Fig. 31.1
Operating room efficiencies study. These are the results of our local operating room efficiency study. The x axis is the issues studied. The y axis is the frequency of the issues expressed as a factor of 1. The light color represents the efficiency of the operating rooms that performed a preoperative briefing and the dark color represents the operating room that did not have a preoperative briefing
In February of 2008 a retired pediatric surgeon was hired to help coach surgeons on how to do a briefing. This surgeon would circulate among the rooms observing cases. She interacted with surgeons on a one-to-one basis providing guidance and advice on the best way to do a briefing. Her presence also was a reminder to do a briefing. She was present for approximately 3 months.
The combination of a single conference devoted to preoperative briefings, a local study demonstrating increased OR efficiency, and hiring a physician coach resulted in an increase in the number of surgeons doing briefings. Once we could show surgeons how care is improved with the briefings, it removed some of the skepticism over the process. By the end of 2008 48 surgeons were doing preoperative briefings. Throughout this time we were also conducting periodic cultural surveys. Over time the use of briefings has made our operating rooms a less hostile environment although we still have significant work to do. Figure 31.2 documents the improvement in operating room culture from before training and preoperative briefings to the present time. Specifically we found that as more and more surgeons did briefings the operating room staff felt that there was more teamwork and openness in communications than previous. We also found that the staff felt that there was less of a punitive reaction to errors. Overall the staff thought that the operating room was less hostile because of the briefings. In May 2009 54 % of the over 6,000 cases done at our system have had a preoperative briefing.
Fig. 31.2
Agency for Health Care Research and Quality (AHRQ) Survey results for operating room safety before and after human factors training. These are the Agency for Health Care Research and Quality Survey results of operating room culture before and after human factors training. The x axis is the specific questions asked. The y axis is the frequency of a positive answer expressed as a percentage. The dark line with the triangular data points represents the results of the survey done before human factors training. The dark line with the square data points represents our most recent results
At the beginning of 2009 the World Health Organization endorsed the implementation of a surgical checklist to help improve the safety of operating room. Using the lessons that we learned from the preoperative briefing process we developed our own checklist and incorporated that into the briefing process. The development of the checklist was entirely physician led and took us about a year to fully implement. The checklist was initially rolled out to a few physicians who tried it and then provided feedback on how to make it better. We had to balance having a process that was quick and easy to use with one that had all the elements to insure patient safety. The WHO checklist was used as a template and then modified to our circumstances. For example we have had a problem with the core measure of perioperative beta blocker administration so we added that to our checklist. The surgeon briefing was also an integral part of our checklist. Once the initial feedback was obtained the form was modified and rolled out to all of the surgical sections for their use and input. It was only after the entire physician staff got a chance to use the checklist that we came up with the final edition. We understood this process would take longer than forcing physicians to use the checklist but we felt it was important to have the physicians involved in the development of the checklist. In 2010 our Board of Trustees mandated that the checklist be used in all of the operating rooms.
Overcoming Challenges
Our struggle since the implementation of the checklist has been to maintain our success. Once the initial effort with human factors training and development of the checklist were over it was easy to lose focus as other issues arose. We also had a problem as staff and physicians left our system and new people came on. The culture of safety wasn’t as ingrained as we would have liked. As a result we saw a decrease in the use of the checklist. In 2012 we rededicated ourselves to the briefing and the checklist. In order to mitigate the effects of staff turnover, we incorporated the lessons we learned into the orientation for all new employees to the operating room. Our system has a perioperative education program for staff who have no experience in the operating room. The checklist and briefing are part of the perioperative communications module for these students. For the experienced OR staff the checklist is part of the orientation done by our Perioperative Clinical Educator. The educator is in routine contact with the new employee throughout the orientation process to assess their experience with the checklist. A part of the program for both students and experienced staff is to give positive feedback to the surgeons when the checklist is performed properly. The idea is to empower the staff to insist on a culture of safety.
The physicians presented a different problem. Since most of our medical staff are independent, we don’t have as much leverage as with employees. We had to develop a different process for physicians. All new surgeons meet with a member of physician leadership where we discuss the culture in the operating room and the Board of Trustees expectation that all cases include the use of the checklist. We also have a DVD of an actual case where the checklist is being used and have the physician sign off that they have viewed the DVD. Intraoperatively the circulating nurse is responsible for documenting if the checklist was used. Since we have implemented these changes, use of the checklist has improved to 98–100 % across all operating rooms. Our next challenge is to determine if the checklist is being used in a way that actually improves patient care.
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