy choice
RECYCLE
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• Starting point to build knowledge as individuals and a team • Building understanding and empathy with the situation • Important for our credibility across the project
• Discussed four ‘briefs’ and various levels of intervention within the NHS • Clarified our project around an achievable, localised brief about waste reduction • Agreed methods and stakeholders for cocreative investigations
• Discovered most innovative work was coming from individual hospitals • Saw how critical individuals were in creating institutionwide change • Recognised the value of small, incremental changes over large initiatives
• Recognised that sustainability is not formally taught • Began to understand that all practice is not evidence based and there were contradictions • Began to see the sheer scale of systemic waste in single use plastics
• Experienced the constraints on admin and information sharing for many staff • Where we got responses, we were surprised at the lack of ambition for change being expressed • Saw that remote engagement was not going to work for this group
June
May
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• Saw a huge positive shift in engagement when we invited people to ignore procedures • Witnessed the energy created from people sharing and being heard • Started to see new and recycled ideas coming through to address pain points
Workshop debrief to agree focus of next phase
Workshop with Freeman staff
Pre-workshop online engagement with Freeman Staff
Visited Northumbria peri-operative simulator
Investigation of Global best practices
Agreed a local waste brief at initial client meeting
Desk Research on sustainable operating theatres
Project Timeline
• Witnessed the expansion of scope and influence from Lisa’s engagement • Saw the opportunity to add value through witnessing an end to end patient journey • Appreciated being taken seriously and being granted access
July
Key observations and feedback from Department
Exploring research briefs for product innovations
Final client presentation and report
• Saw the positive acceleration effect of a burning platform from the HES scandal • No one can magic the problem away- careful, ongoing internal management adds up to change • What goes in must come out- waste consequences begin at procurement stage
Follow-up session with workshop participants
• Saw how core individual practice and choice is to a doctor’s identity • Witnessed how single use is ubiquitous to patient safety in the environment • Few quick winsreplacing single use would mean more work and unpicking established practice
Visit to Freeman waste collection and disposal areas
Surgery visit to observe patient journeys
Roadmap session with Ian and Cathy • Leveraged opportunities to influence next generation through university curricula • The mandate for the longer term plan came from co-creation in the workshop • Understanding of starting from a place of influence and growing agency outwards
• Saw the empowering effect of taking individuals’ opinions and ideas and scaling them up • Some products are used universally but only benefit some groups of patients • Practitioners have so much useful feedback for manufacturers but no route to give it
• Experienced strong interest- most people had opinions and views to contribute • People want to be engaged in the why and the how of sustainability- not just the what • Some staff have already changed their practice but how do they share this?
• Professor Justin Perry “most things can be reprocessed but there is a cost- who is going to pay?” • Recognised that the low cost of new materials suppresses market for recycled materials • Looked at ideas to minimise syringe use in the Anaesthesia Room
• Professor Justin Perry “most things can be reprocessed but there is a cost- who is going to pay?” • Recognised that the low cost of new materials suppresses market for recycled materials • Looked at ideas to minimise syringe use in the Anaesthesia Room
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Sense-making
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Drawing on our collated research findings, insights, questions and paradoxes, we have identified five high-level themes that span meta, macro and micro lenses on our project brief. These sense-making themes are neither problem nor solution statements, aiming instead to articulate the complexity within the situation.
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• Fighting nature • Doctor knows best • Naive eyes • Reframing the clinical mindset • Self-improving system
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Fighting nature
The Lancet recently stated that “climate change is the biggest global health threat of the 21st century� (Costello, Abbas et al. 2009). In June of this year, while our project was underway, Newcastle Hospitals was the first NHS Trust to declare a climate emergency and commits to be carbon neutral by 2040. The huge paradox is that in trying to make people better, healthcare is actually making people sick. Public health risks and consequences attributed to climate change have been well documented (WHO). These are associated with increased air pollution, vector borne illnesses and natural disasters which are increasing as we continue to abuse the planet.
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Facilities are preparing for climate refugees and it is likely that wars will be fought over water, food and land. Our team went to quite a dark place during a future-casting exercise where we considered what healthcare might look like in a resource-rationed future; nick-named the ‘zombie apocalypse’ task. We continued to identify paradoxes and conflicts when juxtaposing an individual vs a utilitarian view of medicine. In completing our empathy mapping (Gray, 2010), we concluded that people will always want what is best for themselves and their family. We felt that many of healthcare’s proudest achievements in fact fight nature.
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We discussed the triple bottom line, but found that while patient safety and finances most definitely factored into the daily workings of the NHS, the environment appears to not yet be given the same weight. We couldn’t help but wonder who’s winning here? It’s not people, it’s not the planet, but more often than not large corporations - big pharma, manufacturers, sugar, cigarettes, alcohol- who leave healthcare to deal with the messy aftermath of their profit such as waste, obesity, and air quality. CJD is a stark example here. The root cause of many single-use prophylactic measures in hospitals, it is the direct result of bad practice within the food industry. These lines of inquiry helped us to recognise the challenges of addressing healthcare sus-
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tainability through a top-down medical paradigm. That would be too controversial a journey to take, paved with difficult ethical questions about clinical need vs resource allocation. Instead, we focused on a human-centred approach where individual practices and values are considered and leveraged for meaningful ground-up change.
In a world aiming to reduce consumption, how do we apportion healthcare resources?
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Doctor knows best
The role of the doctor is unique within society. Individuals from all walks of life defer to doctors with their extensive knowledge and training, trusting them to keep us well. This universal trust in the medical profession brings with it a deep responsibility- one we recognised early through our empathy mapping exercise, putting ourselves in the shoes of key operating theatre actors to better understand their situations. With multiple competing concerns and literally focused on life and death, can we ask clinicians to worry about paper vs plastic?
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Deductive, evidence-based reasoning is fundamental to the medical profession. Inductive or abductive methods, key tools of the design-thinker (Dorst 2015), could be actively dangerous to patients and have no place in a day to day clinical setting. Paradoxically, major medical advances such as transplants and transfusions drew on a ‘fail fast and pivot’ innovation mindset. We are becoming accustomed to patients using internet information to take back some agency, questioning doctors’ decisions and even accusing them of medical paternalism.
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However, patients in an operating theatre setting have little or no opportunity to challenge or even witness procedure. As a result, the perioperative environment goes largely unchallenged and it is up to the clinicians themselves to question sustainability within it. Our perception of doctors as uniformly following the same route to a single answer was challenged during our investigations. Lloyd Howell, Northumbria Operating Department Practitioner (ODP) Senior Lecturer was first to highlight inconsistencies in practice and we
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began to understand how process and procedure were not always evidence based. Variables around institutional procedure, resources and individual preference all influence clinical decisions. Our surgical visit threw further light on this and we saw how deeply individual ‘practice’ guides clinicians, representing both their medical experience and human values.
We trust doctors with our individual health- can we trust them with the health of the planet?
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Naive eyes
As a team, we took a ‘vow of humility’ early on. We are by no means experts when it comes to activities which happen in and around operating theatres; we likened ourselves to children. We broke down the brief and set critical success factors to equip ourselves for the project. We found that peer lead change works best in the NHS as there can be a sense of ‘not invented here’ when things are suggested or imposed by those external to the system. Several of our workshop activities were crafted to exploit our naivety and the fact that we don’t have clinical reputations to uphold.
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When we asked staff to ‘tell us where it hurts’, we heard people saying “don’t write that...”, “that’s illegal”. When given permission to break the rules in some ways by ignoring policies, procedures, infection control, patient safety and just tell us what doesn’t feel right in terms of things they have to waste as part of their practice, there was a lot to share. We felt this was like holding up a mirror but not being judgmental nor blaming. We let the group set the agenda, we just brought provocations.We presented ‘solutions’ on postcards and asked participants start conversations with ‘yes but’ as to why that wouldn’t work and then ‘yes and’ as to why it might. Participants did not know that these were in fact
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all best practice examples that have been implemented in different hospitals across the globe. We found we could add value by observing the end-to-end patient journey with a sustainability lens as this is not something clinicians, who are assigned to a specific part of the process, nor the patient, who is asleep for part of it, ever do. We sought advice around planning our ethnographic observations of the patient journey from an anthropologist, however, we mainly just looked for objects and processes that had already been highlighted by the staff in the workshop ‘pain points’ exercise. After our visit, analysis determined concerns that had
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been mentioned by staff and then validated by ourselves. While there were additional things they said that we didn’t have a chance to see and also things they hadn’t mentioned which we saw, the focus for the infographic poster were those in the first category. It was empowering for participants to see what they’d shared scaled up and listened to.
In an environment that thrives on routine, how do you gain a fresh perspective?
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Reframing the clinical mindset
Fundamental change in attitudes around sustainability in the operating theatre will come when enough clinicians start asking difficult questions and pushing for change. The catalyst for this is more likely to come from outside- the Attenborough effect or pressure from their concerned children- than from within the medical profession. This will see the deductive scientific viewpoint crashed together with the concerned human perspective to create a new paradigm for sustainable healthcare. A key insight across our project was the transience of process and procedure vs the permanence of individual practice. For example, we were puzzled initially at the reticence to
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address desflurane use with ‘stick’ approaches but began to understand this following our surgical visit. We saw that, while process and procedure may set the context within which clinicians operate, their individual practice defines their purpose and delivers human value; practice is therefore key to defining this new paradigm. The NHS refers to the triple bottom line of social wellbeing, economy and environment, but despite this, sustainability could easily be mistaken for ‘just another initiative’ rather than a core value.
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In the staff areas of the hospital we witnessed the sheer volume of initiatives and signs competing for attention. If sustainability is to be recognised as something more fundamental, staff need to be included in the why and the how- not just exposed to the ‘what’ in a poster campaign. Following our initial workshop, we had fantastic feedback from attendees about the style of working. Accustomed to e-learning and traditional training, they found the design-thinking approach and divergent nature of activities novel and exciting. With scope to explore sus-
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tainability within their own frame and concerns, we hoped to reach people at a deeper level, shifting their individual practice rather than adding to their burden of procedure.
Will objective evidence or human passion drive change?
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Self-improving system
During our patient journey visits we recognised that change will mean extra effort, at least in the short term, as new ways of working are adapted and adopted. Staff also highlighted the top barrier to making operating theatres more sustainable was convenience and habit. We feel it will be important for clinicians from various disciplines and levels of experience to learn from each other in a non-threatening sideways manner, not just through medical hierarchies. Individuals have to change their practice frequently to align with new procedures, guidelines and protocols, but there may also be opportunities to change based on practice sharing.
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Workshop participants gave an example of how the cardiac team already have a solution to one of the top ten pain points identified by operating theatre staff; the use of large plastic bags to transport used laryngoscopes to TSSU. Staff were already sharing changes in practice from the first to second workshop; an anaesthetic trainee had started reloading syringes instead of drawing up individually to cut down on waste. In any change movement here will always be early adopters on one end and laggards on the other. The question becomes how to accelerate adoption. After our visit to waste management areas of the hospital, we saw just how interconnected procurement is with waste- what comes into the hospital must go out. Many of the clinicians
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we spoke to wanted to understand more about the end to end process; how products were chosen and ultimately disposed of. Widening out individuals’ awareness could increase a sense of agency and responsibility amongst clinicians. Opportunities exist across the global community of practice to look outwards for lessons, practices and to share and learn from each other. We found several large, established groups on social media, for example an ODP group on Facebook with over 6,500 members which may be fruitful ground to start asking some big questions. Opportunities for individuals to pursue their specific interests will assist with maintaining momentum and increase reach. An example from best practice literature included staff
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starting a community garden which used composted hospital food waste. While a design sprint was perhaps too ambitious for this project, this approach may work in future as design-thinking matures and becomes embedded within the culture. It could be used to explore a specific waste stream challenge, involving colleagues from procurement, waste and sustainability teams.
If the Freeman becomes a path-finder, how can it ensure others are following?
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Project Challenges
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The original brief set out two overarching challenges for our team• to understand the circumstance, emerging best practice and related opportunities • to work co-creatively with time-poor people, some with entrenched views We took these challenges very seriously from the outset, designing our process around them and identifying the critical success factors that would be required to overcome themcredibility, empathy, targeted practice and demonstrable value.
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Demonstrating credibility Whilst our naivety was an asset at key stages of the project, we recognised that we needed baseline knowledge to navigate the brief and be taken seriously. We built a structured research framework early on to support this. We were fortunate to have a team member with a medical background- Hannah, a practising children’s physiotherapist. Hannah’s knowledge and experience working within the NHS helped us to rapidly pinpoint research resources and identify relevant insights within them. She also leveraged her extensive network across several continents to widen our perspective. The perioperative simulator at Northumbria also provided valuable background and context .
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Engaging time-poor stakeholders No doubt related to time scarcity, this impacted on the time to initially engage our client and setting a date for the Project B workshop. It was also impacted by our choice to use remote engagement for the design sprint (Project A) with clinicians who do not regularly access computers at work. These challenges were overcome by using our time effectively to build knowledge, explore best practices and plan for the workshop, which was delivered ‘in a box’ format at the end of the project. We also used expert ‘proxies’ to expand our access, for example our visit to Lloyd Howell at the perioperative simulator at Northumbria.
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Co-creating for beginners Recognising that perioperative staff were time poor and unaccustomed to design-thinking, we were careful in our choice of design methods and exercises and flexible in our practice. For example, providing paper-based alternatives in parallel to the online survey and shifting the emphasis of the in-person workshop away from a design sprint to a less ambitious approach that was more suited to ‘design-thinking beginners’.
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Understanding our value From our initial interrogation of the brief, we recognised we had to shift our paradigm about the value we were able to bring as innovators and designers. For example, our group included a product designer, Kai; researching and designing a change in circumstance rather than a tangible product required him to translate his design skills to an unfamiliar plane. Added to this, we were operating at a bit of a distance as we were not directly engaged in any of the dynamic changes that our work was influencing. We had initially hoped that the workshop would identify one ‘big idea’ that we could prototype in the final stages of the
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project. As we built our understanding of NHS systems and specifically operating theatre protocols we realised this was unrealistic, and our focus shifted from a quantitative experiment to a qualitative intervention. Given the breadth of our brief, we saw that individuals’ perception of the problems and how they think they could and should be addressed would actually be more valuable than an evidence-based trial.
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Outcomes and Impacts
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During set-up, our group recognised the design challenge for this project was not about creating a product or service or even a concept. Rather, it was to help our clients to design a circumstance capable of accelerating and amplifying the work they were already doing. We have summarised the outcomes and impacts of our work across three categories:
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• Dynamic impacts- changes and initiatives that started during our project • Deliverables- key project artefacts and documents that we created in direct support of Dr Lawson and Dr Baxters’ mission • Recommendations- strategic recommendations at various levels of intervention
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Dynamic impacts
• Key Stakeholders engaged- specifically the manager of the Operating Department Practitioners who took a leadership role within the workshop and debrief • Seeding design-thinking- modelling interactive exercises and ideation to 15 team members during the half day June workshop • Placement of bins- team looking into the ergonomics of waste stream placement in key areas, based on best practice insights • Staffroom cups and cutlery- plan in place to replace disposable items • ODP Degree Programme at Northumbria- introduction made to Lloyd Howell, Pro-
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gramme Leader, Dip HE Operating Department Practice regarding a collaboration to include a sustainability module within the new curriculum • Departmental participation- engaging clinicians across the Department in an audit day Infographic Feedback session with 56 completing a feedback survey about the patient journey. Voting for preferred engagement methods pointed clearly at the desire for a Departmental Sustainability Plan and further design-thinking based training • Pharmacology introduction- introduction made to Professor Justin Perry regarding pharmacological waste and plastic recycling • Skills transfer- sharing our methods and approaches with Drs Lawson and Baxter
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Deliverables
• Research Briefs- summary of initial best practice desk research across four topics- utilities, medication, waste segregation and overage • Departmental Plan- Transformation Map looking outwards across the next 3 years at research, rethink, reduce, reuse and recycle initiatives based on the outputs of the June workshop • Top Ten Patient Journey Pain Points- ranking of the sustainability pain points, initially identified at the June workshop and validated during our surgical visit, based on feedback by 56 team members along with data on how they viewed the problem and solution opportunities
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• Project B in a Box- pre-work for a session with paediatric cardiothoracic anaesthetic team to look at leaning the central line kits currently in use • Primary Evidence- original outputs from June workshop and July audit day along with documented capture of individuals’ responses • Final Presentation- slides and video recording from the final project presentation including key project insights and timeline • Client Report- this document
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Recommendations
Individual • consider succession strategies, building capacity within the Department to enable your whole agenda • consider how to achieve a mandate for the Transformation Map to make it the Department’s plan, refined and adapted over time • incorporate design-thinking into internal training and workshops to encourage a self-improving system
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Department • maintain ongoing communications leading up to the October Audit Day, recognising and including the early adopters • addressing the top pain points within your Departmental plan, perhaps through working groups to audit and explore chosen projects • don’t assume knowledge- people want the why, the how and the what. Perhaps start with tours to waste management areas to help people visualise scale
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Trust • widen your influence across the Trust into surgical, intensive care, maternity and A&E where you are already interconnected • consider how you can audit and share best practice across department and sites- maintaining ‘fresh eyes’ between formal waste and sustainability audits Region • alongside work on sustainability element of ODP degree at Northumbria, create a community of practice that enables the next generation of practitioners to support each other
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by sharing knowledge and practice • work across the Region’s 8 Trusts to prepare them to receive the new trainees Influencers • decide what you want to be famous for on the National/Global stage • work with design communities and key stakeholders across Universities, Industry, Professions, NHS and Governments to progress one area that will have national and international reach- e.g. via an Open Design Challenge
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Patient journey
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Conclusion
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While we have focused on unpicking the complexity within the perioperative environment and how it relates to patients, individual clinicians, teams, society and business, it may be that these esoteric questions are somewhat irrelevant to the solution. We feel that, just like societal changes that are currently unfolding, making operating theatres more sustainable will ultimately come from a critical mass of individuals wanting it. Our project helped to provoke conversations, build awareness and engage clinicians, and we hope that our activity was in some way a catalyst to accelerate the team at The Freeman Hospital towards that critical mass.
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The data we gathered gives a useful snapshot of the appetite for change. The roadmap gives direction for a more strategic journey. The design-thinking approaches certainly caught people’s attention and could be leveraged to build further momentum. However, we wonder if the missing ingredient in this situation is pressure from outside the system. The successful tiger bag initiative in the Trust was a response to an external circumstance, the HES closure, that forced rapid change with very impressive results. If a documentary was released tomorrow spotlighting what happens in operating theatres while patients are asleep, would wider public scrutiny and awareness bring positive urgency?
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References BABU, A. M., DALENBERG, K. A., GOODSELL, B. G., HOLLOWAY, M. A., BELAU, J. M. & LINK, J. M. 2018. Greening the Operating Room: Results of a Scalable Initiative to Reduce Waste and Recover Supply Costs. Neurosurgery. CHARLESWORTH, M. & SWINTON, F. 2017. Anaesthetic gases, climate change, and sustainable practice. The Lancet Planetary Health, 1, e216-e217. COSTELLO, A., ABBAS, M., ALLEN, A., BALL, S., BELL, S., BELLAMY, R., FRIEL, S., GROCE, N., JOHNSON, A., KETT, M., LEE, M., LEVY, C., MASLIN, M., MCCOY, D., MCGUIRE, B., MONTGOMERY, H., NAPIER, D., PAGEL, C., PATEL, J., DE OLIVEIRA, J. A. P., REDCLIFT, N., REES, H., ROGGER, D., SCOTT, J., STEPHENSON, J., TWIGG, J., WOLFF, J. & PATTERSON, C. 2009. Managing the health effects of climate change: and University College London Institute for Global Health Commission. The Lancet, 373, 1693-1733. DORST, K. 2015. Frame innovation: Create new thinking by design, MIT Press. 76
GRAY, D. 2010. Gamestorming : a playbook for innovators, rulebreakers, and changemakers, Sebastopol : O’Reilly. KNAPP, J. 2016. Sprint : how to solve big problems and test new ideas in just five days, London, London : Bantam Press. WYSSUSEK, K. H., KEYS, M. T. & VAN ZUNDERT, A. A. J. 2019. Operating room greening initiatives – the old, the new, and the way forward: A narrative review. London, England. https://www.who.int/globalchange/en/ http://www.newcastle-hospitals.org.uk/downloads/About%20us%20pages/Sustainability_Strategy.pdf
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