Safer Surgery part 29 pot

In research terms, future work might usefully explore the effect of different styles of communication on patient anxiety, patient satisfaction, anaesthetic team performance and markers o

knowledge of anaesthetic practice Expertise in anaesthesia, as in other fields

of practice, rests on the successful relationship between these different forms of knowledge There is ‘explicit’ knowledge, which is capable of being written down, codified and communicated in textbooks and journals and set out in examination syllabuses There is also ‘tacit’ knowledge, defined as ‘knowledge that has not been (and perhaps cannot be) formulated explicitly and therefore cannot be stored or transferred entirely by impersonal means’ (MacKenzie and Spinardi

1995, p 45) It is typically acquired via demonstration followed by practice Our work has begun to unravel the relationship between formal knowledge and the knowledge born of experience in expert anaesthetic practice Formal training in communication skills is to be welcomed but we would suggest that a substantial amount of teaching and learning of these skills goes on almost unrecognized during the kinds of interactions we have documented The danger of course is that if safe, effective care depends on the understanding of informal, idiosyncratic procedures and communicative devices, then staff who are not familiar with them pose a threat These may include locum and agency staff and those from overseas

or otherwise different working cultures

There does not seem to be a great deal in the research literature on how relationships between members of the interprofessional team are negotiated In the context of handovers, there is a substantial body of research on nurse-to-nurse handovers (Kerr 2002, Manias and Street 2000, Sherlock 1995), and some recent interest in handovers between doctors (Horn et al 2004, Solet et al 2005), but little work exploring interprofessional handover Our data suggest that nurses may sometimes be manoeuvred into taking the responsibility for setting the boundaries

of doctors’ safe practice – for instance in saying when they consider the anaesthetist can safely leave the patient and return to the operating theatre – and this may prevent them from effectively voicing concerns about safety Paradoxically, they do appear to influence medical practice, though not in the explicit fashion one would expect in a fully developed ‘safety culture’, but instead in variable, informal, and less visible ways Handovers provide an opportunity to check progress and review care Manias and Street (2000) have suggested that nurse-to-nurse handovers (observed in an intensive care unit) act to maintain conformity of practice, as a nurse’s work during the previous shift is under scrutiny by the colleague relieving her or him Typically, intraoperative problems were underplayed in the handovers

we observed This may simply be because few of them lead to problems in the recovery room, but we suggest that anaesthetists’ practice may be similarly exposed to the recovery nurses’ subtle and implicit judgement of what constitutes

an acceptable clinical standard Whatever the circumstances, the handover process must still be conducted to the satisfaction of both parties, and take place in such

a way that neither party ‘loses face’ so that future encounters are not jeopardized (Goffman 1967) One characteristic of safety-sensitive organizations is that everyone, no matter how junior they are, feels free to voice concerns about safety (Sexton et al 2000, Smith et al 2006b) In the context of anaesthetic practice this has to be done using coded language and without confrontation This informal,

Teams, Talk and Transitions 255

implicit approach goes against the standardized approaches to handover in safety critical industries (Arora and Johnson 2006, Patterson et al 2004)

Conclusion

Approaches to improving care relying on protocol and standardization are widely promoted as ways of enhancing patient safety We argue that, unless the tacit and implicit cultural factors underlying interprofessional working and communication

in the operating theatre are taken into account, such approaches will not achieve their potential In research terms, future work might usefully explore the effect

of different styles of communication on patient anxiety, patient satisfaction, anaesthetic team performance and markers of patient safety

Key to extended Transcript extracts

ODP Operating department assistant

LM/LMA Laryngeal mask airway (airway management device) PCA Patient-controlled analgesia machine

Names, where given, have been changed

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PART III Observation of Theatre Teams

Chapter 16

An Empiric Study of Surgical Team Behaviours, Patient Outcomes, and a Programme Based on its Results

Eric Thomas, Karen Mazzocco, Suzanne Graham, Diana Petitti, Kenneth Fong, Doug Bonacum, John Brookey, Robert Lasky and Bryan Sexton

introduction

As one of five principles for creating safe systems of healthcare delivery, the Institute of Medicine (IOM) report on medical error (Kohn et al 2000) concluded that healthcare organizations need to ‘promote effective team functioning.’ Their recommendation for promoting team behaviour was based primarily upon qualitative research methodologies and approaches such as root cause analyses In the airline industry, research linking effective team functioning to flight safety led to specific training in teamwork that was subsequently associated with improvements

in safety Healthcare settings involving high risk of harm such as labour and delivery (Sexton et al 2006b), critical care (Pronovost et al forthcoming) and especially surgery (Makary et al 2006a, Sexton et al 2006c) share many of the same fundamental elements of the airline industry, where people are working with other people in a high-tech and high risk work environment Research suggests the need for improved teamwork and communication in neonatal intensive care (Falck

et al 2003, Halamek et al 2000, Thomas et al 2006) emergency departments (Morey et al 2002) the operating room (Carthey et al 2003, Makary et al 2006b), trauma resuscitation (Santora et al 1996, Sugrue et al 1995, Xiao et al 1996) and among residents of all disciplines (Sutcliffe et al 2004)

Nevertheless, very little quantitative research has assessed the relationship between team behaviours and outcomes in healthcare Despite a significant amount

of rhetoric around teamwork, team training and the impact of communication breakdowns, the evidence that directly links the interpersonal interactions of caregivers to the outcomes of their patients has not been well documented For example, two recent reviews concluded that no studies have shown that team training can improve teamwork and the quality of care (Baker et al 2005, Salas

et al 2006) and a cluster randomized trial of team training for labour and delivery teams did not find significant changes in process of care or outcome measures (Nielsen et al 2007) Knowledge about how to improve team behaviour appears

to be in its infancy We conducted and have published the results of study to determine whether patients of surgical teams who exhibited good teamwork had better outcomes than patients of teams with poor teamwork (Mazzocco et al 2008) We summarize this study’s methods and findings and go on to describe how the data from the study were used to develop and implement a multi-institutional programme to improve surgical teamwork

Methods

This study was conducted in the operating rooms of two medical centres and two ambulatory surgical centres affiliated with the Kaiser Foundation Health Plan in the USA It involved structured observation of personnel (surgeons, anaesthesiology providers, nurses, technicians and others) doing surgical procedures at the four sites during the period from March to August, 2005 and assessment of 30-day post-surgical outcomes (by retrospective chart review) of patients whose surgical team had been observed

Observed providers consented in writing to be observed We approached 149 physicians, registered nurses, operating room technicians and nurse anaesthetists;

19 (12.7 percent) declined to participate Provider consent was first sought after presentation of information about the project at a regular meeting of the provider group Some provider groups (surgeons, MD anaesthesiologists and Certified Registered Nurse Anaesthetists) voted at the information meeting to participate universally, although 2 of 44 of the physicians attending the informational meeting declined in spite of this group vote Seventeen of 69 (25 percent) nurses and technicians attending the informational meeting initially declined to participate

in the study but some of these providers consented to have specific procedures observed when they were asked at the time the procedure was selected Providers who did not attend the informational meetings were asked whether or not they consented to participate in having specific procedures observed but the consent rate by provider was not tracked for these individuals Patients were observed if they did not opt out of observation after being informed of the study during their pre-operative visit (29 patients opted out of the study) The study sample size of

300 surgical cases was chosen based on resource and time availability A statistical

power analysis done a priori based on the sample size showed that the study had

a power of 0.95 to detect a correlation of 0.20 or more between a rating of team behaviour on a four-point scale and rating of outcome on a five-point scale using

a two-tailed statistical test The study was reviewed and approved by the Kaiser Permanente Institutional Review Board for protection of human subjects

Observers and Training

Observers of the surgical procedures were all registered nurses Standardization of observations and calibration between observers was achieved in a training session

An Empiric Study of Surgical Team Behaviours and Patient Outcomes 263

given at the Johns Hopkins University Quality and Safety Research Group Training of four registered nurse observers included an overview of behavioural observation and peri-operative teamwork, and a series of calibration exercises whereby observers watched video clips of team behaviours, rated the frequency with which the behaviours occurred on the data collection form used in the study, and then debriefed the exercise to discuss discrepancies and verbally justify their ratings This iterative process involved observing, rating and debriefing five videos, during which time the real-time calibration level of the observers was calculated and shared with the observers using a within group measure of inter-rater agreement (RWG) (James et al 1984), requiring a 70 cut-off for acceptable agreement

Behavioural Markers

The study defined team function based on behavioural markers (Klampfer et al 2001) Behavioural markers are observable, non-technical behaviours that have been demonstrated empirically to contribute to performance in work environments, including the airline industry (Sexton et al 2000) and healthcare (Thomas et al 2004).Behavioural marker data were collected using a standard instrument adapted for this study (Thomas et al 2006)

The instrument used in this study assessed the following six behaviour domains: briefing, information sharing, inquiry, assertion, vigilance and awareness, and contingency management Operational definitions for behaviours in each domain are given in Table 16.1 (Mazzocco et al 2008) For each domain, the observer gave the surgical team a score from 0 to 4 on how often the specified behaviours related to that domain were observed A score of 0 was given if the behaviours were never observed; 1 if the behaviours were observed rarely; 2 if there were isolated examples of the behaviour; 3 if the behaviours were observed intermittently; and

4 if behaviours were observed frequently throughout the observation period For each domain, separate team scores were assigned for the induction, intra-operative and hand-off (transition to the next level of care) phases of the procedure

Selection of Procedures for Observation

Procedures were selected for observation on the morning of the surgery based on consent of all team members to be observed, compatibility with the operational needs of the surgical suite, anticipated length of the procedure and availability of the observer Each selected procedure was observed by one observer, who joined the team to begin observation when the patient was brought to the operating room Observation ended when the patient was taken out of the operating room and handed off to the next level of care