Monday, September 12, 2016


A few months back I spoke with multiple folks responsible for the South Carolina Safety Initiative (for details see:
With several years of experience in implementation of the WHO Surgical Safety project, the Harvard team lead by Atul Gawande, MD, MPH and William Berry, MD, MPA, MPH (Chief Medical Officer at Ariadne Labs) was a natural advisory component for this project.
When I began to inquire more, Dr. Gawande referred me to Dr. Berry, who was gracious to talk with me a few weeks ago about this project and his experience in surgical safety.
 How did you get involved in this project?
Dr. Berry:
I was an actively practicing cardiac surgeon and as I approached 50, I decided I wanted a change in career. That led me to become a student at the Harvard Kennedy School and after that, the Harvard School of Public Health. After graduation I started to work for CRICO – Harvard’s Malpractice Carrier and through met  Dr. Atul Gawande.  Because of that connection, when Dr. Gawande was asked by the WHO to do a project to improve surgical safety globally, he asked me if I could help.  That project led to the creation of WHO surgical safety checklist.  After the checklist project had been launched, a private foundation approached Dr. Gawande with funding and the work in South Carolina with the hospital association and the SC hospitals was begun.
What do you see as the major difference between the WHO surgical checklist implementation in third world countries and places like the US and UK?
Dr. Berry:
The biggest difference I think, is the baseline level of quality improvement work that has already been done in the developed world. In an sub-Saharan African country, while there may be a University/Academic Medical Center, that facility will usually not have the same resources devoted to quality improvement. Outside of the academic centers in those settings, primarily because of constrained resources, quality improvement experience is even more limited.  Again, because of resource limitations, they may not even have access to basic surgical supplies. In many countries, certain surgical safety processes like routine sponge counting are not performed.  There are many other drastic differences.  While the surgeons are often very well trained in American/European training programs, they suffer a lack of infrastructure and supplies. In some parts of the world, the availability of well-trained professions is also limited forcing surgical needs to be met with less trained providers.
Finally, while hierarchy in developed world operating rooms can pose challenges to teamwork and patient safety,  in developing world countries where the educational difference between the surgeons and other staff can be much greater, these issues can present even greater challenges.
The literature is wrought with reports that surgeons and anesthesiologists remain as major barriers to implementation in Surgical Safety projects. In the Harvard / Mass General Studies on implementation of the crisis checklist simulation project the attending surgeons were noticeably absent (replaced by fill-ins).   How do you get surgeons motivated to participate?
Dr. Berry:
We learned that a major challenge to doing a simulation trial with clinical team is the difficulty in getting teams to participate without compensating them for lost clinical time. Attending anesthesiologists were easier to recruit because one of the principle investigators could backfill them clinically. The similar approach could be used for nursing staff – substituting one nurse for another.   It was impossible to use that strategy with surgeons – their clinical roles are not easily backfilled. 
We have since published a paper where we were able to recruit surgeons (vascular, CVT, etc.) to participate in a team training program in part by including a 10% reduction in their malpractice premium.  Many surgeons want to be involved but we need to be creative in finding ways to make it easier – more convenient for them.  We need to find a way to use the time that is already put aside outside of the operating room – like grand rounds or departmental meetings.  This is time that is already “paid for” and can sometimes be repurposed to great effect. We have also found that trying “bite sized” training (short lunch time sessions) seems to be more successful. The feedback has been positive. Ideally, it would be great to get into every hospital surgery staff meeting but that is often logistically impossible.
For certain kinds of programs, like those that are webinar based, it can often be easier to reach the nurses and try to use them as a connector to the surgeons- if you help the nurses figure out how to effectively approach the surgeons you may have success.
In your experience how does your group gain the interest in participation by very busy surgeons/anesthesia providers who have a low expectation of change from these projects with high expectations of creating more inefficient processes? How do we find ways to implore these very busy surgeons to participate in these exercises and in the implementation phases? If you don’t have the surgeon’s buy in AND support, you will not have success.
Dr. Berry:
I don’t think that we are always making the right arguments to the surgeons and anesthesiologists. We need to promote better checklists use as a way for surgeons and anesthesiologists to lead the team and make care better for their patients. Many surgeons, in particular, believe that they are already doing everything that they can to provide the very best care to their patients even when there is convincing evidence that even the best can improve. To make that point to operating room teams, we designed a safety culture survey to identify the gaps in the existing OR culture prior to the implementation of the checklist. This is based on the work of two pioneers in patient safety, Dr. Marty Makary and Peter Pronovost, who have previously shown a disconnect between perceptions of team members about the level of safety and teamwork in operating rooms – with the surgeons being the most “optimistic”.  This disconnect is further magnified by the difficulty that surgeons have understanding that they are not the only critically important people in an OR.  Every team member is important and surgery cannot take place without that team.   Making matters worse, many surgeons act as if those around them can read minds – making assumptions about things that may not be true. I have found sometimes that surgeons can be convinced to support checklist use – not because it wioll necessarily help them – but because they are convinced that there are other surgeons who do need it.   When I was early in my clinical experience, I had what I called a “ need-know policy” – which translated to – “Don’t ask me so many questions about things that you don’t need to know”. I eventually realized that many times – they did need to know and that even if they didn’t, they needed to know because they were interested and so they felt more a part of the patient’s care. I then started a routine habit of beginning each case making sure everyone knew something about the patient as a person and why the surgery was so important to them.  This eventually became my “preop” briefing too.
What surprises you most during these projects? What was most expected?
Dr. Berry:
How hard the projects can be and how much time it can take to change practice and culture.  Before we started the work in South Carolina, I had extensive experience in quality improvement and patient safety work through IHI and CRICO – and I knew already that change was hard. But every time I am involved in work like this – I learn again that moving practice and the culture along with it – is really hard.  I think that I have also been surprised by how hard it can be to change things even with very simple tools. Simple doesn’t mean easy.
What has been the biggest disappointment thus far?
Dr. Berry:
The checklist is a way to help patients get better care and teams to provide that care.  It is filled things that we should do, with process checks and prompts for discussions that stand on evidence – sometimes evidence that is decades old.  That gap – between things that we know we should do – and what we actually do – needs to be closed. My greatest disappointment is in how hard it is to close that gap and get change implemented.  Getting physicians actively involved in closing these care gaps is also difficult and that is disappointing too.  That said, it is getting better. I think that we are on the right road and that the next generation may have it easier.
Kenneth A. Lipshy, MD, FACS

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