Studies have shown that a huge percentage of medical errors are due to non-technical issues such as poor team behavior. Health care institutions that implement special team training programs for all surgical staff have been able to reduce morbidity and mortality rates and even see success beyond the operating room.

 

It’s called a surgical team, but recent studies suggest that more focus needs to be on teamwork. Reports on surgical error rates show that between 40% and 70% of errors can be attributed to non-technical issues such as poor communication [2,8,11] and approximately half of closed malpractice claims cite ineffective teamwork [4]. A study on pediatric cardiac surgery found a correlation between the number of technical errors that occurred and the quality of the surgical team’s non-technical skills [5].

​Read an interview with Robert Postigo

Healthcare is a team sport

Borrowing from the airline and other high-risk industries, healthcare has recently started to adopt crew resource management or team training initiatives to address error rates. Two decades of research in other high-risk industries have established that team training is successful [6] and in the last five years in particular, nearly 500 studies on teamwork topics in healthcare have been published [7].

 

​This brief news piece describes a study that found that communication and teamwork training delivers improved patient outcomes.

 

Team training is based on the assertion that outstanding technical skills alone are not sufficient for high levels of surgical performance; non-technical skills such as teamwork, communication, leadership, task management, and situational awareness are also vital [3].

 

​This video shows three healthcare professionals (anesthesiologist, surgeon and patient safety coordinator) adopting to the role of flight crew, to illustrate the comparison between the 'safe surgery checklist' of an operating room and the checklist used by airline pilots. What if an airplane was an operating room?

 

What is team training?

Team training has become an all-encompassing phrase that includes a wide range of teamwork skills and learning strategies. Weaver et al (2014) wrote, “The critical element defining team training is that the learning activity focuses on developing, refining and reinforcing knowledge, skills or attitudes that underlie effective teamwork behaviors such as communication, coordination and collaboration.” [7] In many team training programs, there is an attempt to reduce the hierarchy within a team so that all team members feel comfortable speaking up if there is a problem. The skills taught can be valuable for both intact (always working together) and ad hoc teams (the norm for surgical teams) [6].

 

Various team training curricula include TeamSTEPPS, Crew Resource Management (CRM), and Medical Team Training (MTT) [7].

 

Surgical team training may include these common tools:

• Checklists
• Feedback
• Simulations

 

Whether the team flies a plane or performs spine surgery, team training approaches have been shown to improve safety, turnaround times, and in the case of surgical team training, decrease infection rates and OR waste.

 

Make a list, check it twice

Checklists are proven tools that bring focus to teams, from aviation to the operating room.

 

The World Health Organization (WHO) initiated the Safer Surgery Saves Lives project in 2007 [8], in which standards for the safe delivery of surgical care and a 19-item Surgical Safety Checklist (SSC) were trialed in eight countries and then globally circulated.

 

​World Health Organization Surgical Safety ChecklistWHO has developed a 19-point surgical check-list to decrease errors and adverse events. Available in six languages, the organization also provides information on implementation 

 

Mirroring the three phases of take-off, cruise and landing in the aviation industry, the SCC directs surgical teams to systematically follow standard checklist questions during “sign in” (before anesthesia induction), “time out” (before skin incision) and “sign out” (before the patient leaves the OR).

 

This includes, amongst other points: confirming patient identity and surgical site, team introduction and critical events review, confirmation of post-operative handling of specimens and patient destination.

 

A 2009 paper [9] published in the New England Journal of Medicine reported the results of the SCC trials and found that the rate of death declined from 1.5% before the checklist was introduced to 0.8% afterward. Inpatient complications also declined from 11.0% of patients at baseline to 7.0% after introduction of the checklist.

 

​Source: Adapted from Yule S, Flin R, Paterson-Brown S et al (2006) Non-technical skills for surgeons in the operating room: A review of the literature. Surgery; 139(2) 140-149.Interpersonal SkillsCommunicationLeadershipTeamworkBriefing/planning/preparationResource managementSeeking advice and feedbackCoping with pressure/stress/fatigueExamples of non-technical/team training skillsCognitive SkillsSituational awarenessMental readinessAssessing risksAnticipating problemsDecision makingAdaptive strategies/flexibilityWorkload distribution

 

 

Feedback loops

Feedback is an important part of the learning and growth process in team training. It is often an aspect of debriefings and serves as course correction. It is a critical facet of personal growth and cultural change.

 

Feedback can be both formal and informal. Formal feedback can occur during debriefing, morbidity-mortality committee meetings, or goal assessment strategy meetings. Informal feedback during team meetings provides education opportunities and the evaluation of teamwork behaviors.

 

No matter where feedback occurs in the process, “the ability to capitalize on improvements to produce more change over time is critically linked…through a systems feedback loop” [10].

 

Testing it out

Simulations are a way for a surgical team to “get the kinks out.” Many simulations are designed to enable trainees to learn from adverse clinical outcomes or test out newly learned interpersonal or cognitive skills.

 

The University of Basel in Switzerland developed a simulation program called Team-oriented Medical Simulations (TOMS) [11]. The TOMS program provides interdisciplinary team training for nurses, anesthesiologists, orderlies, and surgeons using mannequins and live abattoir organs. Video is also used for debriefing and feedback after the simulation.

 

While the benefits of simulations for learners is apparent, there is little evidence to show that this translates directly into safer outcomes for patients. Instead, simulations are just one of the essential ingredients for improved patient outcomes.

 

Determining if the training is effective

There are four levels at which team training can be assessed for effectiveness [12].

Level 1: learner reactions to the training

Level 2: learner knowledge, confidence, and attitudes

Level 3: teamwork behaviors and skills

Level 4: clinical process and patient outcomes.

It is necessary for changes on the first three levels to occur to have organizational changes at level four. Studies on team training have assessed outcomes at various levels, but few studies have examined all four.

 

​Surgical outcomes are a function of several interrelated events. From a sociotechnical perspective, surgical outcomes are influenced by (a) individual experience, (b) individual competence, (c) collective knowledge, and (d) collective experience. These factors inform and shape role expectations and role performance. source: Leach L, Myrtle RC, Weaver FA et al (2009) Assessing the performance of surgical teams. Health Care Manage Rev; 34(1), 29-41.https://msbfile03.usc.edu/digitalmeasures/dasu/intellcont/hcmrarticle-1.pdf Influences on surgical team performance and outcomes
(click to zoom)

Effects of team training on patient outcomes

The largest study on the effects of a team training program on surgical outcomes in the US was conducted by the Veterans Health Administration (VHA) from 2006 to 2008 [13,14]. The study included 108 VHA facilities and over 180,000 procedures. The VHA team training borrowed heavily from the aviation industry training theories (CRM) and utilized checklists for preoperative and postoperative briefings.

 

Approximately two thirds of the facilities underwent team training while the remaining 34 facilities had not yet done so at the time of article publication and acted as a control. Patient outcomes were measured for one year after training occurred and compared with control facilities.

 

The facilities that received training experienced an 18% reduction in annual mortality [13] and a 17% reduction in annual morbidity [14], a statistically significant amount greater than the control facilities. A dose-response relationship was also derived which showed that for every quarter the training program was in place there was a reduction of 0.5 deaths per 1000 procedures [13,14].

 

In several write-ups of the study, the authors noted their belief that preoperative checklist-driven briefings were key to avoiding adverse events and establishing a shared mental model between surgical team members [13,14].

 

 

Benefits of Surgical Team Training at VHA Facilities

 

• 18% decrease in annual mortality
• Continued decrease of mortality rates the longer the program was implemented
• 17% decrease in annual morbidity
• Significant decrease in deep venous thrombosis, superficial surgical infection, and deep wound infection
• Improved communication, staff awareness, and teamwork

 

The Veterans Health Administration in the US conducted team training at 74 facilities and compared them with 34 control facilities; over 180,000 surgical procedures were examined. Facilities that received training were followed for one year afterwards.

 

 

Other studies have found significant decreases in technical and procedural (non-technical) errors following team training for surgical teams [15]. Rates of revision surgery and complications such as infection have also been shown to decrease [16]. The converse is also true; patients whose surgical teams demonstrate less teamwork behaviors are at higher risk for complications and death [16].

 

Outside the OR

Team training has benefits that extend beyond better patient outcomes. Several studies have shown that efficiency and timeliness increased in facilities that conducted team training [4]. Likewise, case length and turnaround time in the OR have been shown to decrease [4]. One study even found that average length of hospital stay decreased after team training, although these results were not significant [5]. Team training can also help increase efficiency and communication in outpatient offices and clinical practices. Some facilities report that job satisfaction also increases following team training, which is likely a side benefit of a more collegial, efficient, and safe workplace.

 

While the benefits of team training can be myriad, the importance of buy-in and follow-up are essential to success. Initial cultural resistance by medical staff to the adoption of team training practices and the time needed for education has been noted in a few studies [5].

 

In some cases, the OR was closed for a day to conduct training, and without the support of medical staff to these types of occurrences, team training can be less effective. Continued education (just technical, skills-based CME) or follow-up is also essential to reinforce skills, keep medical staff up-to-date, and realize the full value of team training.

 

​Back to top

 

 

 

“The better the preoperative briefing, the better the teamwork”

 

AOSpine spoke with Chilean spine surgeon Robert Postigo about his experiences with surgical teamwork. He shares his preoperative routine with us to highlight how important, and crucial to patient safety, a good briefing is.

 

What do you do in the OR to enhance effective communication and teamwork?

One of the biggest problems during the perioperative period is precisely bad communication between team members, rather than fatigue or overload of work, and a little bit less than inexperience or lack of competence. Therefore, communication is highly important in the spine surgery specialty. I've been especially aware of communication needs and communication importance during operations because I have experienced these problems. So, thinking about it, I've been involved in how to manage this and how to make all the people that integrate the operation more comfortable. In spine surgery there are a lot of people inside the OR so it's vital that you work on communication.

 

Do you use any tools (checklists, briefings) before or after operations?

Yes, we do a briefing before the operation when we are all inside the OR with the patient awake. Everybody has to check the name of the patient, their age, and the correct side and diagnosis, and whether everything inside the OR is ready and prepared for the surgery. When everyone says, "Yes, I'm ready" we put the patient to sleep. Next, the surgical team goes through all the images and the medical record and checks the medical record again before we begin the operation.

 

After the operation, there is a postoperative briefing - what went well, what went wrong, and what should we do next time so this won't go wrong again. Also, we have a preoperative meeting each Friday where we discuss all the patients that will be operated on the next week. And we check on all the patients who had surgery the week before. This extends our knowledge and allows us to learn from others' experience.

 

Half of malpractice claims are attributed to poor team-communication. Have you ever read about or had any such experiences?

Literature says that about 50% of medical malpractice can be attributed to this issue. I've had a couple of those. And every one of us surgeons can tell you one or two cases of such a terrible experience. There are a lot of them described in the literature, I will tell you one of mine. I had a patient with a lumbar disc herniation. In admission, the nurse marked the disc herniation as the right side on the chart, although in the medical record it was stated that it was the left side. In the preoperative briefing the nurse marked the right side also. The young fellow, reading this put the MRI sheet in the inverse position, so the right turned to left and the left turned to right. He did not ask or show his doubt to the surgical team.  Here is the crucial moment of communication failure. So everybody was happy when the operation began.   After flavectomy, no disc herniation was felt in the Penfield discector. That made us check all over again and we discovered the error. So fortunately we could do the right operation going to the contralateral side.

 

 

Do you have any advice on how to prevent errors and enhance better teamwork?

Error is human; there is always a chance for failure. We, doctors can also fail as humans that we are. So whatever you can do to make your patient's safety better,  it is important to do it.  In this respect working well as a surgical team is one of the key factors of success. You don't have to act as a superhero,  but as a simple human being, so always be aware. Follow the rules, be prepared, things may happen, do briefings. As with any airplane previous to departure, you have to do a briefing before the surgery with all your team and then you will have better results. Literature is conclusive in this regard.

 

______

Roberto Postigo

Roberto Postigo, MD is a spine surgeon at Clínica Las Condes in Santiago, Chile. He  was chair of the Chilean chapter of AOSpine and served as the AOSpine education officer for Latin America and AOSEC member from 2011 to 2013. Dr Postigo has also chaired and served as educational advisor for numerous AOSpine courses including Davos Masters Courses.

 

 

 

References

1. Gillespie BM, Chaboyer W, Murray P (2010) Enhancing Communication in surgery through team training interventions: a systematic literature review. AORN; 92(6)642-657.
2. Rabøl LI, Andersen ML, Østergaard D et al (2011) Description of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf; 20(3)268-274.
3. Yule S, Flin R, Paterson-Brown S et al (2006) Non-technical skills for surgeons in the operating room: A review of the literature. Surgery; 139(2) 140-149.
4. Harden SW (2011) Surgeons and teamwork. AAOS Now. http://www.aaos.org/news/aaosnow/mar11/managing3.asp
5. McCulloch P, Mishra A, Handa A et al (2009) The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Staf Health Care; 18:109-115.
6. Leach L, Myrtle RC, Weaver FA et al (2009) Assessing the performance of surgical teams. Health Care Manage Rev; 34(1), 29-41. https://msbfile03.usc.edu/digitalmeasures/dasu/intellcont/hcmrarticle-1.pdf
7. Weaver SJ Dy SM, Rosen MA (2014) Team-training in healthcare: a narrative synthesis of the literature. BJM Qual Saf; 23(5):359-72. http://qualitysafety.bmj.com/content/early/2014/02/05/bmjqs-2013-001848.full
8. World Health Organization (2008) World Alliance For Patient Safety – Safe Surgery Saves Lives. Geneva: WHO. Available:http://www.who.int/patientsafety/safesurgery/en/index.html
9. Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med; Jan 29;360(5):491-9.
10. King HB, Kohsin B, Salisbury M (2005) Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense. Advances of Patient Safety (v3: Implementation issue). http://www.ncbi.nlm.nih.gov/books/NBK20545/
11. Baker DP, Gustasfon S, Beaubien JM et al (2005) Medical team training programs in healthcare. Advances of Patient Safety (v4: Programs, Tools, and Products). http://www.ncbi.nlm.nih.gov/books/NBK20580/
12. Sevdalis N, Hull L, Birnbach DJ et al (2012) Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. BJA; 109(S1)i3-i16.
13. Neily J, Mills PD, Young-Xu Y et al (2010) Association between implementation of a medical team training program and surgical mortality. JAMA; 304(15)1693-1700. http://jama.jamanetwork.com/article.aspx?articleid=186748
14. Young-Xu Y, Neily J, Mills PD et al (2010) Association between implementation of a medical team training program and surgical morbidity. Arch Surg; 146(12)1368-1373.
15. Armour Forse R1, Bramble JD, McQuillan R et al (2011) Team training can improve operating room performance. Surgery; 150(4)771-778.
16. Massocco K, Petitti DB, Fong KT et al (2009) Surgical team behaviors and patient outcomes. Am J Surg; 197:678-685. http://www.americanjournalofsurgery.com/article/S0002-9610%2808%2900459-5/abstract

 

 

 

The articles included in the Newsletter represent the opinion of the individual writer exclusively and not necessarily the opinion of AOSpine.