Biomimetics applied to the Operating Theatre


So now it gets to the point where my ant farm is ticking over, and I get to make some discoveries.

Biomimetics is a dangerous science.


It offers many useful solutions to particular problems, such as how a desert chameleon wicks

moisture from its tail to its mouth.

And it offers many compelling pitfalls, such as thinking we need to flap wings in order to fly.


So the path I go down here is a thought experiment, which may be right, or it may be wrong.

It is only wholly wrong, however, if it fails to make us think.


So in terms of 20 signals which get everything done, I chose to start with the dot-point singularity of

the individual, the backbone for every organisation.

1: Nurturing their natural nature

Juniors are supported, tended and grown from the inside of the nest out.


They start in close proximity to the queen, and attain her 'smell', which is enough to make them identifiable as life members of the colony.


The robustness in creating 'identity' correlating to the colony is that every ant is nurtured, and thus becomes invested in the nest.


To give an example, and I hope she doesn't mind me using her name, just a short period of time spent with Phyllis is enough to instil a lifetime of inspiration.


So when she spends quality time with her most junior members of staff, both she and they find it invaluable and a treasured opportunity.


I believe she gets the best out of her team because she spends such time with them early, whilst she can inscribe them with her ability to listen with an open mind and instil them with her passion.


She uses the opportunity to set the cultural tone.


It is too late once they have passed through the Dreyfus 'quantum gates' of skill acquisition and have acquired seniority, because they then only need her attention to validate their authority.


Engagement is something that happens because people are willing to be engaged.


Phyllis wills that engagement and sets the cultural tone of her operating suite by establishing from the very start an intrinsic value connection.


If you have to order them to be engaged, what you get ain't engagement.

2: Progression

Progression: Seniors get the most risky assignments.

They, by their actions, provide a role model for the next generation of ants who are destined to take over their 'role'.

Traditionally, the in-charge appears at the top of the hierarchy, then the most experienced, then the stabiliser, then the advanced novice and then the novice.

This is a competency based hierarchy where ability to perform advances you to the next level.

The flip-side is that it becomes an allegiance-based hierarchy.

For the newbie, it is like walking into a room with one door, and the person who is the decision-maker is at the other end of the room, the furthest away and infinitely inaccessible.

Novices claw their way up the ranks through their ability to integrate into the social fabric of the group, and the stabiliser is effectively outcast and forms a barrier between novice and proficiency, making the team construct a crony-ist one.

You only advance when you make the right connections, and learn to ostracise the marginalised.

I have created the metaphorical construct of the L-shaped room to add value to the team, advance skill-based progression, and upset the hierarchical pattern to make talent identification and skill acquisition the more structured, strategic and apparent focus of the team.

In doing so, I have placed the experienced person between the novice and the newly competent, drawing one in by coaching from novice to advanced beginner and advancing the other by pushing their experiential learning forward to grow them from being competent to being proficient.

The stabiliser is now between the leader and the advancing potential, allowing better advocacy and better stability in the team, since the stabiliser is the mature go-between and the buffer in the team.

Thus the leader has a team which grows in capacity and maturity without her excessive input, and the revised perspective gives her access to the best talents of everyone, making it more likely that EVERYONE will be accelerated in their potential, and will get the best engagement out of their

enhanced feeling of intrinsic value and esteem.

Obstacles to inclusion are removed and the unique capacities of all are being strategically utilised to the max.

Everyone is coached to coach.

Of course, advancing competency is one thing. Advancing maturity is another.

One thing that worries me in terms of 'teams' is the sociopathic member who is harmful to performance and skill-based learning and thus erodes skill acquisition and progression.

Until recently, I assumed that the opposite to 'sociopathic' was 'benevolence'.

However, I now see benevolence as merely a midpoint on a maturity scale.

Benevolence is, in fact, nothing more than neutral.

Doing no harm.

I now take the scale one step further, and consider a quality I call 'pro-evolence':

Potentiating the individual and thus the team.

Now it is not about 'doing no harm'.

It is about actively advocating on each individual's behalf to potentiate their capacity.

Different. Pro-active. Naturally nurturing. Better.

3: Responsive Collaboration
4: Roster Strategically

A champion team beats a team of champions.


It is the best collaborative, persistent and flexible 'team' despite apparent individual differences in capacity, that gets the best results, not the aggregated collective of 'best individuals'.


One day when Haz and I were taking rubbish to the tip, we got into a discussion on how he builds a Pokemon team.


I asked him, "How do you go about building a strong team?"

It seems the secret is in diversity and complementary strengths and weaknesses


He was like..."well, the most important person in the team is not the most experienced person....


it is the one with the most POTENTIAL.


And sometimes you get stuck on a level, and you just have tolearn to grind.


That is, you have to work hard for not much apparent reward to level-up, using the experienced players to increase the capabilities of all your 'best potential' team players, and sometimes that takes just investment over time."


"And learning to grow and flex your collective well-balanced musculature because that is what 'muscle memory' is, and what the situation requires."


And there you have it.


Haz's Pokemon teams are legendary, and you have it from the horse's mouth.


Similarly, when it comes to ideas, the best ideas expose themselves to collaboration.


I know I am NOT the bastion of all good ideas.


I have always found that 'letting go' and exposing my ideas to other people for their consideration AND input strengthens it immeasurably. 


And increases ownership of the final result.


You want a winning idea?


Collaborate. It can be frightening, but the rewards are worth it.

Or, to put it another way:

Why I don't play chess any more.


I used to like chess.

And I used to think I was not too bad at it, in an ordinary goodness sort of a way.


But then I bought a computerised travel chess set, and all was still well. 

I beat it every now and again. 


But then I made the mistake of changing the batteries.


Now I have to turn the thing down to 'stupid' to be able to win, and even then it's a struggle. And there's no fun in beating 'Stupid'!


Recently I read in a science magazine that scientists have programmed a computer to play poker. They set it to 'learn' mode, and within two months, it had played a billion billion games of poker; more games than have ever been played by the entirety of humanity. ever.


And in that time, it virtually 'solved' the problem of poker.


So if computers can do that, what does it mean for rostering?


It means that my one dimensional thinking sucks when an adequately programmed computer could produce something much more strategic, taking into account skill mix, good work combinations, fatigue mitigation, personal preferences and the likelihood of everyone succumbing to the after-effects of the winter chill.


It doesn't mean that I should not still do the rosters.

It DOES mean that I should have a damned good think about what I am trying to achieve and the multiple permutations possible before I pin it on the board!


Making everyone happy all of the time?




But if I need to screw someone over, I'm going to think in terms of inducement.

What's in it for them, as well as WIIFM!


Because the only reason I'm screwing them over, is because I suck at Rosters.

5: Optimise Psychomotor Performance
6: Human Factor Ergonomics & Systems of Work

People can only do their best when they ARE at their best.


Bodies and brains perform at peak capacity when they are rested, fed and not overloaded.


Similarly, emotions work best when they have opportunities for de-escalation, processing and debriefing.


It's not too hard to figure out, is it?


Expecting too much from too few leads you closer to the ever-present risk horizon.


I know Winston Churchill once said:


"Never have so many owed so much to so few"


But we wouldn't want to make it an every day sort of thing, now, would we.

We do what we do because that's what we do.


But sometimes it takes a bricklayer to point out to us what we should have been able to see all along.


Twists, turns, reaching, stretching, people getting in the road, flow, flux, futility.


If it was a ballet, the review would read:


"They filled in the alloted time, and I sort of got the story-line, but the choreography was a DISASTER!"


As my teachers used to write on my school reports:


"Could do better."


Except for my English teacher, who wrote:


"I don't think he CAN do any better."

7: Allocate, then don't interfere
8: Monitor Resource Boundaries and negative feedback loops

One of the central precepts of 'High Performance Teams' is trust.


And this is where you get to trust:


That every team member is maximally engaged in their work and getting things done to the limits of their ability.


Once you've given them a job, an operation to do, a list to perform, get out of their way and let them get on with it.


Distraction only makes the assignment more difficult.


And then, if you want a status update, or if you have further instructions, communicate as efficiently as you can with the one person who can navigate the team, the situation, and your interposition:


The team leader.




Managers often bemoan engagement.


But it is important to differentiate:


Despite the fact that our own theatre complex has a statistical 9% engagement, when I walk around, I see all the nurses maximally engaged in their work, and putting 110% effort into what they are doing.




Simply because it is asked of them;

And because they care.

Even if they try hard not to show it.


If you want to interfere constructively, try this:


When they come to you,

Actively Listen.


Sounds simple.

Is hard

Is the biggest compliment you can ever show them.

And the reward is that they will engage with you because you have shown them that simple respect.


Tactical redundancy for the purpose of reinforcement?

Napoleon built a nation on it.


Twenty distinct behaviour-producing pheromone signals?

I can almost smell them now!!!!



Ten Theatres;


Bed access;



There is a lot going on.

Controlling it is a lot like standing in the middle of a cyclone and trying to howl.


The hardest part is visualising what is going on, where, and identifying where the leverage points and the limits are.


Once you can see that, you can make the cyclone sit up and dance.


It may not LIKE sitting up and dancing, but that is the choice you make.


Negative feedback loops are not new.


They are an essential part of most natural systems.


Every now and then you see a positive feedback loop.




A run-away system.


Health is like that.


We are very clever. We can do more and more with sicker and sicker patients, and because we expect to be able to do everything for everyone, we forget that there are limits.


You want sustainability?


You are going to have to do the maths.

And the maths is the easy part.


Learning what should and should not be in the equation?


Now there is a headache the not-so-brave will NOT want to solve!



9: Resource or Restrain Workload

Things got out of control?


Don't worry. They always do.


Limited resources, overwhelming workload.


If we didn't like to be challenged, we wouldn't be here!


However, we have a choice.


Most times.




Continue on and pretend that the consequences are not serious enough to warrant our serious consideration. Who cares if she has been in the Cardiac Theatre for almost 24 hours solid? She gets paid!




Restrain the workload. What decision matrix should I apply, what decision should I make, and when is the most effective time to make it?


Then, next day: Review! What happened to make things spin out of control? Where were the critical decision making points, what were the end results and how can we do better?


Sounds a lot like skill acquisition LEARNING!






The hardest one in Health: Resource the runaway workload.


Systems redundancy?

Ability to flux?

Contingency plans?

Practiced contingency plans?


And the hardest: 

Making sure that you haven't used up all your contingencies to manage SYSTEMS of WORK.


Expecting the unexpected is a lot more difficult when you can't even manage to expect the expected!


A choice?



Who would have thought!

10: Advocate and Communicate (including listen!)

tCommunication is what ants do well.


It is a chain.


One ant links to the other, and passes the message.


We do it better.


We have communication trees.


So rather than the command "Danger! Echidna!" being communicated by every ant running in CIRCLES to communicate the message to each other individual ant they meet, we get to spread a message much more effectively.


The Charge Nurse passes the message to the team leader.


The team leader passes the message to the many people and groups in her team.


Better, the chain also goes the other way:


Message goes to the team leader.


Team leader advocates to the Charge Nurse.


Leaders are communicated THROUGH, not communicated TO.


And so a single connectivity point makes the communication structurally efficient, and saves a lot of running around in circles.


Equally important is that each node must ADVOCATE on behalf of those they represent.


There is no getting around the fact that the Charge Nurse has to advocate up to executive as well as advocate down to Team Leaders.


Unfortunately, nurses find it hard to do so on behalf of other nurses, despite the fact that they have ALL the skills to passionately, persuasively and assertively do so on behalf of their patients.


Why? Historical layers of culture. We choose who it is safe to listen to.


Advocacy is not about avoidance.


It is about creating 'Safe' for ALL.


We want GREAT outcomes.


We shouldn't be afraid to chase them down.


Even if it means stopping for long enough to engage, communicate.....

and listen. 

Below Ten Thousand

An international collaboration

Empowering clinicians in safety culture