The Path to a Culture of Operating Room Safety

1. 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

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

3. 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

4. Operating Room and Team 1914 Saint Francis Hospital

5. Operating Room and Team 2012

6. Culture of Blame and Shame

7. Example of a blank slide As reported by Joint Commission Sentinel Event Types 3Q 2011 www.jointcommission.org

8. Identifying Culture Communication Behavior Rituals Tolerance

9. OR Safety Attitudes Questionnaire - SAQ www.uth.tmc.edu/...safety/questionnaires/SAQBibliography.html

10. SAQ Participants N=161 N=161

11. Overall SAQ Results

12. 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)

13. Why Team Training? Gives all employees a voice Enhances communication Addresses improper behavior Helps to build trust Encourages leadership Improves the overall safety culture

14. Launch of Team Training Crucial Conversations Leadership Training

15. 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

16. 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?

17. Confront With Positive Outcomes Violence Safety Safety Pool of Shared Meaning Safety Silence We must first reflect on ourselves How do I deal with conflict?

18. What Is The Story? Our story becomes our truth… EVENT See/ Hear Tell a story Feel ACT …and assumptions are made.

19. 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)?

20. 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

21. Session 2 - Communication Strategies to Get What You Need Recognize your Style Under Stress • Refuse the Sucker’s 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.

22. The Meaning of the MessagePerception vs. Intent Sender of MessageReceiver 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

23. Checklist Introduction

24. Session 3 Achieving a Positive Outcome Fight natural tendency to silence and violence Clarify intent or real motivation Establish a mutual purpose Listen for understanding Rebuilding Safety

25. 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 It’s not what you say but how you say it

26. OR Change Agents OR Ambassadors OR Observers Executive Leadership

27. 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.

28. American College of SurgeonsNational Surgical Quality Improvement Program Evidence-based Risk-adjusted Data driven = Improved Surgical Outcomes Shukri F. Khuri, MD

29. Quantitative Results N=73 general surgery cases ACS NSQIP data 3391 cases vs. 153 cases

30. Number of Surgical Cases With Safety-Compromising Events

31. 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

32. 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

33. Thank You sellner@stfranciscare.org