Surgical Team Communications - Perspect Management Consulting

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This paper shares an overview of communications amongst the surgical team highlighting the impact of both poor and good communication practices and provides methods and tools to improve this process.

Please Contact us at www.perspect.ca for more information.

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Surgical Team Communications - Perspect Management Consulting

  1. 1. SURGICAL
TEAM
 COMMUNICATION
 November
26,
2008
 www.perspect.ca
  2. 2. Communica>on
 
Defini>on:
 ‐
a
process
by
which
informa>on
is
exchanged
 between
individuals
through
a
common
system
 of
symbols,
signs,
or
behavior

  3. 3. 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
  
  4. 4. 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

  5. 5. Primary
root
cause
analysis
of
sen>nel
 events
 delay
in
treatment
   84%
‐
breakdown
in
communica>on
   wrong
site
surgery
   >
50%
‐
breakdown
in
communica>on
between
surgical
team
members
   and
the
pa>ent
and
family
 opera>ve
and
post‐op
complica>ons
   66%
‐
failure
in
communica>on 

   ven>lator‐related
deaths
and
injuries

   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/

  6. 6. 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

  7. 7. 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

  8. 8. 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

  9. 9. with respondents during survey feedback presentations 92.7, respectively). In fact, surgeons perceived that highlighted that nurses often describe good collabora- everyone in the OR is doing a good job in terms of tion as having their input respected, and physicians of- teamwork (Fig. 2). Figures 3A, 3B, and 3C display the ten describe good collaboration as having nurses who contrast between surgeons and nurses, surgeons and an- anticipate their needs and follow instructions. Histori- esthesiologists, and anesthesiologists and nurses, respec- cally, there are differences between the expectations that tively, and Figures 4A and 4B demonstrate interposition physicians and nurses bring to a communication en- differences in teamwork among all members of the OR. counter. Nurses are trained to communicate more holis- Such differences underscore the disconnect in teamwork tically, using the “story” of the patient, and physicians and the methodological barrier in aggregating measures of teamwork in surgery. are trained to communicate succinctly using the “head- Table 2. ANOVA Results for Teamwork Ratings by and of Each Operating Room Provider Type Mean ratings* of teamwork by OR nurses† Ratings of df F p Value Surgeons Anesthesiologists CRNAs Overall Surgeons 4, 2058 41.73 0.001 4.38 4.03 3.72 3.52 3.68 Anesthesiologists 4, 1990 53.15 0.001 4.39 4.80 4.25 3.85 3.96 CRNAs 4, 1571 37.36 0.001 4.37 4.58 4.67 3.94 4.04 OR nurses 4, 2061 12.93 0.001 4.42 4.31 4.10 4.25 4.20 Surgical technicians 4, 2044 6.17 0.001 4.36 4.17 3.95 4.07 4.10 *1 very low; 5 very high. † Scrub and circulating. CRNAs, certified registered nurse anesthetists; df, degrees of freedom; OR, operating room. !
  10. 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.

  11. 11. 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

  12. 12. 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

  13. 13. 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

  14. 14. 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

  15. 15. CRM
Training
 encompasses
knowledge,
skills
and
aftudes
     includes:
   communica>on
   leadership
   problem‐solving
   situa>onal
awareness
   decision‐making
   teamwork
skills
   conflict
resolu>on

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

  17. 17. 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?

  18. 18. 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

  19. 19. 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

  20. 20. 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.

  21. 21. 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

  22. 22. 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

  23. 23. 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
 
 
 
 
9
   ajer
arrival,
before
induc>on 
 
5
   ajer
induc>on
 
 
 
 
4
 loca>on
     in
OR
 
 
 
 
 
 
13
   in
hallway
 
 
 
 
 
4
   in
holding
area
 
 
 
 
1

  24. 24. Development
and
pilot
implementa>on
of
 a
checklist
 Pros
 Cons
 not
>me
consuming
or
 inconvenient
to
surgeons
     onerous
 interrupted
workflow
   increased
nursing
 if
too
late,
redundant
     knowledge
of
history
and
 plan
 improved
OR
efficiency
   reduced
equipment
delays
  
  25. 25. 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

  26. 26. 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)

  27. 27. 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

  28. 28. 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
  
  29. 29. Implementa>on
 BARRIERS
 ASSETS
 OR
professionals
 engaging
team
     accustomed
to
 members
 independence
   stake‐holder
mee>ngs
   “individual
excellence
   surgeon
“champions”
 should
be
sufficient”
   overwhelmed
and
 may
priori>ze
other
 du>es

  30. 30. 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”

  31. 31. Medical
Team
Training
 team
training
focuses
on
non‐technical
skills
     leadership
   decision
making
ability
   situa>on
awareness
   communica>on
   team
skills
   coordina>on
   vigilance

  32. 32. Approaches
to
Team
Training
 CLASSROOM‐BASED
 MEDICAL
SIMULATION
 TEACHING
 high‐fidelity
simulated
 lectures
     OR
   videos
   prac>ce
new
protocols
   case‐reviews
 in
work
sefng
   problem‐solving
   exams

  33. 33. Approaches
to
Team
Training
 CLASSROOM‐BASED
 MEDICAL
SIMULATION
 TEACHING
 hands‐on
prac>ce
 no
expensive
     equipment
   deploy
new
skills
in
 complex
environment
   teach
many
staff
 simultaneously
   enhance
cross‐role
 understanding
   can
update
and
orient
 new
staff
as
needed
   immediate
feedback

  34. 34. 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

  35. 35. 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

  36. 36. Pilot
evalua>on
of
WHO
“Surgical
 Safety
Checklist”

  37. 37. 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

  38. 38. 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
  39. 39. 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
  
  40. 40. Framework
for
Harm
Preven>on

  41. 41. 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

  42. 42. 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

  43. 43. 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)

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