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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. [ABSTRACT FROM AUTHOR]

Objective: To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies. Summary Background Data: Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs. Methods: Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3. Results: The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach. Conclusions: Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers. [ABSTRACT FROM AUTHOR]

This study quantitatively investigates the heterogeneous nature of the structures and characteristics of real-life auto-parts supply networks, through complex network analysis of large-scale empirical data. Comprehensive data containing “who-supplies-what-to-whom” information successfully highlights the wide diversity of product characteristics, companies’ production capabilities, and also their resulting strategies. Furthermore, by using an advanced complex network analysis technique, the supply networks are projected into a different information space, generating another network that elucidates the proximities between product types and between companies’ production strategies. Analysis of this network provides profound insights into how supply network structures may emerge reflecting various factors. [ABSTRACT FROM AUTHOR]