Stephanie Russ

Do Safety Checklists Improve Teamwork and Communication in the Operating Room? A Systematic Review

Objectives: The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). Background: Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. Methods: A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Results: Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. Conclusions: Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National Implementation: A Longitudinal Study.

OBJECTIVE To evaluate impact of WHO checklist compliance on risk-adjusted clinical outcomes, including the influence of checklist components (Sign-in, Time-out, Sign-out) on outcomes. BACKGROUND There remain unanswered questions surrounding surgical checklists as a quality and safety tool, such as the impact in cases of differing complexity and the extent of checklist implementation. METHODS Data were collected from surgical admissions (6714 patients) from March 2010 to June 2011 at 5 academic and community hospitals. The primary endpoint was any complication, including mortality, occurring before hospital discharge. Checklist usage was recorded as checklist completed in full/partly. Multilevel modeling was performed to investigate the association between complications/mortality and checklist completion. RESULTS Significant variability in checklist usage was found: although at least 1 of the 3 components was completed in 96.7% of cases, the entire checklist was only completed in 62.1% of cases. Checklist completion did not affect mortality reduction, but significantly lowered risk of postoperative complication (16.9% vs. 11.2%), and was largely noticed when all 3 components of the checklist had been completed (odds ratio = 0.57, 95% confidence interval: 0.37-0.87, P < 0.01). Calculated population-attributable fractions showed that 14% (95% confidence interval: 7%-21%) of the complications could be prevented if full completion of the checklist was implemented. CONCLUSIONS Checklist implementation was associated with reduced case-mix-adjusted complications after surgery and was most significant when all 3 components of the checklist were completed. Full, as opposed to partial, checklist completion provides a health policy opportunity to improve checklist impact on surgical safety and quality of care.

Observational Teamwork Assessment for Surgery: Feasibility of Clinical and NonClinical Assessor Calibration With Short-Term Training

Objectives:To assess the feasibility of training clinical and nonclinical novice assessors to rate teamwork behavior in the operating room with short-term structured training using the observational teamwork assessment for surgery (OTAS) tool. Background:Effective teamwork is fundamental to the delivery of optimal patient care in the operating room (OR). OTAS provides a comprehensive and robust measure of teamwork in surgery. To date, assessors with a background in psychology/human factors have been shown to be able to use OTAS reliably after training. However, the feasibility of observer training over a short timescale and accessibility to the wider clinical community (ie, OTAS use by clinicians) are yet to be empirically demonstrated. Methods:Ten general surgery cases were observed and assessed using OTAS in real-time by an expert in rating OTAS behaviors (100+ cases rated) and 4 novices: 2 psychologists and 2 surgeons. Assessors were blinded to each others scores during observations. After each observation, scores were compared and discussed between expert and novice assessors in a debriefing session. Results:All novices were reliable with the expert to a acceptable degree at rating all OTAS behaviors by the end of training (intraclass correlation coefficients ≥0.68). For 3 of the 5 behaviors (communication, cooperation, and leadership), calibration improved most rapidly across the first 7 observed cases. For monitoring/situational awareness, calibration improved steadily across the 10 observed cases. For coordination, no significant improvement in calibration over time was observed because of high interrater reliability from the outset (ie, a ceiling effect). There was no significant difference between surgeons and psychologists in their calibration with the expert. Conclusions:It is feasible to train both clinicians and nonclinicians to use OTAS to assess teamwork behaviors in ORs over a short structured training period. OTAS is an accessible tool that can be used robustly (ie, reliably) by assessors from both clinical and nonclinical backgrounds.

Operation debrief: a SHARP improvement in performance feedback in the operating room.

Objectives: To explore the current status of performance feedback (debriefing) in the operating room and to develop and evaluate an evidence-based, user-informed intervention termed “SHARP” to improve debriefing in surgery. Background: Effective debriefing is a key educational technique for optimizing learning in surgical settings. However, there is a lack of a debriefing culture within surgery. Few studies have prospectively evaluated educational interventions to improve the quality and quantity of performance feedback in surgery. Methods: This was a prospective pre- and post-study of 100 cases involving 22 trainers (attendings) and 30 surgical residents (postgraduate years 3–8). A trained researcher assessed the quality of debriefings provided to the trainee using the validated Objective Structured Assessment of Debriefing (OSAD) tool alongside ethnographic observation. Following the first 50 cases, an educational intervention termed “SHARP” was introduced and measures repeated for a further 50 cases. User satisfaction with SHARP was assessed via questionnaire. Twenty percent of the cases were observed independently by a second researcher to test interrater reliability. Results: Interrater reliability for OSAD was excellent (ICC = 0.994). Objective scores of debriefing (OSAD) improved significantly after the SHARP intervention: median pre = 19 (range, 8–31); median post = 33 (range, 26–40), P < 0.001. Strong correlations between observer (OSAD) and trainee rating of debriefing were obtained (median &rgr; = 0.566, P < 0.01). Ethnographic observations also supported a significant improvement in both quality and style of debriefings. Users reported high levels of satisfaction in terms of usefulness, feasibility, and comprehensiveness of the SHARP tool. Conclusions: SHARP is an effective and efficient means of improving performance feedback in the operating room. Its routine use should be promoted to optimize workplace-based learning and foster a positive culture of debriefing and performance improvement within surgery.

Emotional intelligence and stress in medical students performing surgical tasks.

Purpose Poor stress management skills can compromise performance in the operating room, particularly in inexperienced trainees. Little is known about individual differences in managing stress. This study aimed to explore the relationship between trait emotional intelligence (EI) and objective and subjective measures of stress in medical students faced with unfamiliar surgical tasks. Method Seventeen medical undergraduates completed an unfamiliar laparoscopic task on a simulator during January to April 2008. Subjective stress before, during (retrospectively), and after the task was measured using the self-report State-Trait Anxiety Inventory. Objective stress was measured using continuous heart rate (HR) monitoring. Participants also completed the Trait Emotional Intelligence Questionnaire short form (TEIQue-SF). The authors computed scores for global trait EI and the TEIQue-SF four factors and carried out descriptive and correlational analyses. Results The highest levels of subjective stress were reported during the task and correlated positively with trait EI as well as with the trait EI factors of well-being and emotionality. Objective stress (mean HR) during the task was positively related to the sociability factor of trait EI. Higher trait EI scores were also associated with better after-task recovery from stress experienced during the task. Conclusions Students with higher trait EI are more likely to experience stress during unfamiliar surgical scenarios but are also more likely to recover better compared with their lower-trait-EI peers. Trait EI has implications for the design of effective stress management training tailored to individual needs and potential applications to surgical trainee selection and development.

Teams under pressure in the emergency department: an interview study

Objective To identify key stressors for emergency department (ED) staff, investigate positive and negative behaviours associated with working under pressure and consider interventions that may improve how the ED team functions. Methods This was a qualitative study involving semistructured interviews. Data were collected from staff working in the ED of a London teaching hospital. A purposive sampling method was employed to recruit staff from a variety of grades and included both doctors and nurses. Results 22 staff members took part in the study. The most frequently mentioned stressors included the ‘4-hour’ target, excess workload, staff shortages and lack of teamwork, both within the ED and with inpatient staff. Leadership and teamwork were found to be mediating factors between objective stress (eg, workload and staffing) and the subjective experience. Participants described the impact of high pressure on communication practices, departmental overview and the management of staff and patients. The study also revealed high levels of misunderstanding between senior and junior staff. Suggested interventions related to leadership and teamwork training, advertising staff breaks, efforts to help staff remain calm under pressure and addressing team motivation. Conclusions This study highlights the variety of stressors that ED staff are subject to and considers a number of cost-efficient interventions. Medical education needs to expand to include training in leadership and other ‘non-technical’ skills in addition to traditional clinical skills.

Measuring Safety and Efficiency in the Operating Room: Development and Validation of a Metric for Evaluating Task Execution in the Operating Room

BACKGROUND Although a number of validated tools are available for assessing nontechnical skills and teamwork in the operating room (OR), there are no tools for measuring completion of key OR tasks, which is fundamental to effective teamwork, patient safety, and OR efficiency. This study describes the development and content validation of a new tool (ie, the Metric for Evaluating Task Execution in the Operating Room) for measuring basic task completion during surgical procedures. STUDY DESIGN The content validity of 106 OR tasks was assessed using 50 real-time observations of general surgical procedures, followed by a process of expert consensus. A panel of 15 OR experts (ie, surgeons, anesthesiologists, and OR nurses) were asked to rate all tasks observed in <70% of procedures for relevance to patient safety and OR efficiency (using scientifically accepted definitions). Tasks rated highly were retained. Those perceived less relevant were removed. A second panel of patient-safety experts refined the tool to remove duplication, ensure usability, and include novel tasks. RESULTS Twenty-four of the original 106 tasks were observed in <70% of cases. Seven of these were rated highly by the OR experts for relevance to patient safety and efficiency and were retained in the Metric for Evaluating Task Execution in the Operating Room. Of the remaining 17, four were retained and 13 were removed by the patient-safety experts. In the final revision phase, an additional 23 tasks were removed and 10 new tasks added. The final tool consists of 80 OR tasks relating to well-established processes of care. CONCLUSIONS The Metric for Evaluating Task Execution in the Operating Room is easy to use and can identify specific gaps in safety and/or efficiency in OR processes. Next, we should examine its links with additional measures of OR performance, for example, patient outcomes, list cancellations/delays, and nontechnical skills.

The WHO surgical safety checklist: survey of patients’ views

Background Evidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study was to assess patients’ views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in. Method Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients’ views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire. Results 141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact positively on their safety and on surgical team performance. Those worried about coming to harm in hospital were particularly supportive. Views were divided regarding hearing discussions around blood loss/airway before their procedure, supporting appropriate modifications to the tool. Patients did not feel they had a strong role to play in safety improvement more broadly. Conclusions It is feasible and instructive to capture patients’ views of the delivery of safety improvements like the checklist. We have demonstrated strong support for the checklist in a sample of surgical patients, presenting a challenge to those resistant to its use.

The cancer multi-disciplinary team from the co-ordinators’ perspective: results from a national survey in the UK

BackgroundThe MDT-Coordinators’ role is relatively new, and as such it is evolving. What is apparent is that the coordinator’s work is pivotal to the effectiveness and efficiency of an MDT. This study aimed to assess the views and needs of MDT-coordinators.MethodsViews of MDT-coordinators were evaluated through an online survey that covered their current practice and role, MDT chairing, opinions on how to improve MDT meetings, and coordinators’ educational/training needs.Results265 coordinators responded to the survey. More than one third of the respondents felt that the job plan does not reflect their actual duties. It was reported that medical members of the MDT always contribute to case discussions. 66.9% of the respondents reported that the MDTs are chaired by Surgeons. The majority reported having training on data management and IT skills but more than 50% reported that they felt further training is needed in areas of Oncology, Anatomy and physiology, audit and research, peer-review, and leadership skills.ConclusionsMDT-Coordinators’ role is central to the care of cancer patients. The study reveals areas of training requirements that remain unmet. Improving the resources and training available to MDT-coordinators can give them an opportunity to develop the required additional skills and contribute to improved MDT performance and ultimately cancer care. Finally, this study looks forward to the impact of the recent launch of a new e-learning training programme for MDT coordinators and discusses implications for future research.

Implementation Science: A Neglected Opportunity to Accelerate Improvements in the Safety and Quality of Surgical Care

Objective: The aim of this review was to emphasize the importance of implementation science in understanding why efforts to integrate evidence-based interventions into surgical practice frequently fail to replicate the improvements reported in early research studies. Summary of Background Data: Over the past 2 decades, numerous patient safety initiatives have been developed to improve the quality and safety of surgical care. The surgical community is now faced with translating “promising” initiatives from the research environment into clinical practice—the World Health Organization (WHO) has described this task as one of the greatest challenges facing the global health community and has identified the importance of implementation science in scaling up evidence-based interventions. Methods: Using the WHO surgical safety checklist, a prominent example of a rapidly and widely implemented surgical safety intervention of the past decade, a review of literature, spanning surgery, and implementation science, was conducted to identify and describe a broad range of factors affecting implementation success, including contextual factors, implementation strategies, and implementation outcomes. Results: Our current approach to conceptualizing and measuring the “effectiveness” of interventions has resulted in factors critical to implementing surgical safety interventions successfully being neglected. Conclusion: Improvements in the safety and quality of surgical care can be accelerated by drawing more heavily upon implementation science and that until this rapidly evolving field becomes more firmly embedded into surgical research and implementation efforts, our understanding of why interventions such as the checklist “work” in some settings and appear “not to work” in other settings will be limited.