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
84% ‐ breakdown in communica>on > 50% ‐ breakdown in communica>on between surgical team members and the pa>ent and family 66% ‐ failure in communica>on 70% ‐ communica>on breakdown 72% involved communica>on issues (with 55 percent ci>ng organiza>on culture as a barrier to effec>ve communica>on and teamwork)
wrong site surgery
opera>ve and post‐op complica>ons
ven>lator‐related deaths and injuries
infant death and injury during delivery
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
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 “headMean ratings* of teamwork by Anesthesiologists CRNAs
Table 2. ANOVA Results for Teamwork Ratings by and of Each Operating Room Provider Type
Ratings of df F p Value Surgeons OR nurses† Overall
Surgeons Anesthesiologists CRNAs OR nurses Surgical technicians
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
4.03 4.80 4.58 4.31 4.17
3.72 4.25 4.67 4.10 3.95
3.52 3.85 3.94 4.25 4.07
3.68 3.96 4.04 4.20 4.10
*1 very low; 5 very high. † Scrub and circulating. CRNAs, certified registered nurse anesthetists; df, degrees of freedom; OR, operating room.
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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:
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)
9 5 4 13 4 1
>ming
(number of checklists done)
before pa>ent arrival
ajer arrival, before induc>on ajer induc>on
loca>on
in OR
in hallway in holding area
Development and pilot implementa>on of a checklist
Pros
Cons
not >me consuming or onerous increased nursing knowledge of history and plan improved OR efficiency reduced equipment delays
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 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
Safe Surgical Teams
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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)