Anne van Dalen

Summary and General Discussion I 261 changing the surgical approach, or requesting different instruments. 57 In Chapter 9 the importance of improving the safety culture in the OR is highlighted. Strategies aiming to improve the safety culture can be categorized into two routes; technological/managerial/engineering versus non-technical/human factors related. 64 The first relates to the higher level in an organization and the latter at the workers’ level, including job satisfaction, motivation and attitudes, all influencing safety behaviour. Both routes, however, impact the same outcomes and are likely to influence or even complement each other. 21 64 The aviation industry has reached an impeccable level of safety by using the six sigma approach. The concept of Six Sigma has originally been developed by Motorola engineers in the 1980’s, to provide greater resolution in measuring and decreasing defects. It helped to optimize operational processes. 65 This Six Sigma approach guarantees ultra-high-quality systems, in which only 3-4 defects occur per 1 million opportunities (i.e. nearly perfect). 65 66 The fundamental objective of the Six Sigma methodology is the implementation of a structured data-driven strategy, focusing on reduction of variation and process improvement. 66 To date, most safety improvement strategies in healthcare still focus on retrospective data and post-hoc error analyses to identify poor quality. Moreover, the use of technology to objectively monitor and analyse human factors affecting safety remains suboptimal, causing a knowledge gap on perioperative process optimization. The Six Sigma strategy includes five steps: define, measure, analyse, improve and control (DMAIC). 66 If we want to apply the Six Sigma strategy optimally, a continuously monitored OR, capturing natural behaviour and standard operative processes, is required. Implementation of a platform like an ORBB is an important tool to facilitate more transparency concerning error management and culture. 67 Following the DMAIC steps, safety improvement initiatives ought to involve the entire team, promoted and supported by the organization. The ORBB may be used in accordance with the Six Sigma Strategy, to support process optimization and to ultimately create a sustainable safety culture in which errors are managed responsibly. 12 50