National Surgical Patient Safety Summit (NSPSS) Program Aug 4-5 2016 Chicago IL- Summary

National Surgical Patient Safety Summit (NSPSS) Program Aug 4-5 2016 Chicago IL- Summary

 

In spite of advances in technology, as well as numerous protocols and regulations, surgical adverse events and patient harm plague all healthcare organizations. In August 2016 representatives from 80 medical -surgical organizations attended the National Surgical Patient Safety Summit (NSPSS) program sponsored by the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS). Dr. Gordon Telford, MD and I were honored to represent the Association of VA Surgeons (AVAS) at this landmark event. The mission of the program was to "propose solutions that effectively combine elements of safety science, principles of high reliability and best safety practices across all phases of surgical care." Key leaders from the ACS and AAOS have been meeting over the past two years to establish the framework for proceeding with a safety summit. The preliminary workgroup identified key surgical safety content (knowledge), current knowledge gaps, and key evidence / consensus-based surgical safety practices and behaviors. This initial group expanded to include the ASA and AORN to draft initial safety standards, propose content for safety education programs, and identify surgical safety data needed to improve safety for surgical patients. This effort culminated with the August Summit which had the following goals:

• Define essential surgical safety knowledge, behaviors and systems

• Identify required safety data collection and performance measurement

• Propose surgical resident/fellow and surgeon safety education and skills curricula/programs

• Identify surgical safety knowledge gaps and research priorities

• Propose surgical safety standards for surgical education programs and practices.

 

The Summit was divided into four key workgroup (WG) sessions, each with its own unique goal. WG1, key safety definitions / elements / processes/phases of care, identified and defined essential surgical safety elements and processes, as well as the multiple teams involved responsible for all phases of the surgical care continuum. WG2, human factors / behaviors / culture / high reliability, identified principles, behaviors, and systems needed to improve surgical communication and leadership supporting a highly reliable and sustainable culture of safety. WG3, Technology/Data/Performance Measurements, identified principles, measures, and programs needed for collection and analysis of surgical safety data to drive performance measurement. WG4, Education/Training Programs, identified and strategies for education programs needed to advance surgeon recommended implementation, surgical team, and surgical facility safety knowledge and practices. Each workgroup which led by a team of well-known surgical safety advocates (list found below).

(The following is a summation of the 50-page meeting outline and 8 hours face to face time)

 

WORKGROUP 1: SAFETY DEFINITIONS:

• David Hoyt, MD, William Robb, MD; Dwight Burney, MD, Anthony Battie, RN, MN, CNOR; Arthur

Boudreaux, MD

GOAL: identified and defined essential surgical safety elements and processes, as well as the multiple teams involved responsible for all phases of the surgical care continuum.

 The quest for the achievement of surgical safety occurs in a background of many challenges. Patients often enter this system with complex co-morbidities, poor family support and limited or no health literacy. The healthcare system is challenged by a disjointed system wrought with potential human factor, instrument, equipment, infrastructure and other system failures. The possibilities for technical and non-technical slips, lapses or mistakes are endless. Transitions between phases of surgical care are plagued with loss of critical patient information and propagation of misinformation. While multiple professions are charged with the responsibility of coordinating challenging aspects of surgical care, surgeons are "uniquely obligated ethically and professionally to serve as the patient's navigator and advocate".

Important safety element to optimize implementation of safety cultures:

1.   Surgical leadership must optimize team performance and advocate a 'Culture of Safety' using open respectful communication, setting the expectations, coaching towards performance improvement, managing / facilitation conflicts.

2.  Surgical leaders must perfect non-technical skills via establishment of psychological safety and advocating a shared mental model, utilize standardized evidence based surgical clinical pathways, adopting locally endorsed checklists, collect and follow safety data, endorse high reliability principles in surgical teams (see below).

3.  Surgical leaders endorse the use of safety technology demonstrated to reduce patient harm (??)

4.  Surgical leaders are committed to the establishment and maintenance of safe surgical environment thru policies and values which provide core surgical teams with the skills and knowledge to proceed safely, optimize team performance including minimization of fatigue effects, optimize nurse-patient ratios, maintain an undistracted situationally aware team via elimination of distractions, prioritize safety as essential, assuring the sufficiency of supplies, equipment, etc.

To assure everyone is on the same page, the workgroup utilized these definitions for consistency:

1.  ADVERSE EVENT: any event during episode of care directly or indirectly resulting in temporary or permanent harm
2.  NEAR MISS EVENT: event risking patient harm
3.  WRONG EVENT SURGERY- wrong site surgery-wrong patient, wrong surgical side, wrong spinal level, wrong implant or wrong procedure.

4.  HIGH RELIABILITY PRINCIPLES (Weick and Sutcliffe):

a.  Pre occupation with failure: the organization acknowledges the inevitability / potential for failure and therefore has a grasp of human fallibility, system complexity, ambiguity, uncertainty, limitations of training effects of distraction and fatigue, dynamic conditions, time constraints and system vulnerabilities. They focus on potential or actual adverse events. Their incident reporting system is designed for organizational learning and improvement (not punitive).

b.  Sensitive to operations: they continually evaluate local operational team and system performance with focus on the successful and failed intervention.

c.  Reluctance to simplify: they do not simply accept the first or easiest explanation to the etiology of adverse event but investigate these thoroughly to find out "what went wrong" as opposed to "who went wrong".

d.    Commitment to resilience: knowing that errors are inevitable, they have adaptable team and redundancies to mitigate risks of harm preventing disruption of routine workflow.

e.  Deference to expertise: use of team situational leaders who speak up (and are listened to) when they have concerns.

5.   CULTURE OF SAFETY: accepts that the environment is high risk and error prone, maintains a blame free structure support, encourages collaboration without hierarchy, willingness to direct needed resources to address safety concerns, and is vigilant towards improving they environment while expecting untoward events.

6.   SURGICAL TEAM: group of care providers responsible for providing direct care during multiple specific phases of surgical care (i.e. preoperative, immediate preoperative, intraoperative, postoperative and discharge phases). The core team always includes the surgeon, patient and the patient’s family.

7.   PERIOPERATIVE SURGICAL SAFETY / RISK REDUCTION STRATEGIES:

a. Preoperatively:

i.    Surgeon / patient shared decision making and informed consent at educational level / language appropriate for the patient; Medical comorbidity and lifestyle optimization (when possible); risk assessment using available tools (ACS/NSQIP calculators); Hospital approved preoperative safety element (lab/x-ray guidelines, HP etc.).

ii.   Site Marked: Utilize a uniform standard surgical site marking using surgeons INITIALS on the PLANNED SURGICAL SITE in the pre-op holding area immediately before the planned surgery with confirmation by an alert and informed patient.

b. Immediate preoperative phase: assess readiness just prior to the patient being brought into the OR utilizing hospital and provider approved preoperative surgical bundles designed to eliminate errors, optimize patient outcomes and reduce excessive variability in clinical practice

c. Intra-operative:

 i. OR safety Processes (safe patient positioning/padding, secure transfers, fire and burn safety)

ii. Distraction Free surgical environment: enforced by policy.

iii. OR SURGICAL CHECKLIST

iv. Team Brief- surgeon led discussion prior to the case - before induction of anesthesia with all surgical team members present. Discuss specific needs, special concerns, and contingencies; using a shared mental model w/ psychological safety; review of essential elements of checklist (pt id, procedure, consent, site mark, anesthesia checklist, allergies, blood products, etc.)

 v. Surgical Time Out with a check list- Surgeon announced, full stop, full engagement Patient name, BD/SSN, consent present, site marked. Anesthesia confirmation of abx.

vi. De-brief:  Procedure name, sponge count, specimen labels, disposition plans. (then what went well, what needs to be changed, what will we do differently?)

vii. Use of Surgical Bundles: hypothermia, glucose control, VTE P, ABX, Intraop medication use, wound management, team safety, sponge counts, Patient disposition.

d. Postoperative Surgical Care bundles.

e. Cross phase tools: Consistent, unambiguous, effective, succinct hand off communication.

 

 NSPSS WG 1 PANEL LEADER PRE-MEETING RECOMMENDATIONS-

1. SAFETY CHECKLIST:

1. Consistent use of all communications tools contained in the OR surgery checklist- surgical team brief, surgical team time out and surgical team de-brief- with active participation by all surgical team members for all surgical patients and surgical procedures in all surgical settings.
2. All surgical facilities must provide regular OR-SC training and education programs with compliance monitoring to assess proper use by all surgical team members.
3. Surgeon leadership supported by administrative facility safety commitment is key to development, implementation and maintenance of effective OR-SC use.
4. Surgical facilities should develop and implement OR SC based on the WHO model with local modifications as appropriate.

1. SITE MARKING: Site marking policies and programs should include:

1. The surgeon OR A DESIGNATED LICENSED INDEPENDENT MEDICAL PRACTITIONER, should correctly identify, verify and INITIAL the planned surgical procedure site.
2. SS marking is best performed in the pre-surgical OR holding area immediately before the surgical procedure.
3. Site should be marked with surgeons’ initials (blue or black indelible ink in legible block style letters) directly over the location of the planned surgical procedure (where it will be clearly visible within the surgical field following positioning, prepping and draping) with simultaneous verification of the planned surgical site and surgical procedure by an alert informed patient prior to sedation and surgery. DO NOT USE X’s, Yes’s or No’s.
    

1. SHARED DECISION MAKING BETWEEN THE PATIENT and THE SURGEON: Patient is invited by the surgeon to share in the decision making including discussions behind the reason for surgery, alternative treatment options, beneficial outcomes and RISKS, options for choice of surgical facility, disclosure of surgeon performing the procedure, discussion regarding Advanced Directive (resolution of inconsistencies between AD and necessary post-op care), time for questions and answers (consider use of a checklist to inform the discussion between the surgeon and patient).
   Follow AHRQ limited Health literacy by assuring material is at appropriate educational level, assure comprehension and avoid medical jargon.
   ACGME and ABMS should include Share-decision making as requirements for surgical residency and for surgeon credentialing.
2. CONSENT:

1. The surgeon as the primary patient advocate supported by the surgical team and surgical facility share accountability for an informed, timely and accurate surgical consent document and process.
2. All errors or ambiguity in a surgical consent must be resolved prior to the patient entering the OR.
3. All surgical facilities should define and consistently use a standardized safe surgical consent process and document containing:

1. Patient centered, easily readable, and readily understandable consent form
2. Use of understandable language and surgical team speak with patients.
3. Continual use of patient feed-back for improved patient understanding and surgical team verification.
4. Absence of use of complex medical/legal jargon
5. The consent process should include comparison and verification of patient name / identity, procedure, and surgical site from the medical record/surgical scheduling document and consent document.
6. ACGME should include knowledge and training of the surgical consent process as a requirement for surgical residency.
7. The Joint Commission and similar surgical facility credentialing organizations should include assessment of the surgical consent process as a component of surgical safety programs.
8. ABMS should include knowledge of the surgical consent process as a requirement for credentialing.

1. INFORMATION SHARING- “the Handoff”:

1. All surgical team members should be educated and trained to use standardized communication tools to support accurate and efficient information transfer for all transitions of surgical patient care.
2. All facilities should adopt, support and monitor use of standardized communication tools to improve the accuracy and efficiency of surgical information transfer during the entire episode of care.
3. Hand off tools should include:

1. Distraction free environment.
2. Face to face communication
3. Clear unambiguous transfer of responsibility
4. Opportunity to question, clarify and challenge the information
5. Written documentation of the transfer.

1. EMR should support these tools.

 

WORKGROUP ONE DISCUSSION:

Workgroup One began with an assumption that patient safety is the highest priority of the surgical community.

What is surgical safety? Surgical safety is an emergent property of competent surgical care as surgical teams scan the environment searching for threats and identifying opportunities and methods of eliminating those threats.

The premise is that medical provision of care should follow the High Reliability principles espoused by Wieck and Sutcliffe's philosophy on HROs. WorkGroup one’s presentation immediately brought up the following crowd commentary and concerns:

 

1. Duplicate documentation distraction- Several participants were concerned regarding the distractions due to duplicative documentation for the same point of care. They expressed the need to consolidate documentation to reduce useless distractions. Multiple members reiterated the theme that Patient Safety initiatives should augment patient care and not hinder it.
2. Informed consent process concerns – Several members noted that the recommendations appear to be focused on the actual signed document rather than the interactive process between the patient and doctor. The informed consent process is designed to assure the surgeon and the patient have a mutual understanding to the indications, risks and benefits of the offered procedure AND that the patient trusts the surgeon to proceed. David Hoyt expressed concerns that CMS activity is in progress to standardize the consent document. The group expressed lack of concern over the paper document that serves as a legal document and reinforced that the informed consent discussion between the patient and doctor and that documentation is more relevant. They felt that anyone can hand the patient the consent and have the patient sign it and that the documented conversation between the patient and doctor about the decision process is much more important.
3. Consent process-Advising that the consent be done in the holding area immediately prior to the operation in an area prone with a multitude of distractions as opposed to performing this in a more relaxed quiet environment is counterintuitive and the group recommended rephrasing that recommendation.
4. Transitional Teams-Transitional teams create a concern in that we spent a significant period of time on the briefing but then the team changes mid-case and it is not clear that there is any transmission / handoff of information to the incoming team.  This alone practically negates the entire preoperative process that the original team spent quite a bit of time on. This will be a challenge.
5. Systems- we need to assure that we do not limit our field of influence by our use of the term "surgical team" when it takes a whole village to make this happen and we need to assure that the outer environment is included so they do not get left behind when we are all a part of a greater team.
6. Regulatory agency vs toolbox- Candice Greenberg is concerned that we need to consider a. utilizing our human factors engineer partners in these processes b. Create Non-punitive mandatory reporting so we can identify high and low outliers c. Identify and assist the ‘Second Victim’ - we punish these providers when they need a peer support d. Consider the use of Video coaching and assessment for the individual surgeon and the “team”- She did confide a word of warning that if we do not assess the use of video assessment of cases someone else will (similar to police video surveillance) and if that happens we will lose the opportunity for performance improvement.
7. Introductions: Taking time for team name introductions when the same team members work with each other every day may not be the most effective time managing strategy. Having said that, when a crisis happens people do not think clearly and going thru first names (as one panel member suggested) at the beginning of the case may allow more focal directed communication when the team is stressed.
8. Suggesting that all handoffs are face to face may not be best especially in busy practices covering for one another. Electronic communications serve as a means to provide information and allow questions and answers and would not disrupt the flow of the physician on duty. As long as the provider remains available, that should suffice. In the ICU the nurse caring for the incoming patient may be tied up and the one taking the handoff may not be the nurse caring for the patient.
    
   I proposed Three major pitfalls in this venture-

1. Challenge between goal of reducing variability via the utilization of stringently rigid process as opposed to allowing tailored structures that accomplish the goals but fit the team that will be using the tools- we understand the need to reduce excessive variability in clinical practice, because if every surgeon does something different it is next to impossible for the nurses to participate safely in safety checklist support (especially if there are staff rotations or new staff). By obtaining consistency the nurses theoretically spend less time on the variable and more on the patient. Having said that a. the process is remarkably redundant already creating unnecessary distractions and b.  variability should be expected depending on the case type and patient type. Richard Karl recently stated that "you Can't just slip the checklist under the OR door and tell the team -use this! "The teams must give buy in or it’s just another "I agree" exercise. For instance, stating that the consent and the site mark should be done in the holding area immediately prior to the procedure may not fit in the typical process whereby the elective surgical patient has their consent done in the office or on the ward and the site mark is done the day of the procedure in the holding area or on the ward with an awake patient and another member of the team. Having the team do a briefing in the room (with the patient) covering all the material that is in the checklist immediately prior to doing the checklist may not be conducive to maintaining the flow in a very busy practice whereas the briefing could be done without the patient in the room or in the holding area just prior to taking the patient in the room. In many practices and institutions workload production is the highest priority and the surgeons are pulled in many different directions (OR, Ward, Office, administrative duties...) so we need to find a methodology that allows that flow to continue but maintains safe standards.
2. Teams- surgeons should function as member of a partnership rather than Captain-of-the-ship where we spend our time enforcing that others are doing their job. The surgeons need to focus more on the team if they want to succeed. Amy Edmondson explained recently that top down management is counterproductive and partnerships achieve the desired goal more efficiently. Having said that we cannot allow staff to become too comfortable in forgetting their main duties. They still need to go thru the case preference cards, pull the items that are listed, and assure that radiology or pathology is available as listed on the case posting.
   3.  Inappropriate nurse staff ratios- improving staffing has been the best predictor of success in patient safety ventures and we must emphasize this to our partnering hospital organizations.
    
   WORKGROUP 2: HUMAN FACTORS
   • Andrew Grose, M.D.; Michael marks, MD, MBA; Frank Opelka, MD, Fred Shapiro, Thu;
   Charlotte Guglielmi, MA, BSN, RN, CNOR
   GOALS: identified principles, behaviors, and systems needed to improve surgical communication and leadership supporting a highly reliable and sustainable culture of safety.
    Premise:

1. Well-designed policies and procedures should support both reliability as well as resilience through adaptation.
2. The surgical team is fluid- membership may vary based on the immediate situation of the patient. Secondarily there is the necessity for changing situational leadership based on domain expertise. It is expected that the surgeon will be the leader in the absence of necessary team adaptation based on situation and expertise.
3. Surgical teams must be reliable during routine events and resilient during stressful events.
4. Communication depends on a shared mental model.
5. Administrative leadership must support all efforts in these models.

To foster the optimal performance and well-being of all team members the culture must account for the individual, the team and the situation/system.

1. Recommendations regarding individuals:

1. Education in personal resilience begin in medical school and continue thru training.
2. Research on fatigue management be supported at the federal level (including performance variability due to fatigue, stress recognition among providers, effect of new care transitions to patient care, effect of introduced changes on providers.
3. MOC and research support devoted to provider resilience

1. Recommendations regarding teams:

1. Basic teamwork skills applicable to patient care beginning in undergraduate medical education.

That persists throughout postgraduate training.

1. MOC dedicated to advanced teamwork training
2. Surgical Team training with formal programmatic implementation led locally by surgical team leaders. This should be accompanied by reassessment and reinforcement devoted towards internalizing teamwork behaviors into unit culture and maintain sustainability.

1. Recommendations regarding Clinician-patient communication skill building:

1. Training on communication skills in undergraduate medical education with reinforcement using simulation and feedback as in GME.
2. MOC to ensure skills components in communication are reinforced.

1. Regarding the system:

1. All institutions embrace a restorative Just Culture model including a Second Victim support system.
2. All healthcare institutions should recognize that behavior is contextually bound and measurement techniques should assess “work as done” as opposed to “work as imagined” and applied to optimize both provider performance and well-being.

1. Creation of Performance Standards and Certificate Creation in Patient Safety curriculum.

 

WORKGROUP 2 DISCUSSION

Workgroup two moderators began with a discussion regarding ‘teams’ definition as a shared mental model.

• In addition, there is a gap between reality in our working environment as opposed to recommendations being made by outside agencies.
• The experience in Aviation showed that while you can put pilots in the simulator to train them away from their mistakes when you put them in the field, they make the same mistakes all over again. So simple didactic and simulation training will not suffice and there is clearly more to the equation.
• The bottom line is that we are prone to error: slips, mistakes, and lapses.  We need to remember that error is a symptom of what is going on around us- it is the starting point when we begin to understand how the event occurred. "Error is actually a part of work". To succeed we must adapt our tasks every day every minute of our lives to take this into account.
• Normal operations audits- Instead of distribution of rigid processes we should be asking "show me how you do this". Where does videotaping fall into this? We need to embrace non-punitive video feedback that can provide positive feedback and positive changes in our practice.
   

1. Professionals- a. we are all professionals and not providers b. Collegiality - we need a buddy system watching our colleagues. We all are at risk of mental distraction whether due to personal medical or other personal issues (divorce, litigation) and we need to observe and assist one another. C. We should take a stance beyond simply telling organizations this needs to be espoused in ACGME requirements and request this training be a part of medical school curriculum d. Disruptive behavior is not the same as dangerous behavior. For example, I can disrupt a process when I see a danger but that is not the same as the dangerous surgeon. WE need to be careful in providing institutions with the ammunition to punish behavior that is in direct response to negative and probably dangerous behavior due to staff especially when it is recurring. We all understand that the surgeon behavior may overshadow the negative event that prompted this reaction but the administration must agree to assess the event that prompted this.  
2. We should be cautious about endorsing specific training MOC because they may change and no longer be desirable.
3. Is it required to have the Whole team present during the time out when the team is actually in flux? The team is in a dynamic state and the efforts to pull the entire team together can be time-consuming and distracting from other functions so it is not clear this is a fruitful venture.
4. Trauma video recording. Candice Greenberg - Observation coaching and feedback is extremely proactive and helpful if used as a non-punitive training methodology. This needs to be a Self-assessment and learning process. You cannot use this as a policing activity but must use this as a coaching tool. We must learn and remember past mistakes such as that which occurred in Rhode Island in 2009, whereby the facility video-audited staff without the staff or patients’ awareness or consent. We were reminded that the Wisconsin state legislature is now pushing for mandated videotaping if we are asked by the patients to do so. On the flip side, it is proven that teamwork does typically improve when the team does know they are being audited or recorded.
5. Crew vs teams- CRM is consistent whereby team training may not be. The concept of Teams imply a consistency to the membership when even in medicine the team is actually a crew with potential alternating membership.
6. Empowering staff- staff must be empowered to create a hard stop and not be afraid to slow the OR schedule. No one is NOT paying attention- everyone is paying attention.  Surgeons must empower the staff. Errors in diagnosis can be reduced by second eyes by engaging professionals in the room to speak up. We should educate professional students how to respond to that situation.
7. The task cannot be ‘checking the box’ on the checklist. The focus must be on the actual task you are validating.
8. Unprofessionalism may be secondary due to frustration when the staff is not providing the support needed to optimally care for the patient and this can be dangerous. Staff and the surgeon needs to be prepared. If someone is new you need to ask if they are prepared. If the surgeon makes any changes it needs to be communicated clearly.
9. We need to ask if stress and fatigue is really bad or if we need to train people in stress and fatigue recognition (asking for help), management and response. We do need to understand that chronic stress and fatigue is debilitating. Avoiding stress altogether may not be possible.
10. The purpose of simulation is to allow one to crash a plane and not kill anyone. This is where you learn to mitigate risk in real situations. We cannot undervalue that training.
11. Team STEPPS was originally designed to instill team trust which is ultimately needed to manage conflict.  Pilot monitoring is only via audio and not video, because they did not trust the administrative agencies.
12. IQ may not be modifiable but EQ - emotional intelligence- is trainable.
     
    WORKGROUP 3: TECHNOLOGY
    • Kevin Bozic, MD, MBA; David Jevsevar, MD, MBA; David ring, MD, PhD; Clifford Ko, MD,
    Janice Kelly, MS, RN-BC; Laurent gloss, MD
     
    GOALS: identified principles, measures, and programs needed for collection and analysis of surgical safety data to drive performance measurement.
    PROPOSAL: Presently, the American College of Surgeons and the American Society of Anesthesiologists have
    created separate data registries (ACS NSQIP, NACOR) for measuring and reporting surgical outcomes for
    patients undergoing non-cardiac surgery. Other surgical subspecialties are in the process of building
    separate outcome registries. Each of these registries is a stand-alone database. We propose to create a
    virtual data warehouse linking NSQIP, NACOR, and surgical subspecialty data registries. NSQIP and
    NACOR would comprise the core of the new registry. NACOR would augment NSQIP with information
    on intraoperative management – data on hemodynamics, fluid and blood replacement, drug
    administration, intraoperative outcomes, and staffing. Each of the subspecialty registries would include
    specialty-specific outcomes (e.g. functional outcomes in orthopedics) and specialty-specific risk factors.
     
    WORKGROUP 3 DISCUSSION:
    Discussion
    .We have learned that the debriefing process is critical - we use data to augment this process by assessing the care of 1000’s of patients.
    .We have the data infrastructure in place and recognize that the data is the backbone of an HRO.
    .Our ultimate goal should be data sharing but we are challenged by linking these data sets for various reasons. One route would be to give everyone a lifetime patient identifier. That has proven to be next to impossible thus far.
    .We are being asked to move from volume-based care to value-based care and we should be in control of that. To do this we must evaluate teams and not surgeons alone. If we claim that this is a partnership, then we need performance measures that evaluate how we do this together and not focus on one individual. We need surgeons, anesthesiologists and nurses to work together to develop this model.
    .It will be up to us to go to the EMR vendors to explain that our data needs to be incorporated into the EMR and we must clarify definitions that are consistent. Several expressed that currently vendors may not be as adaptable as we would like.
    David Hoyt stated that the College is interested in measurement fields that those in practice desire collecting and measuring so they can modify the database to include this.
     
    WORKGROUP 4: EDUCATION
    • Ajit Sachdeva, MD, Larry Marsh, MD, Scott Levin, MD, Paula Graling; Philip Stahel, MD,
    Adam Levine, MD
    GOALS: identified and strategies for education programs needed to advance surgeon recommended implementation, surgical team, and surgical facility safety knowledge and practices.
    1. Importance of education- necessary to have a lasting effect of this effort or the results of a summit will not have a lasting impact
    2. Review of current educational products on surgical patient safety
    A new educational effort will require an understanding of the strength and weaknesses of current educational products (Inside and outside medicine, surgery).
    3. The educational programs should target all those engaged in the care of the surgical patient – HOW DO WE engage busy tired practicing surgeons.
    4. Educational Content- Focus will be on non-technical skills related to safety, i.e.,
    communications, human factors, hand offs, teamwork; not on technical surgical skill
    5. Types of educational venues were discussed including web based courses, symposia, simulation…..
    6. Finance- a. Who will pay for educational programs and materials after the
    summit is over?
    7. Collaborate with other Professional societies, ABMS Boards, ACGME and surgical RRCs, and Non-surgical groups
    8. Accreditation- Certification- MOC
    9. Measures of success- How do we measure success/ competency of these educational programs? How do we maintain competency of learned skills?
     
     
    WORKGROUP 4 DISCUSSION
    Moderator points
    Educational program targets- surgeons, perioperative crew member, residents, medical students, institution.
    1. Shared decision making:
    Indications- absolute, relative -our avenue for shared decision making, unnecessary, contraindication.
    2. We may be hypocritical in that we may offer a surgery to same age, gender match that we would not have chosen for ourselves.
    3. Listening- pts in the office are interrupted within 12 seconds and in the ED its 9 seconds. If we want to improve patient care, value and safety then we must develop a system that allows us to listen to the patient. We just never know when the patient provides us with cues that may save their lives.
    4. Are we teaching surgeons to alleviate responsibility? Is the system set up so that the surgeon no longer feels responsible for the work/duties of others? We need to look at this in depth.
    5. We need to uphold credible leadership- if we don't believe in these principles then they won't believe. There should be no excuses. People are watching you- ‘what we permit we promote’.
    6. The question is- how do we implement this process?  Should there be mandatory institutional certification?
     
    .Dr. Hoyt? How do we implement this? Dr. Sachdeva reminded us that a one-size-fits-all approach is not appropriate. It needs to fit your field, level of learning, etc. It needs to be relevant with visible benefits. CME and the usual educational formats are ineffective and we must look at other avenues.
     
    .We can only rely so much on training to develop a safety culture. We need to assure that everyone is integrated as a part of team.
    .Audience- focus should be on mentorship, leadership, rather than on products that are already out there.
    .Panel- 45 years ago the orthopedic group was opposed to certified skills courses and now no one would argue the importance. We will need to develop contents and standards and the measure.
    .Conflict is likely useful as long as you don't allow it to progress into a battle.
    .Dr Neumeyer- MOC is already a system that creates conflict in many conversations so we need to create a system that surgeons agree with. It needs to be a safe environment. We also need to understand how we motivate learners.
    .Checklists need to be designed by and believed by surgeons.
    .We need to teach surgeons that behavior is innate but your reaction and control is modifiable.
    .patient education is an integral part of this process.
    .surgeons may not be receiving the training they need locally but the societies could integrate this into lunchtime agendas.
    . To make this meaningful we need to assist the medical centers with the tools to measure their culture.
    .education is not the same as training and both are important, but we need data to tell us how to optimally achieve this.
    .It was stated that”even pilots do not voluntarily attend simulation, but it is mandated” . It turns out this is not true and the pilots I interview agree that originally this may have been true but they value this educational experience (they simply wish it was annual and not every nine months). In New York, Anesthesia, OBGyn, ED, IR etc must be accredited every two years for them to maintain privileges.
    Dr. Hoyt- we mandated ATLS years ago for surgeons in trauma centers. It all depends on how we present this- we must present this as a learning opportunity and not MOC.
     
    CONCLUDING REMARKS:

Dr. Hoyt challenged us to ask three questions:

1. Is the Panel on target?
2. Was anything missing from the Workgroup Reports?
3. Are there any strategic/tactical changes the group should make?

In addition the panel asked for the following input

1. Which organizations should be asked to endorse the outcome of the Summit?
2. Who should be identified to be on the workgroup who are well known safety experts, champions, etc?

 

Everyone agreed that we should probably have a follow-up meeting next year.

Suggestions should go to Dr. Zemaitis at Zemaitis@aaos.org.