What is a pickup basketball game? It involves players of varying skill levels forming a team on the fly and hoping to win the game. Often the players have some or no familiarity with each other or their skill levels. What is the analogy to surgery? Often, surgeons walk into an operating room and have to form teams with unfamiliar or unknown personnel, and teams may not be consistent. However, the desired outcome — safe surgery, minimizing risk or harm to the patient — is much more critical than a game of basketball. The onus is on the team to come together and provide safe surgical care.
The importance of surgical checklists and timeouts to enhance patient safety has been written about in books and scientific journals. Organizations such as the WHO have recommended adoption of standardized perioperative checklists. But studies have also shown that merely mandating adoption of checklists does not lead to enhanced patient safety or reduction in surgical error. Our institution, unfortunately, fell into this category — despite early adoption and near-universal compliance with a mandated checklist, surgical errors continued to happen. Root cause analyses of these incidents revealed two common themes — poor communication and teamwork in the OR.
Outside of surgery, teams of health care providers around a disease state are common — such as breast cancer, asthma, or diabetes. In such circumstances, there is a more predictable or understood clinical scenario or outcomes and providers form a team to address or prevent them. However, team building in the OR poses a unique set of challenges. There is no standard patient with common sets of diseases, yet a well functioning, empowered team that is focused on delivering safe, surgical care is paramount, and, as outlined above, the team may not have familiar members.
The core of any high functioning team is trust and communication. We have addressed this by focusing on four behaviors:
- Engage the team.
- Humanize the patient.
- Empower the team.
- Create a safety focus.
We introduced the entire surgical staff to these concepts at a safety summit in 2013. We have used our simulation center to train teams of OR personnel — surgeons, anesthesiologists, nurses and techs. Techniques to address difficult scenarios in the OR without escalation and maintaining respect, communication skills to engage the team and creating a safety focus and humanizing the patient are worked on bimonthly. We do not script the language in an effort to make the team building more natural, and make it consistent with the surgeon’s and team members’ native personalities. Additionally personnel during each training session are from different clinical backgrounds (e.g., a transplant surgeon, a circulating nurse from ophthalmology and a technician from orthopedics, for example); we feel enhances team-building skills.
Since adopting this training program focused on team behavior, our surgical safety has been enhanced (no critical adverse or never events for about a year), and our safety culture has been improved. We have also noted an improvement in our surgical site infection rates but these findings are preliminary. We feel these measures are sustainable and easy for any organization to adopt. Our interventions have made the checklist process more effective and we hope to build on our success to date with this strategy.
Giri Venkatraman is associate quality officer, division of quality, safety, and value, section of otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.