Improving Communication and Teamwork in the Surgical Environment

Improving Communication and Teamwork in the Surgical Environment

AHRQ Safety Program for Ambulatory Surgery Improving Communication and Teamwork in the Surgical Environment Module AHRQ Safety Program for Ambulatory Surgery AHRQ Pub. No. 16(17)-0019-2-EF Communication and Teamwork | 1 Objectives Describe challenges with teamwork and communication

in the surgical environment Use structured briefings to improve communication and teamwork AHRQ Safety Program for Ambulatory Surgery Use debriefings and ongoing quality improvement Demonstrate how the

checklist can improve teamwork and communication Learn how to use structured language to voice concerns Design a quality improvement initiative using closed-loop communication Communication and Teamwork | 2

Overview Communication and teamwork defined Improving surgical team communication with briefings Improving surgical team communication with debriefings The surgical checklist as a communication and teamwork tool Customizing the surgical checklist Speaking up using structured language Closed-loop communication AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 3 Communication and Teamwork Defined This section covers

The definition of communication Barriers to effective communication The impact of poor communication on patient outcomes The definition of teamwork The impact of poor teamwork on patient outcomes Perceptions of teamwork among members AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 4 Communication Is Getting the necessary information to the right people so decisions can be made The interaction among members of the surgical team

Briefing Debriefing AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 5 The Problem: Challenges of Effective Communication Operating and procedure rooms are chaotic and noisy environments Visual and auditory cues are hard to see and hear when people are wearing masks The person who is supposed to act on information isnt always clearly identified AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 6

The Impact of Poor Communication on Patient Outcomes Studies show that communication failures are the cause of 80 percent of adverse events1 Lack of communication has resulted in Wrong sites Wrong procedures Incorrect implants Missing equipment Mislabeling of specimens Delays in surgery Mazzocco K, Petitti D, Fong KT, et al. Surgical team behaviors and patient outcomes. Am Journ Surg.. 2009;197(5):678-85. PMID: 18789425. 1 AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 7 Team Structure As seen in TeamSTEPPS AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 8 High-Performing Teams Teams that perform well2 Hold shared mental models Have clear roles and responsibilities Have clear, valued, and shared vision Optimize resources Have strong team leadership Engage in a regular discipline of feedback Develop a strong sense of collective trust and confidence

Create mechanisms to cooperate and coordinate Manage and optimize performance outcomes Salas E, Burke CS, Stagl KC. Developing teams and team leaders: Strategies and principles. In: Demaree RG, Zaccaro SJ, Halpin SM, editors. Leader development for transforming organizations. April 2004 as cited in: TeamSTEPPS Fundamentals Course: Module 1. Introduction. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. http://www.ahrq.gov/professionals/education/curriculum-tools/te amstepps/instructor/fundamentals/module1/igintro.html . 2 As seen in TeamSTEPPS AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 9

The Impact of Poor Teamwork on Patient Outcomes Patients whose surgical teams exhibited fewer teamwork behaviors were at higher risk for death or complications.3 Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. Journal of the American College of Surgeons. 2007; 204(2):236-43. PMID: 17254927. 3 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 10 We Do Not All See Things the Same Way3 100% 90% 80% a

70% 60% b 50% OR nurse rates surgeon Surgeon rates anesthesiologist c 40% 30% d

20% 10% Surgeon rates OR nurse a b c Anesthesiologist rates surgeon d 0%

% Rating quality of collaboration and communication high or very high Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. Journal of the American College of Surgeons. 2007; 204(2):236-43. PMID: 17254927. 3 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 11 Improving Surgical Team Communication With Briefings This section covers Briefing defined The story of briefings in the surgical environment Benefits of team briefings Components of a good briefing Example of a briefing in an ambulatory surgery center

AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 12 A Briefing Is a Discussion That Facilitates clear and effective communication Gets the team on the same page Creates a sense of teamwork and collaboration Fosters an environment where team members can openly address a perceived problem Every member of the team actively participates in Can set the tone for the day and/or procedure

As seen in TeamSTEPPS 13 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 13 Historical Perspective: The Orange County Briefing Card at Kaiser Permanente4 Kaiser Permanente created preprocedural briefing cards for its Orange County hospitals in 2003 Contained key information for the entire team Cards were placed in every operating room Reduced wrong-site surgeries and other adverse events Increased staff morale Reduced nursing turnover

Shepard S. Teamwork in the OR. The Doctors Company: Patient Safety/Risk Management Strategies. An Ounce of Prevention. 2015. http://www.thedoctors.com/KnowledgeCenter/Publications/TheDoctorsAdvocate/Teamwork-in-the-OR. Accessed May 2015. 4 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 14 Briefings Help Us To Better know the game plan and be on the same page Monitor a situation and raise red flags Ensure each others needs and expectations are met Avoid unwanted surprises Reduce surgical flow disruptions Improve patient safety

15 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 15 Components of a Good Briefing All team members introduce themselves Team confirms Patient identification Procedure/surgical site and side Surgeon shares operative plan and possible difficulties Anesthesia professional shares anesthetic plan and airway and/or other concerns Nurse and scrub tech share equipment issues and/or other concerns Nurse and scrub tech confirm medications are correct and labeled and implant is the correct type and size

Surgeon sets the tone with a statement Does anybody have any concerns? If you see something that concerns you during this case, please speak up. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 16 Briefing Select to play video: https://youtu.be/NhFU4h3aQE4 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 17 Improving Surgical Team Communication With Debriefings

This section covers The definition of debriefing The benefits of team debriefing at the end of a case Components of a good debriefing Example of a debriefing in an ambulatory surgery center Timing of the debriefing discussion The use of debriefings for continuous quality improvement AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 18 A Debriefing Is a Discussion Where All team members participate before the patient is

transferred to recovery Team members reflect on what happened during the procedure This gives the team a chance to discuss Making a plan for the recovery of the patient Equipment problems encountered Improvements that could have made the procedure safer and/or more efficient As seen in TeamSTEPPS AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 19 Benefits of Debriefing Ensures all team members are on the same page Confirms critical information Provides a place to discuss adverse or potentially

adverse events that occurred Facilitates discussion of how to stop problems from reoccurring Promotes patient safety AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 20 Components of a Good Surgical Debriefing Verification of sponge and needle count Review of the procedure performed Confirmation of specimen labeling

Discussion of Equipment issues or problems Key concerns for patient recovery and management Actions needed to make the next case safer or more efficient AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 21 Debriefing Select to play video: https://youtu.be/fKmNhVn9R1I AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 22

Timing the Debriefing Discussion A good practice is to conduct the debriefing discussion in the operating or procedure room. The team should decide whether the debriefing should occur with the patient present. The debriefing should take place as soon after the procedure as possible. It may be helpful to begin the debriefing after the sponge counts have been completed or when the surgeon or physician removes their gloves. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 23 Problems Identified by Debriefings

Near misses Incorrect sponge and needle counts Equipment issues Mislabeling of specimens AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 24 Using Debriefings for Continuous Quality Improvement Create a way to collect identified problems or other important information Designate someone in the facility to monitor and

fix problems identified Update those who reported problems about steps taken to fix them AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 25 The Surgical Checklist as a Communication and Teamwork Tool This section covers Checklist background and evidence The checklist as a vehicle for briefings and debriefings Examples of surgical checklists that incorporate communication and teamwork AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 26 The Surgical Checklist Integrates process and communication items into one tool Ensures that the team discusses and performs critical safety steps for every patient at all times Requires the surgical team to stop at three critical points for safety review Before induction of anesthesia/before the patient enters the operating room Before skin incision/start of the procedure Before the patient leaves the room Designed to be Used by the entire team Read aloud from a hard copy AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 27 Benefits of the Checklist Enhances communication among team members Raises awareness of whats happening in the room Sets a positive tone Improves teamwork AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 28

Checklist Evidence Examples of Successful Use Haynes AB, Weiser TJ, Berry WB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009;360(5):491-9. PMID: 19144931. 6 Neily J, Mills PD, Yinong YX, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. PMID: 20959579. 7 Neily J, Mills PD, Yinong YX. Association Between Implementation of a medical team training program and surgical morbidity. Arch Surgery. 2011 Dec;146(12):1368-73. PMID: 22184295. 8 De Vries EN, Hollman MW, Smorenburg SM, et al. Development and validation of the SURgical Patient Safety System (SURPASS) checklist. Quality and Safety in Health Care. 2009;18(2):121-6. PMID: 19342526. 9 Van Klei WA , Hoff RG, van Aarnhem EE, et al. Effects of the Introduction of the WHO Surgical Safety Checklist on In-Hospital Mortality. Annals of Surgery. 2012 Jan;255(1):44-9. PMID: 22123159. 10 Bliss LA, Ross-Richardson CB, Sanzara LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. 2012

Dec;215(6):766-76. PMID: 22951032. 5 29 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 29 Checklists Used as Communication Tools WHO Surgical Safety Checklist Safe Surgery 2015 Checklist

Cardiac Surgery Checklist Endoscopy Checklist Ambulatory Surgery Center Checklist AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 30 Ambulatory Surgery Center Checklist: Before Patient Enters Room Nurse, Anesthesia Professional, and Patient Review Nurse and Anesthesia Professional Discuss

Implants available in the operating room Correct type and size Essential imaging available Risk of hypothermia - operation >1 hour Warmer in place Risk of venous thromboembolism Boots and/or anticoagulants in place Anesthesia safety check is completed Type of anesthesia Anticipated airway and aspiration risk Changes in patients cardiac history Changes in patients respiratory history

Patient identification (name and date of birth) Surgical site Surgical procedure to be performed matches consent form Site marked Patient position Known allergies Patient weight AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 31 Ambulatory Surgery Center Checklist: Before Skin Incision

Before Skin Incision Entire surgical team Is everyone ready to perform the timeout? Please state your name and role. Surgeon, nurse, and anesthesia professional perform the timeout Patients name Planned surgical procedure matches listing on the consent form Surgical site Has antibiotic prophylaxis been given within the last 60 minutes, if indicated? AHRQ Safety Program for Ambulatory Surgery

Briefing Surgeon shares Any changes to operative plan and possible difficulties Anesthesia professional shares Anesthetic plan Airway and other concerns Circulating nurse and scrub tech share Equipment issues Other concerns Circulating nurse and scrub tech confirm All medications are correct and labeled Implant type and size Surgeon states Does anybody have any concerns? If you see something that concerns you during this case, please speak up

Communication and Teamwork | 32 Ambulatory Surgery Center Checklist: Before Patient Leaves the Room Before Patient Leaves Room Nurse reviews with team Instrument, sponge, and needle counts are correct Name of the procedure performed Specimen labeling Read back specimen labeling including patients name AHRQ Safety Program for Ambulatory Surgery Debriefing

Surgical team discusses Equipment problems that need to be addressed Key concerns for patient recovery and management Actions needed to make the next case safer or more efficient Communication and Teamwork | 33 Customizing the Surgical Checklist This section covers How to build an implementation team What to think about when customizing your checklist

How to test your checklist outside of the patient environment using tabletop simulation How to test your checklist in the patient environment AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 34 Building an Implementation Team Create a team that will help lead this work in your facility At a minimum the team should include at least one Administrator Surgeon/physician Anesthesia professional Nurse

Scrub technician AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 35 Things To Consider When Customizing Your Checklist It should be customized to fit the needs of your facility Think about Cases Patient population Special needs Do not make your checklist too long AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 36 When Considering Items for the Checklist, Ask AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 37 Testing Your Checklist Outside of the Patient Environment Using Tabletop Simulation Part One This is the first place to try your checklist after making changes. Testing the checklist outside of the operating room/procedure room helps identify items you may want to change without making mistakes on patients. Say the words on the checklist aloud and pretend you are in a real case. Often the words look good on paper but do not necessarily reflect what you would say in

an actual case. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 38 Example of a Tabletop Simulation Part One Select to play video: https://youtu.be/V_nU8WxCH2w AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 39 Testing Your Checklist Outside of the Patient Environment Using Tabletop Simulation Part Two After reviewing the checklist, discuss the changes needed before using it on a patient.

Assign team members tasks, and make changes based on feedback if necessary. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 40 Example of a Tabletop Simulation Part Two Select to play video: https://youtu.be/FY1ZgmC4oJU AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 41 Testing Your Checklist in the Patient Environment Test the checklist with one team for one case, and modify as necessary.

Test the checklist with one team for one day, and modify as necessary. This process may be repeated multiple times with the same team or with different teams to make sure your checklist works before finalizing it. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 42 Speaking Up Using Structured Language This section covers The importance of voicing concerns in the surgical environment The barriers to speaking up The solution the use of structured language The CUS technique

Examples of speaking up As seen in TeamSTEPPS AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 43 Why Voicing Concerns in the Surgical Environment Is Important Problems that happen because no one addressed them Wrong site Wrong procedure Wrong/missing implant Wrong medications Unidentified allergy Wrong equipment

AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 44 Barriers to Speaking Up Fear of Being embarrassed Feeling stupid Being ridiculed Being yelled at Being wrong Saying something thats not important Thinking that They wont listen anyway. Its not that important. AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 45 The Solution: Structured Language Use special words that indicate there is a problem. Both the sender and the receiver need to understand these words. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 46 The CUS Technique As seen in TeamSTEPPS AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 47

Examples of Speaking Up Select audio symbol to play audio, or access audio here: https ://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-surgery /sections/implementation/training-tools.html AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 48 Closed-Loop Communication This section covers Closed-loop communication defined How closed-loop communication works Examples of closed-loop communication

AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 49 The Solution: Closed-Loop Communication Improves the teams ability to exchange clear and concise information Acknowledges receipt of that information Confirms that information is clearly understood AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 50 How Closed-Loop Communication Works As seen in TeamSTEPPS AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 51 Closed-Loop Communication Example Select audio symbol to play audio, or access audio here: https ://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-surgery /sections/implementation/training-tools.html AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 52 Summary There is an opportunity for us to improve patient care by improving teamwork and communication. Ways to improve teamwork and communication Have the entire team perform a briefing before

every case and a debriefing at the end of every case. Bring briefing and debriefing into the surgical environment by using the surgical checklist. Use structured language. Teach people closed-loop communication. AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 53 Tools Checklist demonstration video

Closed-loop communication audio recording CUS technique13 Examples of checklists Ambulatory Surgery Center Checklist11 Endoscopy Checklist Template Safe Surgery 2015 Checklists11 WHO Surgical Safety Checklist12 TeamSTEPPS Debriefing and Briefing Checklists13 Speaking up audio recording CUSP Learn From Defects Tool14 Tabletop simulation Safe Surgery 2015. Ariadne Labs. http://www.safesurgery2015.org/checklist-templates.html. Accessed July 2013. World Health Organization Surgery Checklist. http://www.who.int/patientsafety/safesurgery/checklist/en/. Accessed July 2013. 13Pocket Guide: TeamSTEPPS. Rockville, MD: Agency for Healthcare Research and Quality; January 2014. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.htm. 14Learn From Defects Tool. Rockville, MD: Agency for Healthcare Research and Quality; December 2012. http:// www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.htm. 11

12 AHRQ Safety Program for Ambulatory Surgery Communication and Teamwork | 54 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11. 12. 13. 14. Mazzocco K, Petitti D, Fong KT, et al. Surgical team behaviors and patient outcomes. Am Journ Surg. 2009;197(5):678-85. PMID: 18789425. Salas E, Burke CS, Stagl KC. Developing teams and team leaders: Strategies and principles. In: Demaree RG, Zaccaro SJ, Halpin SM, editors. Leader development for transforming organizations. April 2004 as cited in: TeamSTEPPS Fundamentals Course: Module 1. Introduction. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro.html. Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. Journal of the American College of Surgeons. 2007; 204(2):236-43. PMID: 17254927. Shepard S. Teamwork in the OR. The Doctors Company: Patient Safety/Risk Management Strategies. An Ounce of Prevention. 2015. http://www.thedoctors.com/KnowledgeCenter/Publications/TheDoctorsAdvocate/Teamwork-in-the-OR. Accessed May 2015. Haynes AB, Weiser TJ, Berry WB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009;360(5):491-9. PMID: 19144931. Neily J, Mills PD, Yinong YX, et al. Association between implementation of a medical team training program and surgical

mortality. JAMA. 2010;304(15):1693-1700. PMID: 20959579. Neily J, Mills PD, Yinong YX. Association Between Implementation of a medical team training program and surgical morbidity. Arch Surgery. 2011 Dec;146(12):1368-73. PMID: 22184295. De Vries EN, Hollman MW, Smorenburg SM, et al. Development and validation of the SURgical Patient Safety System (SURPASS) checklist. Quality and Safety in Health Care. 2009;18(2):121-6. PMID: 19342526. Van Klei WA , Hoff RG, van Aarnhem EE, et al. Effects of the Introduction of the WHO Surgical Safety Checklist on In-Hospital Mortality. Annals of Surgery. 2012 Jan;255(1):44-9. PMID: 22123159. Bliss LA, Ross-Richardson CB, Sanzara LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg. 2012 Dec;215(6):766-76. PMID: 22951032. Safe Surgery 2015. Ariadne Labs. http://www.safesurgery2015.org/checklist-templates.html. Accessed July 2013. World Health Organization Surgery Checklist. http://www.who.int/patientsafety/safesurgery/checklist/en/. Accessed July 2013. Pocket Guide: TeamSTEPPS. Rockville, MD: Agency for Healthcare Research and Quality; January 2014. http:// www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.htm. Learn From Defects Tool. Rockville, MD: Agency for Healthcare Research and Quality; December 2012. http:// www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.htm. AHRQ Safety Program for Ambulatory Surgery

Communication and Teamwork | 55

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