Adapting BTT to other Clinical Areas

BTT in other areas.JPG

Recently we were asked:

"Since other areas are now seeing the possibilities of 'Below Ten Thousand', and wanting to adopt

it into their own clinical environments, how do they it?"

The answer was "Hopefully not the way we did it."

Ground-up culture change is hard. It is better to have managers and educators, all those

empowering structures on board, so that the process is refined, reinforced and validated each step

along the way.

That makes it simpler, more powerful, and you get the best of all the opportunities inherent in

making a positive change: enthusiasm, excitement, direction and leadership.

'Below Ten Thousand' is a Situational Awareness concept above all else.

Despite being invented in the operating theatre, we identified early on that it may have a more

universal appeal.

This is because noise and distractions are not endemic only within the operating theatres.

Also, the desire to perform at a high level as a team transcends all healthcare areas.


The first step in introducing Below Ten Thousand into your clinical area is to adapt it to your needs:

When looking at 'Below Ten Thousand' in terms of the opportunities it affords you in your own

particular location, we would suggest a fairly logical pathway delivered in a slightly more radical


First, understand exactly what 'Below Ten Thousand' is:

Noise and distraction abatement;

Situational awareness;

Team behaviours.

Second, think in terms of your own particular context.

You can look to moments where the characteristics of 'Below Ten Thousand' may be useful.

As you identify these moments, take a look at each role within the moment, the events that take

place, and the situational awareness outcomes you seek.

Then adapt 'Below Ten Thousand' as a cultural initiative to let you achieve in that moment the

quality and safety outcome you desire.

So for certain members of our operating team, it was the noise at induction of anaesthesia, and at


For ICU, the moment they decided to focus on was the handover period upon the moment of the

arrival of their post-operative Cardiac Surgery patient.

Once the Adaption process has been undertaken, you are ready to Adopt Below Ten Thousand.

Note: We don't tell you what to do.

You know your area better than we do.

And we not only ask, but we insist, that you modify our original concept to make it do what you

want it to do.

It's no use otherwise, and this way you have ownership of your strategy.

Even better, the enthusiasm generated around your 'ownership' will help it work.


Now that you know what you want to do, the next step is to adopt the idea into clinical practice.

For this, you need to carry the message to your troops and empower them to use it.

You need promotional material and champions.

Our promotional material was stuff we made up ourselves, and you are quite welcome to use it, or

you might want to make up some of your own.

If you do, send it to us if you feel like it, and we will add it to our resources page and reference it to

you. By doing so, others can see 'progress in action', and can benefit from being part of the


In our workplace, we went for a guerrilla marketing style campaign.

Doing so created entertainment and engagement on a different level to that which people were

used to in terms of educational policy, which was invaluable in getting people to talk and

subconsciously spread the message (we could call it 'network theory' if we wanted to sound really


Then we needed to enact BTT, which means getting people to practice it.

Because practicing something builds 'muscle memory', (latent skill), and using it helps to ingrain

the new skill into a habit.

We used Tim Tams as bait.

Each team which used 'Below Ten Thousand' got a packet of Tim Tams.

A packet of Tim Tams takes a team to eat, so everyone got the reward and could sit in the tea room

proudly munching away, inviting jealousy and therefore subconsciously spreading the message

once again (Look who's team got a Tim Tam!).

Enacting 'Below Ten Thousand' also means empowering the right people to practice leadership


For us, there were key moments such as induction of anaesthesia, surgical count, time-out and

extubation, and if the ANUM, the dedicated leader in the room identified noise at those times, he or

she could step up, call the BTT, and thus practice benevolent leadership as a skill.


The final step is embedding.

Embedding means making sure the concept is sustainable over time.

This means, in most cases, Policy.

And a continual review process.

It also means making sure the message gets to new people as they arrive to commence work in

the area.

And positively reinforcing it as a desired behaviour.

This includes focusing on team behaviour parameters in performance management processes, be they formal or informal.


And now that you are pretty much done, you are in a rather fortunate position:

You are one step closer to being a high performance team;

Acknowledge and celebrate your win, somewhere, somehow;

Then get ready to repeat your learned success by chasing down your NEXT quality and safety


Good luck!

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