Surgical Team Communication - Perspect Management Consulting

SURGICAL
TEAM
 COMMUNICATION


www.perspect.ca

November
26,
2008


Communica>on
 
Defini>on:
 ‐
a
process
by
which
informa>on
is
exchanged
 between
individuals
through
a
common
system
 of
symbols,
signs,
or
behavior


Outline
 Importance
of
effec>ve
communica>on
in
surgical
 teams
   Current
piPalls
in
OR
communica>on
   New
communica>on
tools
  

  SBAR
   OR
briefings
   Medical
team
training
  

Implementa>on


Preventable
medical
errors
 Ins>tute
of
Medicine’s
1999
report
“To
Err
is
 Human”
   preventable
medical
errors
result
in:

   44,000‐98,000
deaths/year
in
US
hospitals
  

Primary
root
cause
analysis
of
sen>nel
 events
  

delay
in
treatment
  

 

wrong
site
surgery
  

 

66%
‐
failure
in
communica>on





ven>lator‐related
deaths
and
injuries

  

 

>
50%
‐
breakdown
in
communica>on
between
surgical
team
members
 and
the
pa>ent
and
family


opera>ve
and
post‐op
complica>ons
  

 

84%
‐
breakdown
in
communica>on


70%

‐
communica>on
breakdown


infant
death
and
injury
during
delivery
  

72%
involved
communica>on
issues
(with
55
percent
ci>ng
 organiza>on
culture
as
a
barrier
to
effec>ve
communica>on
and
 teamwork)


Joint
Commission
on
Accredita0on
of
Healthcare
Organiza0ons.

Sen$nel
event
sta$s$cs:

Available
online
 from,
hdp://www.jointcomission.ort/Sen>nelEvents/Sen>nelEventAlert/


Teamwork
in
the
OR
  

posi>ve
aftudes
towards
teamwork
   reduced
errors
in
avia>on
and
ICUs
   increased
job
sa>sfac>on
   less
sick
>me
used
by
employees
   decreased
employee
turnover


Teamwork
in
the
OR
  

Makary
et
al.,
J
AM
Coll
Surg,
2006
   surveyed
OR
personnel
regarding
aftudes
toward


teamwork
and
collabora>on
   60
hospitals
involved
   2769
ques>onnaires
   77.1%
response
rate


Makary
MA,
Sexton
JB,
Freischlag
JA,
Holzmueller
CG,
Millman
EA,
Rowen
L,
Pronovost
PJ.

Opera>ng
Room
 Teamwork
among
Physicians
and
Nurses:
Teamwork
in
the
Eye
of
the
Beholder.

J
Am
Coll
Surg
2006;
202:
 746‐752


Sample
survey
items
  

rated
on
a
5‐point
Likert
scale
   the
physicians
and
nurses
here
work
together
as
a
well‐

coordinated
team
   I
am
frequently
unable
to
express
disagreement
with
the
 staff
physicians
here
   important
issues
are
well
communicated
at
shij
change
   I
am
sa>sfied
with
the
quality
of
collabora>on
I
 experience
with
(staff
physicians/nurses)
in
this
clinical
area


92.7, respectively). In fact, surgeons perceived that everyone in the OR is doing a good job in terms of teamwork (Fig. 2). Figures 3A, 3B, and 3C display the contrast between surgeons and nurses, surgeons and anesthesiologists, and anesthesiologists and nurses, respectively, and Figures 4A and 4B demonstrate interposition differences in teamwork among all members of the OR. Such differences underscore the disconnect in teamwork and the methodological barrier in aggregating measures of teamwork in surgery.

with respondents during survey feedback presentations highlighted that nurses often describe good collaboration as having their input respected, and physicians often describe good collaboration as having nurses who anticipate their needs and follow instructions. Historically, there are differences between the expectations that physicians and nurses bring to a communication encounter. Nurses are trained to communicate more holistically, using the “story” of the patient, and physicians are trained to communicate succinctly using the “head-

Table 2. ANOVA Results for Teamwork Ratings by and of Each Operating Room Provider Type Ratings of

Surgeons Anesthesiologists CRNAs OR nurses Surgical technicians

df

F

p Value

Surgeons

4, 2058 4, 1990 4, 1571 4, 2061 4, 2044

41.73 53.15 37.36 12.93 6.17

! 0.001 ! 0.001 ! 0.001 ! 0.001 ! 0.001

4.38 4.39 4.37 4.42 4.36

Mean ratings* of teamwork by Anesthesiologists CRNAs

*1 # very low; 5 # very high. † Scrub and circulating. CRNAs, certified registered nurse anesthetists; df, degrees of freedom; OR, operating room.

4.03 4.80 4.58 4.31 4.17

3.72 4.25 4.67 4.10 3.95

OR nurses†

Overall

3.52 3.85 3.94 4.25 4.07

3.68 3.96 4.04 4.20 4.10

!

Percentage
(rounded)
of
opera>ng
room
(OR)
caregivers
repor>ng
a
 “high”
or
“very
high”
level
of
collabora>on
with
other
members
of
the
 OR
team.


Barriers
to
effec>ve
team
communica>on
 in
the
OR
  

OR
sefng

   masks
   noise


hierarchical
structure
   work
overload
   distrac>ng
communica>on
   communica>on
plan
   accountability
  

Types
of
Communica>on
Failures
  

Occasion
   occurred
too
late


 

Content
   inaccurate
or
incomplete


 

Audience
   significant
individuals
excluded


 

Purpose
   issues
lej
unresolved


Lingard
L,
Espin
S,
Whyte
S,
Regehr
G,
Baker
GR,
Reznick
R,
Bohnen
J,
Orser
B,
Doran
D,
Grober
E.

 Communica>on
Failures
in
the
Opera>ng
Room:
an
observa>onal
classifica>on
of
recurrent
types
and
effects.

 Qual
Saf
Health
Care
2004;
13:
330‐334


Communica>on
failures
(cont’d)
  

31%
of
communica>on
events
fail
   usually
due
to
>ming
or
content


 

one‐third
result
in
immediate
effects
   delay
   inefficiency

   team
tension


 

May
lead
to
false
sense
of
security
and
migra>on
 into
poten>al
danger
zone


Crew
Resource
Management
  

history
   originated
1979

   NASA
research
showed
that
majority
of
avia>on


accidents
were
caused
by
human
error
   specifically
failures
of
communica>on,
leadership
and
 decision‐making


CRM
Training
 encompasses
knowledge,
skills
and
aftudes
   includes:
  

  communica>on
   leadership
   problem‐solving
   situa>onal
awareness
   decision‐making
   teamwork
skills
   conflict
resolu>on


CRM
in
Medicine
 SBAR
   Opera>ng
Room
Briefings
   Medical
Team
Training
  

SITUATION
   What
is
going
on
with
the
pa>ent?


BACKGROUND
   What
is
the
key
clinical
background
or


context?


ASSESSMENT
   What
do
I
think
the
problem
is?


RECOMMENDATION
   What
do
I
think
you
should
do
and
when?


SBAR
 communica>on
technique
providing
a
framework
 for
a
discussion
about
a
pa>ent
   uses
a
standardized
format
   enhances
clarity
and
efficiency
of
communica>on
  

Possible
uses
of
SBAR
 anesthesia
hand‐offs
   crisis
management
   reques>ng
a
consult
   hand‐overs
at
shij
change
or
for
ward
transfers
   nurse‐physician
communica>ons
regarding
pa>ent
 status
  

Example
of
SBAR

  

 

 

 

 

Dr.
Jones,
this
is
Nurse
McDonald,
I
am
calling
from
 ABC
Hospital
about
your
pa>ent
Jane
Smith.
 Situa&on:
Here's
the
situa>on:
Mrs.
Smith
is
having
 increasing
dyspnea
and
is
complaining
of
chest
pain.
 Background:
The
suppor>ng
background
informa>on
 is
that
she
had
a
total
knee
replacement
two
days
ago.
 About
two
hours
ago
she
began
complaining
of
chest
 pain.
Her
pulse
is
120
and
her
blood
pressure
is
 128/54.
She
is
restless
and
short
of
breath.
 Assessment:
My
assessment
of
the
situa>on
is
that
 she
may
be
having
a
cardiac
event
or
a
pulmonary
 embolism.
 Recommenda&on:
I
recommend
that
you
see
her
 immediately
and
that
we
start
her
on
02
stat.


Opera>ng
Room
Briefings
 also
called
a
team
checklist
   addresses
safety
issues
by:
  

  decreasing
reliance
on
memory
   standardizing
processes
   increasing
access
to
informa>on
   providing
feedback


Development
and
pilot
implementa>on
of
 a
checklist
 Lingard
et
al.
2005
   developed
own
checklist
   studied
its
use
in
18
vascular
surgery
procedures
   elicited
feedback
from
par>cipants
  

Lingard
L,
Espin
S,
Rubin
B,
White
S,
Colmenares
M,
Bager
GR,
Doran
D,
Grober
E,
Orser
B,
Bohnen
J,
Reznick
 R.

Gefng
Teams
to
Talk:
development
and
pilot
implementa>on
of
a
checklist
to
promote
interprofessional
 communica>on
in
the
OR.

Qual
Saf
Health
Care
2005;
14:
340‐346


Development
and
pilot
implementa>on
of
 a
checklist
  

dura>on

   averaged
3.5
minutes
(range
1‐6
min)

 

>ming
















(number
of
checklists
done)


  before
pa>ent
arrival
 



   ajer
arrival,
before
induc>on   ajer
induc>on
 
 
  






 
 



9
 
5
 
4



 
 



13
 
4
 
1


loca>on
   in
OR



 
   in
hallway
 
   in
holding
area



 
 



 
 


Development
and
pilot
implementa>on
of
 a
checklist
 Pros
  

not
>me
consuming
or
 onerous


 

increased
nursing
 knowledge
of
history
and
 plan
 improved
OR
efficiency


 

reduced
equipment
delays


 

Cons
  

inconvenient
to
surgeons
 interrupted
workflow


 

if
too
late,
redundant


 

Study
of
pre‐opera>ve
checklist
to
reduce
 communica>on
failures
 13
month
prospec>ve
study
   #
of
communica>on
failures
pre‐
and
post‐
 checklist
interven>on
   func>onal
u>lity
of
checklist
  

Lingard
L,
Regehr
G,
Orser
B,
Reznick
R,
Baker
GR,
Doran
D,
Espin
S,
Bohnen
J,
Whyte
S.

Evalua>on
of
a
 Preopera>ve
Checklist
and
Team
Briefing
Among
Surgeons,
Nurses,
and
Anesthesiologists
to
Reduce
Failures
in
 Communica>on.

Arch
Surg
2008;
143:
12‐17


Study
of
pre‐opera>ve
checklist
to
reduce
 communica>on
failures
  

observed
302
checklist
briefings
   1
–
4
minutes
   8%
before
pa>ent
arrival
to
OR
   34%
ajer
pa>ent
arrival,
before
induc>on
   47%
ajer
induc>on
of
general
anesthesia
   (11%
>ming
was
not
documented)


Study
of
pre‐opera>ve
checklist
to
reduce
 communica>on
failures
 observed
86
each
pre‐
and
post‐
interven>on
 procedures
   #
of
communica>on
failures
per
procedure
  

  3.95
before
introduc>on
of
checklist
   1.31
ajer
introduc>on
of
checklist
   P
<
0.001


Func>onal
u>lity
of
checklist
briefings
  

34%
(100/295)
showed
some
func>onal
u>lity
   iden>fied
a
problem
   revealed
an
ambiguity
   exposed
a
cri>cal
knowledge
gap
   provoked
a
change
in
plan
   prompted
a
follow‐up
ac>on


 

44%
had
a
direct
impact
on
pa>ent
care


Implementa>on
 BARRIERS
 OR
professionals
 accustomed
to
 independence
   “individual
excellence
 should
be
sufficient”
   overwhelmed
and
 may
priori>ze
other
 du>es
  

ASSETS
 engaging
team
 members
   stake‐holder
mee>ngs
   surgeon
“champions”
  

Medical
Team
Training
 uses
interdisciplinary
team
training
   surgical
teams
work
in
a
high‐stress,
high‐ workload,
>me‐pressured
environment
  

  need
flexible,
open
communica>on
   must
an>cipate
other
members’
needs


GOAL:
   to
transform
a
team
of
experts
into
an











 “expert
team”


Medical
Team
Training
  

team
training
focuses
on
non‐technical
skills
   leadership
   decision
making
ability
   situa>on
awareness
   communica>on
   team
skills
   coordina>on
   vigilance


Approaches
to
Team
Training
 CLASSROOM‐BASED
 TEACHING
 lectures
   videos
   case‐reviews
   problem‐solving
   exams
  

MEDICAL
SIMULATION
 high‐fidelity
simulated
 OR
   prac>ce
new
protocols
 in
work
sefng
  

Approaches
to
Team
Training
 CLASSROOM‐BASED
 TEACHING
 no
expensive
 equipment
   teach
many
staff
 simultaneously
   can
update
and
orient
 new
staff
as
needed
  

MEDICAL
SIMULATION
 hands‐on
prac>ce
   deploy
new
skills
in
 complex
environment
   enhance
cross‐role
 understanding
   immediate
feedback
  

Medical
Team
Training
 difficult
to
cause
permanent
change
with
only
a
 single
interven>on
   people
need
repe>>ve
training
and
prac>ce
to
 change
behaviours
   workplace
re‐inforcement
is
beneficial
   “champions”
of
the
new
behaviours
are
ideal
   classroom
teaching
and
medical
simula>on
could
 be
used
together
  

WHO’s
“Safe
Surgery
Saves
Lives”
 began
in
January
2007
   officially
launched
June
2008
   iden>fied
four
areas
requiring
improvement
in
 order
to
increase
pa>ent
safety
during
surgery
  

  surgical
site
infec>on
preven>on
   safe
anesthesia
   safe
surgical
teams
   measurement
of
surgical
services


Pilot
evalua>on
of
WHO
“Surgical
 Safety
Checklist”


Pilot
evalua>on
of
WHO
“Surgical
 Safety
Checklist”
 1000
pa>ents
   8
sites
worldwide
   adherence
to
proven
standards
of
surgical
care
  

  has
increased
from
36%
to
68%
   reduced
complica>ons
and
deaths


World
Health
Organiza0on.

Safe
surgery
saves
lives.

Available
online
from,
hdp://www.who.int/ pa>entsafety/safesurgery/tes>ng/pilot_sites/en/index.html


one in 5000 chance of death. With improvements in knowledge and basic standards of care the risk has dropped to one in 200 000 in the developed

Safe
Surgical
Teams


world — a 40-fold improvement. Unfortunately the rate of anaesthesia-associated mortality in developing countries appears to be 100–1000 times higher, indicating a serious, sustained lack of safe anaesthesia for surgery in these settings. • Safe surgical teams: Teamwork is the core of all effectively functioning systems involving multiple people. In the operating room, where tension may be high and lives are at stake, teamwork is an essential component of safe practice. The quality of teamwork depends on the culture of the team and its communication patterns, as well as the clinical skills and situational awareness of the team members. Improving team characteristics should aid communication and reduce patient harm. • Measurement of surgical services: A major problem in surgical safety has been a shortage of basic data. Efforts to reduce maternal and neonatal mortality during childbirth have been critically reliant on routine surveillance of mortality rates and systems of obstetric care to monitor successes and failures. Similar

!

Global
support
and
endorsements
    

                     

Accredita>on
Canada
 American
Academy
of
Orthopaedic
Surgeons/
American
Associa>on
of
 Orthopaedic
Surgeons
 American
Academy
of
Otolaryngology‐Head
&
Neck
surgery
 American
Associa>on
of
Neurological
Surgeons
(AANS)
 American
College
of
Surgeons
 American
Orthopaedic
Associa>on
 American
Society
of
Anesthesiologists
 Anesthesia
Pa>ent
Safety
Founda>on
 Canadian
Anesthesiologists'
Society
 Canadian
Associa>on
of
General
Surgeons
 Canadian
Medical
Associa>on
 Canadian
Pa>ent
Safety
Ins>tute
 Royal
College
of
Physicians
and
Surgeons
of
Canada


Framework
for
Harm
Preven>on


Bodom
Line
 IOM
and
JCAHO
have
both
recommended
 adop>on
of
avia>on
safety
principles
   WHO
supports
improved
surgical
safety
and
use
of
 an
OR
checklist
  

  the
WHO
ini>a>ve
is
endorsed
worldwide


Next
Steps…
 How
best
to
implement
and
maintain
new
 ini>a>ves?
   Par>cipa>on
is
crucial
–
consider
becoming
a
 champion
   Next
mee>ng
of
OR
safety
commidee
is
January
 21,
2009
   Contact
Dr.
Craig
Bosenberg
for
further
 informa>on
  

Contact: Dr. O McAllister BSc, MD, FRCP(C) Managing Partner Colin McAllister PEng, PMP, MBA Managing Principal Perspect Management Consulting www.perspect.ca (Contact Us)