- Finally, a recent study reported a significant correlation between subjective ratings of teamwork with postoperative morbidity (Davenport et al. - some studies in other areas have found only marginal benefit for patients (Nielsen et al. - 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.. - There is already a large body of knowledge that can inform the content of such programmes (Baker et al. - These may focus on relatively specific processes of care, like neonatal resuscitation (Thomas et al. - they may try to address multiple processes within a site of care like labour and delivery (Nielsen et al. - 2006, Yule et al. - This would include studies that draw upon the ‘basic sciences’ of safety (Brennan et al.. - 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. - 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. - 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. - 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. - 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 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. - 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. - communication and teamwork – every medical centre closed the operating rooms for 2–3 hours for this training. - 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.. - 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. - 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. - Completion of the process requirements outlined above was monitored and quarterly reports were submitted to the medical centre executive committee and regional leadership. - 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 the successes 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. - Refinement and monitoring of the surgical briefing and debriefing to build communication, teamwork and eliminate verification events – this included use of the script. - and leadership of the surgeon.. - 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.. - Provide a second surgical summit in the fall to celebrate successes and inspire the operative teams to continue to sustain the programme.. - 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.. - 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.. - New England Journal of Medicine . - American Journal of Medical Quality . - Journal of the American College of Surgery . - 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 . - Journal of Applied Psychology 69, 85–98.. - Makary, M.A., Sexton, J.B., Freischlag, J.A., Millman, E.A., Pryor, D. - (2006b) Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. - American Journal of Surgery [doi: 10.1016/. - Journal of Pediatric Orthopedics . - (2002) Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the MedTeams project. - New England Journal of Medicine.. - American Journal of Emergency Medicine . - Sexton, J.B., Thomas, E.J. - (2000) Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. - Journal of Perinatology . - in the operating room: Frontline perspectives among hospitals and operating room personnel. - (1995) A prospective study of the performance of the trauma team leader. - Journal of Trauma . - Thomas, E.J., Sexton, J.B. - Thomas, E.J., Sexton, J.B., Lasky, R.E., Helmreich, R.L., Crandell, S. - (2006) Teamwork and quality during neonatal care in the delivery room.. - Journal of Perinatology 26, 163–9.. - World Journal of Surgery 30, 1774–. - Selected post-operative infections (ICD-9 CM codes 9993 or 00662).. - Post-operative haemorrhage or haematoma.. - Post-operative DIC (disseminating intravascular coagulopathy).. - Post-operative respiratory failure (acute).. - Post-operative sepsis.. - Post-operative fracture (excluding unrelated post-operative falls).. - Post-operative physiologic/metabolic derangement.. - Post-operative cardiac arrest.. - Post-operative hemodynamic instability.. - Counting Silence: Complexities in the Evaluation of Team Communication. - 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. - 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.. - 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
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