Historical development crtitical success factors in surgery

1. Improving Patient Safety in the Dutch OR’sJohan LangeDepartment of Surgery Erasmus University Medical Center Rotterdam

2. Historical development crtitical success factors in surgery factor Results Best practices, protocols (patientsafety) Risk factors patient medication (anesthetics, AB, heparin) Professional training instruments&apparatus 0 21st century

3. Patient safety in the Netherlands (reports) • To err is human (Institute of Medicine 1999) • Hier werk je veilig, of je werkt hier niet (VMS; Rein Willems 2004) • TOP I (toezicht preoperatief proces/registratie; IGZ 2007) • Het resultaat telt (prestatieindicatoren IGZ) • Uitgeteld? (Meijsen, Meers 2007) • Voorkom schade, werk veilig (OMS, NVZ, LEVV 2007) • Koers op kwaliteit (VWS 2007) • TOP II (toezicht peroperatief proces/registratie; IGZ 2008) • Adviesrapport Cie Patiëntveiligheid NVvH

4. Adverse events in the Dutch OR (2005) • 45000 adverse events in 1.000.000 operations/year (all specialisms) • 25000 adverse events in surgery: 2.5% of operations • 10.000 adverse events in surgery: avoidable • Probably only 25% is reported • 400 mortal adverse events in the OR • 130 mortal adverse events in surgery • 40%: avoidable: 50 avoidable death in surgery/year -Report ‘Onbedoelde schade in de Nederlandse ziekenhuizen (Emgo/NIVEL 2007) -Cuperus-Bosma JM et al. NTvG 2005; 149: 2153-6

5. Adverse events in surgery • 36% of all adverse events in health care • Avoidable: 40% • >50%: related to the individual surgeon

6. Tenerife 1977: 583 death

8. Aviation before1977: autocratic leadership =

9. Incidents in aviation: ‘75% (human factors)-rule’ • accident-analysis, blackbox, simulator-research: ‘75% rule’: 75% of incidents caused by teamwork-failure (human factors, chain of errors, human performance limitation)

10. Teamwork: shared mental model • Team situational awareness by: • Sharing knowledge: Goals Tasks Responabilities • Free flow of information among crew menbers, without fear of reservation (beware of dependance and hierarchy)

11. CRM (Crew Resource Management) • Obligation: Joint Aviation Requirements • Coaching instead of autocratic leadership • Leader-follower roles • Cross checking (briefing/debriefing, checklists) • Intervision/peer assessment (blame free-reporting)

13. CRM: technically-complex high risk industries

14. OR 21st century: technically-complex high risk environment

15. Report ‘To err is human’Institute of Medicine USA 1999 "The experiences of other industries provide valuable insight about how to begin the process of improving safety of health care by learning how to prevent, detect, recover and learn from accidents."

16. VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004 • Recommendations: 1) Safety management system in all hospitals (VMS) • Blamefree incident-reporting

17. VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004Rein Willems (CEO Shell) • Recommendations: 1) Safety management system in all hospitals (VMS) • Blamefree incident-reporting

18. Teamwork in the OR • OR nurses are dissatisfied with communication in the OR • Nestel D, Kidd J. BMC Nursing 2006; 5:1 Feeling like a team member: • 75% of surgeons • 53% of residents • 45% of anesthesiologists • 23% of OR-nurses

19. team or….

20. Ongoing taboos in the OR • Failability of the surgeon • Horizontal communication • Mistakes (Culture of Name , Blame and Shame)

21. Communication: conflicts • Conflict between doctors: in 50% of hospitals • Conflicts with or within other professions: 36% Emmeloord/Lelystad Meppel Nijmegen Utrecht Source: L.A.P. Arends, i-BMG Erasmus University 2004

22. Autocratic leadership with vertical communication

24. Ego’s & culture: idolatry

25. CRM: new leadership in the OR-team • Open communication • Coaching/Bindend/Sharing • Applying protocols and S.O.P.’s • Blamefree reporting

26. Professor Rhona Flin (Aberdeen)Behavioural marker observation system for teamwork

27. Advantages teambuilding/CRM (non technical-skills) • Respect and trust • Horizontal communication • Sharing knowledge and targets • Coaching/binding/sharing leadership • Cross checking (protocols, S.O.P.’s) • Peer assessment • Culture of transparancy (blamefree reporting) • Improved climate

28. Teamperformance: CRM + expertise (scenario-based simulation)

29. Teamperformance: CRM + expertise (scenario-based simulation)

30. Joint Commission on Accreditation of Healtcare Organizations (JCAHO) Universal Protocol for eliminating wrong site-, wrong procedure-, wrong person-surgery • Time Out-Procedure • Right side surgery • Type of procedure (protocol) • Identification patient

31. Wrong side-surgery

32. Eye-hospital Rotterdam :disappearance of wrong-side surgery

33. TOP (Time Out Procedure)+ Johan Lange, Linda Wauben, Conny Dekker, Geert Kazemier, Jan Klein, Jeroen PetersDepartments of Anesthesiology and Surgery Erasmus MC

36. Duration 1-2’ Compliance high In 15% of operations incidents can be avoided Anesthiology assistant: director Results pilot TOP+

37. Time Out=double check Time-Out

38. SURPASS (SURgical PAtient Safety System) –perioperative checklist • Validated (Marja Boermeester) • Transfermoments (ward-holding-OR) • Stopping rules

39. Teamwork (CRM): culture shock/paradigma shift • Transforming individual professionals into a professional team • Changing training/medical education • New shared responsabilities • New professional relationships

40. Soft??

41. Medical eduction/training: teamfunctioning

42. Short term-vision: Bureaucracy-reflex model Regulations Audit Long term-vision Regulations Audit Transparance Teamconcept Patient safety in the OR: planning

43. Historical development crtitical success factors in surgery factor Results Best practices, protocols (patientsafety) Risk factors patient medication (anesthetics, AB, heparin) Professional training instruments&apparatus 0 21st century

44. Historical development crtitical success factors in surgery factor Teamwork! Results Best practices, protocols (patientsafety) Risk factors patient medication (anesthetics, AB, heparin) Professional training instruments&apparatus 0 21st century