The Path to a Culture of Operating Room Safety

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The Path to a Culture of Operating Room Safety

• Scott Ellner, DO, MPH, FACS
• Director of Surgical Quality
• Saint Francis Hospital and Medical Center
• September 19, 2012

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Objectives

1. Discuss the implementation and use of the AORN
   surgical checklist.
2. Discuss the use of a validated safety attitudes
   questionnaire to understand behavior in the
   surgical environment.
3. Discuss OR team training to change culture.
4. Discuss the use of the American College of
   Surgeons National Surgical Quality Improvement
   Program to assess 30-day postoperative
   complications.

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Saint Francis Hospital and Medical Center

• 600 Bed tertiary care facility
• Level 2 Trauma Center
• University of Connecticut Surgical Residency
  Program
• 8,000 General surgery cases/yr.
• 30 Operating rooms
• ACS NSQIP since 2007
• ACS TQIP since 2011

Hartford, Connecticut

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Operating Room and Team 1914
Saint Francis Hospital
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Operating Room and Team 2012
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Culture of Blame and Shame
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Example of a blank slide
As reported by Joint Commission Sentinel Event
Types 3Q 2011 www.jointcommission.org
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Identifying Culture

• Communication
• Behavior
• Rituals
• Tolerance

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OR Safety Attitudes Questionnaire - SAQ
12. In the OR, it is difficult to discuss errors. 1 2 3 4 5
21. The culture in the ORs here makes it easy to learn from the errors of others. 1 2 3 4 5
All the personnel in the ORs here take responsibility for patient safety. 1 2 3 4 5
www.uth.tmc.edu/...safety/questionnaires/SAQBiblio
graphy.html
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SAQ Participants
N161
N161
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Overall SAQ Results
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Pre-Training Observations of Team Communication

• Language Barriers
• Shared commitment
• Assumptions (they should know)
• Efficiency
• Interruptions
• Side conversation
• Fatigue and stress

• Multi-tasking
• Complacency
• High-risk
• Personal Issues
• Workload/Staff fluctuation
• Shared understanding (roles/terms/purpose)

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Why Team Training?

• Gives all employees a voice
• Enhances communication
• Addresses improper behavior
• Helps to build trust
• Encourages leadership
• Improves the overall safety culture

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Launch of Team Training
Crucial Conversations
Leadership Training
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Team Training Tool

• Session 1 Crucial Conversations
• Session 2 Getting What You Want Communication
  Strategies That Help You Get What You Need
• Session 3 When the Going Gets Tough Achieving
  a Positive Outcome

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Session 1Crucial Conversations

• Confront with positive outcomes
• How can I have crucial conversations and confront
  issues I need to address?
• Open environment
• How do I contribute to creating an open
  environment?

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Confront With Positive Outcomes

• We must first reflect on ourselves
• How do I deal with conflict?

Violence
Safety
Safety
Pool of Shared Meaning
Safety
Silence
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What Is The Story?

• Our story becomes our truth

EVENT
Tell a story
See/ Hear
ACT
Feel
and assumptions are made.
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Learn To Look At Patterns - CPR

• Content What just happened (a single event)?
• Pattern Behavior/events that occurs again.
  Patterns help to articulate the issue.
• Relationship What is happening to us (individuals
  and team)?

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Nurture an Open Environment

• How do I help to create a sense of team?
• Commit yourself to being part of the team success
• Help your team build a common understanding of
  the issues, be responsible for what you say and
  do
• Make your best effort to keep commitments
• Contribute your ideas and suggestions to the
  discussions
• Be open to others ideas concentrate on
  understanding their ideas and intentions

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Session 2 - Communication Strategies to Get What
You Need
Recognize your Style Under Stress

• Refuse the Suckers Choice (Violence/Silence)
• Caught between two unpleasant options
• 1. Disagree and get in trouble for it.
• 2. Remain quiet.
• Work on me first
• Remember the only person you can control is
  yourself.
• Focus on what you really want.

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The Meaning of the MessagePerception vs. Intent
Sender of Message Receiver of Message
What people see and hear triggers their
associations, by which they make sense of the
messages they receive.
Your method and means of sending messages makes
up your interactional style.
Style
Experience
Beliefs
Training
Filters
Non-Verbal
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Checklist Introduction
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Session 3 Achieving a Positive Outcome
Rebuilding Safety

• Fight natural tendency to silence and violence
• Clarify intent or real motivation
• Establish a mutual purpose
• Listen for understanding

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Take Home Points

• The only person you can be in control of is
  yourself
• Understand introversion vs. extroversion
• Recognize silence vs. violence energy
• The meaning of the message resides in the
  receiver
• The power of the story
• Its not what you say but how you say it

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OR Change Agents

• OR Ambassadors
• OR Observers
• Executive Leadership

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Observed Qualitative Results
Good teamwork. Specimen sent to radiology during
surgery and received result by phone
immediately. 
Joking by surgeon at expense of female personnel.
No equipment malfunctions. Staff in room joined
together to announce time out and debrief. 
CRNA brought open cup of coffee into case,
raised sheet to cover view of anesthesia area.
Anesthesia initiating the Time-Out.
No site marked for hernia repair circulator
recognized asked surgeon to mark side.
Patient paged overhead by surgical floor while
in surgery.
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American College of SurgeonsNational Surgical
Quality Improvement Program

• Evidence-based
• Risk-adjusted
• Data driven
• Improved Surgical Outcomes

Shukri F. Khuri, MD
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Quantitative Results
N73 general surgery cases
ACS NSQIP data 3391 cases vs. 153 cases
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Number of Surgical Cases With Safety-Compromising
Events
Poor Communication 30 (41)
Change in Decision Making 18 (24)
No Equipment Availability 20 (27)
Equipment Malfunction 19 (26)
Disruptive Behavior 27 (37)
Impeded Flow 30 (41)
Break in Sterility 42 (56)
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Circulating Nurse Exits

• Average 9 exits (4 hour case)
• Observed range 0-25 exits
• Increase in the number of OR exits led to higher
  rates of patient morbidity

Christian et al. Surgery 2006
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Summary

• Acknowledge the need for change
• Measure baseline attitudes SAQ
• Implement team training curriculum
• Introduce tools to effect change
• Observe and audit checklist utilization
• Recognize barriers to change
• Provide resources for sustainability
• Identify metrics to demonstrate change

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Thank You
sellner_at_stfranciscare.org