Safer Surgery part 31 ppsx

At Kaiser Permanente we are implementing a comprehensive surgical safety programme described below which is an example of how these two lines of research can inform the development and i

recommended defined triggers that mandate communication with an attending surgeon; structured hand-offs and transfer protocols; and standard use of read-backs Our work complements these studies by specifying the intra-operative team behaviours (briefings, information sharing, inquiry and vigilance) that should be useful in preventing negative outcomes Finally, a recent study reported a significant correlation between subjective ratings of teamwork with postoperative morbidity (Davenport et al 2007), a finding which lends more support to our conclusions

Implications and Future Directions

Development of interventions based on changing teamwork behaviour and their evaluation is a logical next step for research in this arena Our study provides general support for development of team training programmes for surgical teams Such programmes should be rigorously tested because they will require significant investments of time and money; some studies in other areas have found only marginal benefit for patients (Nielsen et al 2007)

We believe that there are two broad lines of research that should be pursued and that will ultimately converge in the form of effective team training programmes First, research should focus on implementation and evaluation of training programmes There is already a large body of knowledge that can inform the content of such programmes (Baker et al 2005, Clancy and Tornberg 2007) These may focus on relatively specific processes of care, like neonatal resuscitation (Thomas et al 2006); they may try to address multiple processes within a site of care like labour and delivery (Nielsen et al 2007); or there are training programmes (like TeamSTEPPS) which may be applicable across many locations, processes and disciplines (Clancy and Tornberg 2007) However, given the inconclusive results of initial evaluations of such programmes, it is clear that there is a need for a second line of research which asks more fundamental questions about the relationships between specific team behaviours and specific tasks carried out by providers (Undre et al 2006, Yule et al 2006) Such knowledge should result in training that teaches behaviours which are more likely to improve quality This would include studies that draw upon the ‘basic sciences’ of safety (Brennan et al 2005) For example, human factors experts can perform task analyses to determine exactly which behaviours might be most useful for specific tasks, and cognitive psychologists can help link teamwork to prevention of mental slips and mistakes

At Kaiser Permanente we are implementing a comprehensive surgical safety programme (described below) which is an example of how these two lines of research can inform the development and implementation of team training programmes At the University of Texas we have developed a team training curriculum for the Neonatal Resuscitation Program which increases the frequency

of team behaviours during simulated resuscitations (Thomas et al 2007)

The Kaiser programme was a direct outgrowth of the research described above and is described in more detail below

From Science to execution – implementation of a highly Reliable Surgical Team Programme at Kaiser Permanente

The primary driver of the research described above was to develop strategies to continually improve the safety of the care that we provide to our patients The secondary driver was to answer the question of whether or not the communication and teamwork demonstrated by the surgical team had an impact on surgical outcomes Prior to performing this research our patient safety strategy for the peri-operative area had focused on education and training related to human factors, communication and teamwork and implementation of structured pre-operative briefings Based on this work, a pilot project was performed in the operating rooms

of one of our Southern California hospitals The overarching purpose of the project was to improve safety by enhancing teamwork, collaboration and communication among team members in the peri-operative setting

The pilot consisted of providing education and training in human factors and communication and teamwork to the entire peri-operative staff Following the educational programme, a steering committee was formed and a structured pre-operative briefing (including script) was developed The hospital used four different indicators of safety culture to measure the programme’s success: occurrence of wrong site/wrong procedures, attitudinal survey data, near-miss reporting and turnover data Several areas of significant improvement were noted The most notable result was reducing verification injuries to zero within a year; additionally, there was a 19 percent increase in employee satisfaction and a 16 percent decrease

in nurse turnover; and the safety climate in the operating room increased from

‘good’ to ‘outstanding’ after implementation of the pilot study Although this pilot programme was successful and has sustained itself as an ongoing programme

at the one hospital, the efforts to spread the programme to other hospitals were not successful One of the major concerns expressed by leadership and clinicians was that the data did not demonstrate that the effort put into communication and teamwork and pre-operative briefings made a difference to surgical outcomes The evidence base provided by the Highly Reliable Surgical Team (HRST) research project discussed above, coupled with the outcomes of the pilot programme, provided us with a much stronger case for requiring a highly reliable surgical programme in all of our hospitals The HRST research project also had

a qualitative component (narratives of observations provided by the observers) that allowed us to provide leadership and clinicians with information related to potential threats to patient safety that existed within our system The primary

‘threats’ included: interruptions and distractions; inadequate briefing and/or time out; incomplete or no transfer of information during transfer of patient, shift change

or break; equipment and material problems including malfunctioning equipment, potential operator error and incomplete or wrong supplies and equipment for the task at hand; lack of respectful interactions among surgical team members; and interdepartmental coordination and communication challenges These qualitative data enriched the quantitative findings, and armed with these data, we were able

to convince both leadership and clinicians that improved communication and teamwork including pre-operative briefings would not only improve attitudes but also improve the safety of the surgical care that we provide to our patients When the data were presented to executive and physician leadership, the consensus was that the combination of the evidence presented a compelling argument for a mandated programme

The information from the research was presented at our initial expert surgical groups that were charged with developing the programme, clinicians who had previously been sceptical and concerned that strategies such as pre-operative briefings would do nothing but slow down procedure start time began to discuss how, in fact, interventions could potentially end up saving time

Once the pilots were initiated we began to receive ‘stories’ from clinicians

An early story shared by a surgeon at a meeting of surgical leaders related to how, during a briefing, it was discovered that the team did not have all the equipment that was needed for the procedure The surgeon indicated that in the past, not having the correct equipment was in many cases not discovered until a point when the operation was underway The surgeon went on to say that when missing equipment was not identified early on this not only led to delays in the procedure and increased operating time but also potentially impacted the safety

of the patient

In 2007, in conjunction with peri-operative leadership, the Northern California regional leadership required all 19 of the Northern California medical centres to initiate the Highly Reliable Surgical Team Program Expert groups consisting of surgeons, anaesthesiologists and nurse managers met to develop the programme and in the spring of 2007 a regional surgical summit was held Peri-operative teams from each medical centre attended The summit opened with sharing of the results from the research project along with the current state of surgical safety in Northern California (e.g., days in-between surgical events, our medical malpractice experience) Education and training during the summit related to human factors, communication and teamwork, and the importance of the highly reliable surgical team programme Participants were provided with all of the tools necessary to initiate the programme at their individual medical centres The expectations for

2007 required that each hospital develop and implement the infrastructure and processes necessary to support highly reliable surgical teams The four requirements for each medical centre were:

Develop and implement a surgical safety committee that would lead the programme

Implement scripted peri-operative briefings where all members of the team had a speaking role A whiteboard with all team members’ names was also required

Educate and train the entire peri-operative team in human factors/ communication and teamwork – every medical centre closed the operating rooms for 2–3 hours for this training The training included

1

2

3

presenting national, regional, and medical centre specific data related to surgical safety and set the ‘burning platform’ as to why this programme was important Additionally, experts in the area of communication and teamwork discussed the importance and fundamentals of human factors, communication, and teamwork The session ended with planning for how

to implement the programme in every operating room for every specialty Additional elements such as debriefings and ‘glitch books’ were discussed

as potential additional programme elements

Institute regular observation audits to ensure that the briefings were taking place and all required elements were included One of the lessons from our research was the importance of observation by someone not directly involved with the procedure Often, behaviours in the OR are the reality

in which the surgical team works and, digressing from the appropriate or required way of doing things is not recognized By doing the observational audits and reviewing these with the teams and OR leadership, we are able to point out how the teams can improve the communication and teamwork The success of the surgical summit exceeded our expectations Teams remained after the summit to work on plans for implementation in their medical centres Formal evaluations indicated that 100 percent of the participants found the programme had met its goals and 96 percent felt that the programme met expectations More convincing evaluations, however, were the anecdotal comments noting that the summit had moved people to take further action to improve surgical safety Completion of the process requirements outlined above was monitored and quarterly reports were submitted to the medical centre executive committee and regional leadership All medical centres met the requirement that these four elements be in place by the end of 2007 In addition to the above process measures

an outcome measure of days in-between verification injuries was also utilized The days in-between events related to verification has substantially increased since the inception of the programme In the latter part of 2007, the requirements were further refined to make the briefings pre-induction, thereby including the patient in the process (when appropriate) The Surgical Care Improvement Project safety checks (Bratzler and Hunt 2006) were added to the briefing checklist to enhance reliable protection from infection, Venous Thromboembolism (VTE) and Miocardial Infarction (MI)

Building on thesuccesses achieved in 2007, the programme was expanded in

2008 Each one of the elements required the input from a multidisciplinary expert team whose job was to research current literature, define recommended practices, perform small test of change and develop tools/playbooks to guide the change in practice The additional elements included:

Refinement and monitoring of the surgical briefing and debriefing to build communication, teamwork and eliminate verification events – this included use of the script; team engagement; and leadership of the surgeon

4

1

Administration of the Safety Attitude Questionnaires (Sexton et al 2006a)

to measure the culture of safety and teamwork at each medical centre Continued monitoring of the Surgical Care Improvement Project (SCIP) bundles

Implementation of peri-operative practice changes that will eliminate retained foreign bodies (RFO)

Implementation of a briefing protocol specific to intraocular lens implants (IOL) to prevent wrong lens implants in all settings where cataracts are performed Establish a protocol to eliminate wrong side thoracentesis procedures in all settings

Provide a second surgical summit in the fall to celebrate successes and inspire the operative teams to continue to sustain the programme

In conclusion, the quantitative and qualitative data from our research project were critical to get buy-in and inform the design and implementation of our Highly Reliable Surgical Team programme The key contributors to the success of this programme have been:

Immediate utilization of the Highly Reliable Surgical Team research to develop and implement the programme in all operating rooms in the 19 hospitals of the Northern California Region of Kaiser Permanente

Strong executive and physician leadership

Provision of tools and project management to the medical centres

Independent observational audits of the surgical briefing by staff who are not members of the peri-operative team

Regular dialogue and communication with the peri-operative nursing directors and managers

Development of a surgical safety scorecard measuring compliance rate with the SCIP bundles, briefing elements of script, engagement and leadership and listing of surgical never events by facilities

Future work will expand and refine these efforts for both surgical and non-surgical teams

References

Baker, D.P., Gustafson, S., Beaubien, J.M., Salas, E and Barach, P (2005) Medical team training programs in health care Advances in patient safety:

From research to implementation In K Henriksen, J.B Battles, E.S Marks and D.I Lewin (eds) Vol 4, Programs, Tools and Products AHRQ Publication

No 05-0021-2 Rockville, MD: AHRQ

2

3

4

5

6

1

2

3

4

5

6

Bratzler, D.W and Hunt D.R (2006) The surgical infection prevention and surgical care improvement projects: National initiatives to improve outcomes

for patients having surgery Clinical Infectious Diseases 43, 3, 322–30.

Brennan, T.A., Gawande, A., Thomas, E and Studdart, D (2005) Accidental

deaths, saved lives, and improved quality New England Journal of Medicine

353, 1405–409

Carthey, J., de Leval, M.R., Wright, D.J., Farewell, V.T and Reason, J.T (2003)

Behavioral markers of surgical excellence Safety Science 41, 409–25.

Clancy, C.M and Tornberg, D.N (2007) TeamSTEPPS: Assuring optimal teamwork

in clinical settings American Journal of Medical Quality 22, 214–17.

Davenport, D.L., Henderson, W.G., Mosca, C.L., Khuri, S and Mentzer Jr, R (2007) Risk-adjusted morbidity in teaching hospital correlates with reported levels of communication and collaboration on surgical teams but not with scale

measures of teamwork climate, safety climate, or working conditions Journal

of the American College of Surgery 205(6), 778–84.

Dietrich, R and Childress, T.M (eds) (2004) Group Interaction in High Risk Environments Aldershot: Ashgate.

Eagle, K.A., Berger, P.B., Calkins, H et al (2002) ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery – executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the

1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac

Surgery) Journal of the American College of Cardiology 39, 542–53.

Falck, A.J., Escobedo, M.B., Baillargeon, J.G., Villard, L.G and Gunkel, J.H (2003) Proficiency of pediatric residents in performing neonatal endotracheal

intubation Pediatrics 112, 1242–7.

Gawande, A., Zinner, M.J., Studdert, D.M and Brennan, T.A (2003) Analysis of

errors reported by surgeons at three teaching hospitals Surgery 133, 614–21.

Greenberg, C.C., Regenbogen, S.E., Studdert, D.M., Lipsitz, S.R., Rogers, S.O., Zinner, M.J and Gawande, A.A (2007) Patterns of communication breakdowns

resulting in injury to surgical patients Journal of the American College of Surgery 204, 533–40.

Halamek, L.P., Kaegi, D.M., Gaba, D.M., Sowb, Y.A., Smith, B.C., Smith, B.E and Howard, S.K (2000) Time for a new paradigm in pediatric medical education: Teaching neonatal resuscitation in a simulated delivery room environment

Pediatrics 106, E45.

James, L.R., Demaree, P and Wolf, G (1984) Estimating within-group interrater

reliability with and without response bias Journal of Applied Psychology 69,

85–98

Klampfer, B., Flin, R., Helmreich, R.L et al (2001) Enhancing performance in

high risk environments: Recommendations for the use of behavioral markers

Presented at the Behavioural Markers Workshop sponsored by the Daimler-Benz Stiftung GIHRE-Kolleg, Swissair Training Center, Zurich, 5–6 July

Kohn, L.T., Corrigan, J.M and Donaldson, M.D (eds) (2000) To Err Is Human

Washington DC: National Academy Press

Makary, M.A., Sexton, J.B., Freischlag, J.A., Millman, E.A., Pryor, D Holzmueller,

C and Pronovost, P (2006a) Patient safety in surgery Annals of Surgery

243(5), 628–35

Makary, M.A., Sexton, J., Freischlag, J., Holzmueller, C., Millman, E., Rowen, L and Pronovost, P (2006b) Operating room teamwork among physicians and

nurses: Teamwork in the eye of the beholder Journal of the American College

of Surgery 202(5), 746–52.

Mazzocco K, Petitti, D.B., Fong, K.T et al (2008) Surgical team behaviors

and patient outcomes American Journal of Surgery [doi: 10.1016/

j.amjsurg.2008.03.002]

McDonald, J., Orlick, T and Letts, M (1995) Mental readiness in surgeons and its

links to performance excellence in surgery Journal of Pediatric Orthopedics

15(5), 691–7

Morey, J.C., Simon, R., Jay, G.D., Wears, R.L., Salisbury, M., Dukes, K.A and Berns, S.D (2002) Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results

of the MedTeams project Health Services Research 37, 1553–81.

Nielsen, P.E., Goldman, M.B., Shapiro, D.E and Sachs, B.P (2007) Effects of teamwork training on adverse outcomes and process of care in labor and delivery:

A randomized controlled trial Obstetrics and Gynecology 109, 48–55.

Pronovost, P.J et al (forthcoming) A multi-faceted intervention to reduce

catheter-related blood stream infections in Michigan intensive care units New England Journal of Medicine.

Salas, E., Wilson, K.A., Burke, C.S and Wightman, D.C (2006) Does crew resource management work? An update, an extension, and some critical needs

Human Factors 48(2), 392–412.

Santora, T.A., Trooskin, S.Z., Blank, C.A., Clarke, J.R and Schinco, M.A (1996)

Video assessment of trauma response: Adherence to ATLS protocols American Journal of Emergency Medicine 14(6), 564–9.

Sexton, J.B., Thomas, E.J and Helmreich, R.L (2000) Error, stress, and teamwork

in medicine and aviation: Cross sectional surveys British Medical Journal

320, 745–9

Sexton, J.B., Helmreich, R.L, Neilands, T.B., Rown, K., Vella, K, Boyden, J Roberts, P.R., Thomas, E.J (2006a) The Safety Attitudes Questionnaire:

Psychometric Properties, Benchmarking Data, and Emerging Research BMC Health Services Research 6, 44.

Sexton, J.B., Holzmueller, C.G., Pronovost, P.J., Thomas, E.J., McFerran, S., Nunes, J., Thompson, D.A., Knight, A.P., Penning, D.H and Fox, H.E (2006b) Variation in caregiver perceptions of teamwork climate in labor and delivery

units Journal of Perinatology 26, 463–70.

Sexton, J.B., Makary, M.A., Tersigni, A.R., Pryor, D., Hendrich, A., Thomas, E.J., Holzmueller, C.G., Knight, A.P., Wu, Y and Pronovost, P.J (2006c) Teamwork

in the operating room: Frontline perspectives among hospitals and operating

room personnel Anesthesiology 105, 877–84.

Sugrue, M., Seger, M., Kerridge, R., Sloane, D and Deane, S (1995) A prospective

study of the performance of the trauma team leader Journal of Trauma 38(1),

79–82

Sutcliffe, K.M., Lewton, E and Rosenthal, M.M (2004) Communication failures:

An insidious contributor to medical mishaps Academic Medicine 79, 186–94.

Thomas, E.J., Sexton, J.B and Helmreich, R.L (2004) Translating teamwork behaviors from aviation to healthcare: Development of behavioral markers for

neonatal resuscitation Quality and Safety in Health Care 13, S1, 57–64.

Thomas, E.J., Sexton, J.B., Lasky, R.E., Helmreich, R.L., Crandell, S and Tyson,

J (2006) Teamwork and quality during neonatal care in the delivery room

Journal of Perinatology 26, 163–9.

Thomas, E.J., Taggart, B., Crandell, S., Lasky, R.E., Williams, A.L., Love, L.J., Sexton, J.B., Tyson, J.E and Helmreich, R.L (2007) Teaching teamwork

during the neonatal resuscitation program: A randomized trial Journal of Perinatology 27, 409–14.

Undre, S., Healey, A.N., Darzi, A., Vincent, C.A (2006) Observational assessment

of surgical teamwork: A feasibility study World Journal of Surgery 30, 1774–

83

Walker, R (2002) ASA and CEPOD scoring Update in Anaesthesia [serial online]

14(5), 1-1 Available at: <http://www.nda.ox.ac.uk/wfsa/html/u14/u1405_ 01.htm> [accessed August 2006]

Xiao, Y, Hunter, W.A., Mackenzie, C.F., Jefferies, N.J and Horst, R.L (1996) Task complexity in emergency medical care and its implications for team coordination LOTAS Group Level One Trauma Anesthesia Simulation

Human Factors 38(4), 636–45.

Yule, S., Flin, R., Paterson-Brown, S., Maran, N and Rowley, D (2006)

Development of a rating system for surgeons’ non-technical skills Medical Education 40, 1098–104.

Appendix: List of Potential Complications Referred to by Data Abstractors when Reviewing Medical Records

This list was not all-inclusive – abstractors recorded additional complications as indicated Complications were grouped into outcome categories based upon the impact on subsequent care and harm to patients

Accidental puncture or laceration

Surgical burn (heat-producing equipment, chemical)

Adverse drug reaction

Wrong patient/procedure/site/side/device

1

2

3

4

Retention of foreign object.

Transfusion reaction

Pressure ulcers

Peripheral nerve damage/short-term neurological deficits

Complications of anaesthesia (anaesthetic medication error, reaction or endotracheal tube misplacement, regional anaesthetic complications, broken teeth)

Iatrogenic pneumothorax

Pneumonia

Selected post-operative infections (ICD-9 CM codes 9993 or 00662) Post-operative haemorrhage or haematoma

Post-operative pulmonary embolus or DVT (deep vein thrombosis) Post-operative DIC (disseminating intravascular coagulopathy)

Post-operative respiratory failure (acute)

Post-operative sepsis

Postoperative wound dehiscence

Post-operative fracture (excluding unrelated post-operative falls)

Post-operative physiologic/metabolic derangement

Post-operative cardiac arrest

Post-operative hemodynamic instability

Myocardial infarction

CVA

Other undesired outcome, not otherwise specified (e.g., excessive and prolonged pain, unanticipated restriction in range of motion, musculoskeletal injury)

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

Counting Silence: Complexities in the Evaluation of Team Communication

Lorelei Lingard, Sarah Whyte, Glenn Regehr and Fauzia Gardezi

Purpose

Many in the domain of surgical performance research have developed tools

to objectively evaluate team communication Our own tool has been used to describe communication failure patterns in the context of a pre-operative team briefing intervention in four urban teaching hospitals Using examples from this research programme, this chapter explores a critical problem in the objective evaluation of team communication: how do we ‘count’ silence? Because it is relatively easy to document ‘presence’ (communications that can be directly observed), our conventional approaches are not well equipped to deal with

‘absence’ (communicative silences) Yet silence abounds in the operating room, and a comprehensive accounting of team communication must grapple with the meanings of silence, including both its functional and problematic dimensions Drawing on theories of discourse and power, this chapter will describe recurrent patterns of silence in the operating room, consider the actions and relations that these silences embody and discuss their implications for sophisticated evaluation

of the communicative behaviour of operating room teams

Background

Communication has been a dominant focus in the study of operating room (OR) team performance This focus has emerged largely in response to evidence suggesting that preventable adverse events happen at unacceptably high rates in the surgical setting, and that ineffective or insufficient communication among team members is often a contributing factor (Kohn et al 2000, Helmreich 2000, Helmreich and Davies 1994, Joint Commission on Accreditation of Healthcare Organizations 2003).However, despite the general agreement that ineffective communication threatens patient safety, until recently there was little evidence regarding what specific team communication practices and attitudes compromise safety, what methods might effectively change these patterns, or how the outcomes

of such changes might be measured