Friday, August 5, 2016

NSPSS day one- workshop one

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.

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