NSPSS WORKGROUP 4: EDUCATION

NSPSS WORKGROUP 4: EDUCATION
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
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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 on ourselves
3. Listening- pts in the office are interrupted within 12 seconds and in the ED its 9 seconds.
4. Are we teaching surgeons to alleviate responsibility
5. We need to uphold credible leadership- if we don't believe then they won't believe. No excuses. People are watching you- what we permit we promote.
6. The question is how do we implement this? Is this mandatory certification?

.Hoyt? How do we implement this? Sachdeva - one size fits all is not appropriate. It needs to fit your field, level of learning, etc. It needs to relevant w visible benefits. CME and 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 is important but we need data to tell us how to optimally achieve this.
.even pilots do not voluntarily attend simulation, but it is mandated. In New York anesthesia, OBGYn, ED, IR etc must be accredited every two years for them to maintain privileges.
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.

NSPSS workgroup three-data

NSPSS workgroup 3: TECHNOLOGY
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.
Panel: Kevin Bozic, MD, MBA; David Jevsevar, MD, MBA; David ring, MD, PhD; Clifford Ko, MD, Janice Kelly, MS, RN-BC; Laurent gloss, MD

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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.
.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 evaluating surgeons. We need performance measures that evaluate how we do together. We need surgeons, anesthesiologists and nurses to get 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.

NSPSS WORKGROUP 2: HUMAN FACTORS comment from group

NSPSS WORKGROUP 2: HUMAN FACTORS
WG - 2 human factors/behaviors/culture/high reliability
Batch: Identify principles, behaviors, and systems needed to improve surgical communication and leadership supporting a highly reliable and sustainable culture of safety.
• Andrew Grose, M.D.; Michael marks, MD, MBA; Frank Opelka, MD, Fred Shapiro, Thu;
Charlotte Guglielmi, MA, BSN, RN, CNOR

Workgroup two 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.
The bottom line is that We are prone to slips, mistakes, and lapses.
Error is a symptom- 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.
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.

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 personal medical issues or personal  issues (divorce, litigation) and we need to watch on another. C. We should move out past telling organizations this needs to be espoused in ACGME and medical school d. Disruptive behavior is not the same as dangerous behavior. I can disrupt a process when I see a danger but that is not the same as the dangerous surgeon.
We should be cautious about endorsing specific training MOC because they may change and no longer be desirable.
Is it required to have the Whole team present during trying when the team is actually in flux- the
Trauma video recording. Candice Greenberg - Observation coaching and feedback is extremely proactive and helpful if used as a non-punitive training methodology. Self assessment and learning. You cannot use this as a policing activity but as a coaching tool. Rhode Island 2009 video auditing w staff not being aware. Wisconsin state legislature is pushing for mandated videotaping if asked by the patients.
Crew vs teams- CRM is consistent whereby team training may not be. Teams imply a consistency to the membership.
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. Educate professional students how to respond to that situation.
The task cannot be checking the box on the checklist but the actual task you are validating.
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.
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) and management and response. We need to understand that chronic stress and fatigue is debilitating. Avoiding stress altogether may not be possible.
The purpose of simulation is to allow one to crash a plane and not kill anyone but mitigate risk in real situations. We cannot undervalue that training.
Team stepps was originally 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.
IQ may not be modifiable but EQ - emotional intelligence is trainable.

NSPSS workgroup two human factors -definitions and goals

NSPSS WORKGROUP 2: HUMAN FACTORS
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 they culture must account for the individual, the team and the situation/system.
1.      Recommendations regarding individuals:
a.      Education in personal resilience begin in medical school and continue thru training.
b.      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.
c.       MOC and research support devoted to provider resilience
2.      Recommendations regarding teams:
a.      Basic teamwork skills applicable to patient care beginning in undergraduate medical education.
That persists throughout postgraduate training.
b.      MOC dedicated to advanced teamwork training
c.       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.

3.      Recommendations regarding Clinician-patient communication skill building:
a.      Training on communication skills in undergraduate medical education with reinforcement using simulation and feedback as in GME.
b.      MOC to ensure skills components in communication are reinforced.
4.      Regarding the system:
a.      All institutions embrace a restorative Just Culture model including a Second Victim support system.
b.      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.
5.      Creation of Performance Standards and Certificate Creation in Patient Safety curriculum.

NSPSS day one- workshop one

Aug 5 2016 NSPSS WORKGROUP 1: SAFETY DEFINITIONS
The NSPSS began with an introduction to the principles of Safety Definitions and Panel recommendations led by the following panel:
David Hoyt, MD Executive Director of ACS
Dwight Burney, MD Chair of Section on Safety Education, Patient Safety Committee AAOS
William Robb, MD Chair of the Orthopedic Patient Safety Summit
Renae Battie-VP period services for CHI health
Arthur Boudreaux, MD ASA

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 Sutcliff's philosophy on HROs.
The prior post on this workgroup explains the principles behind the goals and structure of this group so I will move onto the discussion phase of the workgroup.

Duplicate documentation distraction- Immediate comment made regarding distractions due to duplicative documentation for the same point of care- we need to consolidate to reduce useless distractions.
Informed consent process concerns - the recommendations appear to be focused on actual document rather than the interactive process with the patient. 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.
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.
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 distraction as opposed to performing this in a more relaxed quiet environment is counterintuitive and the group recommended rephrasing that recommendation.
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.
Regulatory agency vs toolbox- Candice Greenberg is concerned that our instituting a. human factors engineers b. Non punitive mandatory reporting so we can identify high and low outliers c. Second victim - we punish these providers when they need a peer support d. Video assessment - word of warning that if we do not assess the use of video assessment of cases someone else will (police video surveillance).

I proposed Three major pitfalls in this venture-
Challenge between need to Reduce variability vs stringent rigidity-
Section on Rigid process vs tailored structure- I understand the need to reduce excessive variability in clinical practice-that is if every surgeon then does something different it is next to impossible for the nurses to participate safely in safety checklist support (especially if there are staff rotation or new staff). By obtaining consistency the nurses theoretically spend less time on the variable and more on the patient. Having said that variability can be expected depending on the case type and patient type. WHERE AND HOW IS THIS DONE? Bedside briefing? This may not be possible in many institutions where workload production is the highest priority and the surgeons are pulled in many different directions (OR, Ward, Office, administrative duties...).
Richard Karl recently told me 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 its just another "I agree" exercise.
2. Teams- surgeon as member of partnership vs captain of the ship-focus more on the team, Amy Edmondson- top down management as opposed to partnership. We need to be partners in this care and not captains of the ship enforcing that others are doing their job.
3. Inappropriate nurse staff ratios- improving staffing best predictor of success in patient safety ventures and we must emphasize this to our partnering hospital organizations.

NSPSS WORKGROUP 1: SAFETY DEFINITIONS: GOAL: AUGUST 5 2016, Chicago, IL

The NSPSS will commence in the am with a discussion on Patient Safety Definitions, Goals and Recommendations. This is a highly condensed version of the summary the group compiled prior to the meeting.

My questions/concerns are in red. I am sure this discussion will be lively.

Aug 5 2016 NSPSS WORKGROUP 1: SAFETY DEFINITIONS:

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 Sutcliff):

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 (WHAT?) 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-that is if every surgeon then does something different it is next to impossible for the nurses to participate safely in safety checklist support (especially if there are staff rotation or new staff). By obtaining consistency the nurses theoretically spend less time on the variable and more on the patient. Having said that variability can be expected depending on the case type and patient type. WHERE AND HOW IS THIS DONE? Bedside briefing? This may not be possible in many institutions where workload production is the highest priority and the surgeons are pulled in many different directions (OR, Ward, Office, administrative duties...).

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 (why is this here? What does this mean?)

iv. Team Brief- surgeon led discussion prior to the case - before induction of anesthesia with all surgical team members present. (where? w/ whom?) 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 (Introductions- encouraged by not mandated, should not disrupt flow such as anesthesia demands- the patient is asleep or anxious so the faster this goes the better). 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 RECOMMENDATIONS-

A.      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.

B.      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.

C.      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.

D.     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:

a.      Patient centered, easily readable, and readily understandable consent form

b.      Use of understandable language and surgical team speak with patients.

c.       Continual use of patient feed-back for improved patient understanding and surgical team verification.

d.      Absence of use of complex medical/legal jargon

e.      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.

f.        ACGME should include knowledge and training of the surgical consent process as a requirement for surgical residency.

g.      The Joint Commission and similar surgical facility credentialing organizations should include assessment of the surgical consent process as a component of surgical safety programs.

h.      ABMS should include knowledge of the surgical consent process as a requirement for credentialing.

E.      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:

a.      Distraction free environment (not sure how in facilities where each nurse has more than one patient).

b.      Face to face communication (if this is for call check out that may not be possible and other electronic means should suffice to do that):

c.       Clear unambiguous transfer of responsibility

d.      Opportunity to question, clarify and challenge the information

e.      Written documentation of the transfer.

4.      EMR should support these tools.

Kenneth A. Lipshy

Www.crisismanagementleadership.com

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

National Surgical Patient Safety Summit (NSPSS) program

            I am honored to represent the Association of VA Surgeons and the Southeastern Surgical Congress at the National Surgical Patient Safety Summit (NSPSS) event August 4-5 2016. In spite of advances in technology, as well as numerous protocols and regulations, surgical adverse events and patient harm plague all healthcare organizations. Representatives from 80 medical and surgical organizations will attend the National Surgical Patient Safety Summit (NSPSS) program sponsored by the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS).

The mission of the program is to "propose solutions that effectively combine elements of safety science, principles of high reliability and best safety practices across all phases of surgical care." The ACS and AAOS initially met a year ago 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 culminates with the August Summit which has 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 is divided into four key workgroup (WG) sessions, each with its own unique goal.

• WG1, key safety definitions / elements / processes/phases of care, identify and define 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, identify 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, identify principles, measures, and programs needed for collection and analysis of surgical safety data to drive performance measurement.
• WG4, Education/Training Programs, identify 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).

 

As the Summit progresses I will attempt to forward updates.

My personal goal is to assure that the consensus information and message is succinct enough to allow busy practicing surgeons to absorb the mission, goals and recommendations without undue labor.

Kenneth A. Lipshy, MD FACS

www.crisismanagementleadership.com