FIRESIDE CHAT WITH WAYNE MEREDITH, MD: THE FIFTEEN YEAR WAKE FOREST APPROACH TO ESTABLISHING AND MAINTAINING TEAM EFFECTIVENESS AND RESILIENCY.
KENNETH A. LIPSHY, MD, FACS
On August 17, 2023. Dr Wayne
Meredith*, graciously agreed to discuss the Wake Forest Baptist Health approach
to establishing and maintaining Surgical Team effectiveness and resiliency,
which they built over the past 15 years.
(video located at: https://youtu.be/pwiA5nVn2GM )
Dr Meredith and I have had
several prior conversations concerning team effectiveness, leadership,
resiliency and surgeon ownership of the surgical safety process.
We first discussed this topic after he presented his work with NASCAR on team efficiency and communication some 10-15 years ago at the annual meeting of the Southeastern Surgical Congress.
Recently, we discussed the significant challenges most large institutions face with faculty development across vast expanses of practice with markedly increasing staff dispersion. Inevitably, institutions feel forced to rely on virtual synchronous and asynchronous learning.
On August 9, 2023, after
Grand Rounds, we spent an hour in conversation focused on the Wake Forest
philosophy for focusing on disparities in healthcare and on the need and the
challenges in providing staff tools to respond effectively to microaggressions
or outright biases and racism in the workplace. That transformed into a
discussion about staff effectiveness, resiliency and a multitude of other
topics including:
-Wake wings team training
- Critical incident
debriefing
- Identifying and working
with marginalized staff
- Second Victims-moral angst
- Team Resiliency
He was very gracious in
revealing his process of addressing destructive team practices, including
managing team decompensation, creating good habits and understanding bad habits
to address situations that can undermine teamwork.
One other area Dr Meredith
brought up was his leadership style in organizational change management and
decision making, including effective leadership by deconstructing the situation
and removing “sides” and finally avoiding organizational distrust by always
publicly supporting higher level decisions.
Dr Meredith agreed to recap that conversation on video August 17, 2023.
CREATING AND MAINTAINING STAFF EFFECTIVENESS AND RESILIENCY USING A ROUTINE CRITICAL INCIDENT DEBRIEFING:
LIPSHY:
Wayne, can you please recap
our conversation last week about your critical event team discussions?
How do you manage teams that
have witnessed a serious critical event and manage the team and individual
mental health?
This concern has been identified by the American Society of anesthesia, American College of Surgeons, and countless other organizations as a significant cause of burnout and risk for future errors.
MEREDITH:
What we were discussing was
the Wake Forest Operating Room Critical Incident Debriefing.
We have been using this venue
to address individual or team concerns and distress for over a decade now. As a
trauma surgeon we learned from EMS and the disaster management people, that one
of the best techniques for maintaining team cohesion and building resilience in
your teams to recognize when you've had a critical incident, and then to carry
out a debrief on that issue. That debrief is designed to get those emotions
dealt with at the time. It cannot be confused with Morbidity and Mortality
conference or a Root Cause Analysis. At Wake, if anyone in the operating room,
a surgeon, anesthesia, nursing staff, anybody requests a debriefing, it comes
up through the well-versed channel. We find that many it's simply a matter of
getting two people together then having them talk?
But sometimes something
serious happens that is more global- such as unexpected death in the operating
room or some serious team communication breakdown that results in disharmony or
bad feelings. If that’s the case, we carry out a team critical incident
debriefing. The Debrief is focused on preserving, maintaining, or creating team
cohesion - it's pretty simple.
We pull the team together one
morning at 6:30 before everything gets started.
We put the whole team
together- all the circulators, all the scrub nurses, all the anesthesia people,
all the surgeons and all the learners involved in the incident.
I usually have someone to
research it - either the fellow or someone who was participating in the case
just presented, that way we have some background to work with. At the debrief
they go around the room starting with the person who has the least authority in
the room. We start with a simple question for that person “when all that was
going on, what were you feeling?” I have each of them describe what they felt.
Then I make the observation- “OK, you've all told me what you saw, but none of
you told me. What you felt.” I'll go back around the room one more time and at
the end of that, typically I'll say “that was much better. But you told me what
you thought, but you still haven't told me What you felt”. Then people will start to get it and they'll
start saying what’s on their mind. To assist, I'll give some examples such as
were you feeling like you were not being listened to, or feeling like you
didn't have power. Were you feeling like you're going to be fired. Did You feel
like you're going to be blamed? Do you feel responsible?”
Then they go around that room
and it's amazing how different everybody's feelings are.
It is almost universal from
my experience in doing this that the people in the room have no idea what the
surgeon is feeling or even thinking.
One of the spin-offs I've
learned is when you're in one of those situations, you must communicate more
about what you're thinking and what's going on right now because that can calm
you and it needs to be handled then or it will spiral out of control.
I've learned that we think
they're reading our mind and we're all on the same page but more often we are
not. I've been working here 25 years and I've had two of these type incidents
before, and they rankled me for years. It would have really helped me. I really
think these are good.
Staff always come up and confer it's been pretty effective; it's been pretty useful and building theme that team unison. AND… it doesn't take much time if you don't do it for every single event. You have to do it for the really major stuff, that’s worth the trouble for everybody.
Having said that I do prep
the surgeons typically. I do a lot of espionage about the case from other
people before it happens. When something like this happens, basically everybody
knows and so more than one type of team member will bring it up. I'll get the story from all these folks and
ask what they think that issues are. We prepare those people ahead of time,
especially anybody who hasn't ever been in one -that's new. We don't want
people coming into this meeting with a sense of being threatened.
I let them know that we will do a root cause analysis of this in another area to create system catches for the areas where the Swiss cheese lined up for this case, but that we're not here for that- we're here to build team cohesion. We're here to communicate with one another. We're here to bond over a difficult situation and that that that gets them to it. It's pretty effective.
MAINTAINING A SAFETY
CULTURE WITH INSTITUTIONAL PSYCHOLOGICAL SAFETY- CHALLENGES WITH FLUID STAFFING
STRUCTURE:
LIPSHY
Wayne, it's obvious that your institution has adopted a real safety culture center around psychological safety, and I've talked to a few other surgical department chairs who have also managed to succeed in this.
MEREDITH
I think this is a constant
battle and I think it's way harder post-pandemic. We went through years without
much social interaction, without face time with our colleagues and with people.
I think we lost ground during
that time, and it takes space and time to rebuild it.
We never tried to do one of
these with zoom, but I suspect it's doable, but I also suspect that it's too
easy to retreat from the process and observe it and not participate in it by
zoom, whereas in the room there's a feeling of, caring about what each other
feels that I think might be hard to get on zoom.
We do that and everybody must go through Wake Wings. Wake Wings is a crew resource management to create hierarchy flattening and communication. Everybody does that fore they can come into the operating room. We refresh that twice a year with some of it using an outside speaker and internal grand rounds. We review rules that we've changed or the rule that we think we're having trouble with. We have some really good people running that.
LIPSHY
Thanks Wayne! The Director of
Anesthesia at Mercy Hospital (Dr Epperson) says that quarterly, they all meet
for an hour or two of didactic and group discussions. Then they have breakout
sessions where they go to an operating room where they have case based /simulations
to discuss these things.
Is that something that's feasible in this institution? Can Wake Forest Baptist Health do that, given the size and the expanse of everybody in the health care system? Or are you limited to having didactic discussions but not case-based scenario simulation?
MEREDITH
We do that in this
department.
We have 13 scenarios that
Jeff Carter built in his research here. He was an educator prior to getting
into his fellowship and during his research year, he did an amazing volume and
quality of stuff. He and Jim Johnson
built a series of simulations of fire in the operating room, blood loss in the
operating room, and others. We have a room designed for doing this adjacent to
our operating room. I'll have to say that anesthesia started doing this as a
part of the anesthesia safety national anesthesia safety program with
mannequins 25 years ago. Surgery started doing it 10 or 15 years ago and we
will go through those scenarios. We have other parts of the team observe it
through one-way mirrors. Then we debrief using structured debrief. Martin Avery
does that now for us. Sometimes we used cadavers brought in on an ambulance
where the paramedics come in and we've done a whole scenario. I can say that
since we started these simulations and Wake Wings, our communications have
improved. Our Med Mal costs, and wrong
site surgery retained foreign body incidents have been reduced. There are a lot
of tangible benefits from doing this! The
real cost is the time, and it requires a champion that wants to do it. You
can't just assign it to people you know. It requires a champion that wants to
do it and knows how to do it.
They are very worthwhile.
LIPSHY:
From my conversation with staff across the nation with the given difficulty we have to maintain a stable nursing workforce, in very large organizations, it is a challenge to assure that everyone in the OR has a shared mental model. How do y'all integrate the shifting nursing workforce in the operating room and into this training and into this safety culture so they feel free and mostly obligated to speak up when y'all have these critical incident debriefings? How do you know for sure that they're speaking their mind? Do they feel like part of the team? How do you do that?
MEREDITH
Everybody takes the crew
resource management – Wake Wings course. EVERYBODY! Even travelers- even
sterile processing people. When we first began it, 15 years ago, we took 1400
people through this from February to July. In the end every single soul that
worked in the operating room or came to it, took it. Then the time out is ingrained,
and the daily process is performed the same every time. Regarding the timeouts
– we are obviously constantly working on this, but those checklists serve as a
great source of creating safety tools and investigating mishaps. You must keep
your checklists trim, so they are doable. It’s a big deal for us to add
something to it, but when we do it’s a consequence of a great deal of debate. We're
not going to change to a bigger poster, or smaller print. We're going to figure
out how to get this all done and this one little packet of time.
So, to answer your question, everybody who comes on does that, and then in the critical incident debriefing sessions, I've never had anyone that didn't begin to speak up. I have not seen anyone that never spoke, but remember we went through several rounds of it and the more senior people began to open up. Also remember I prep the senior people to assure there is no barrier to free thinking.
LIPSHY
One other common concern
surgeons and anesthesia express is that one of the biggest issues is that in
any case that lasts longer than an hour, you have multiple staff changes,
including anesthesia and nursing changes within the staff. These are staff that
do not originally participate in the initial timeout. How do you assure that
that shared mental model that was created at the beginning of the case? If we
introduce ourselves to the staff at the beginning and then we have staff that
replaces that staff, how do we engrain them into the team immediately and
effectively?
How do we ensure they don't come in feeling lost and uncertain and not sharing
the same mental model that probably the initial team did? That way at the end
of the case, everybody can speak the same language, and everybody understands
what happened and communicate when these problems exist, right? To make sure
that this gets communicated, that this was a particularly challenging case, and
we really need to assure that a critical incident debriefing is done.
MEREDITH:
That's a problem, and it's one where people talk about how effective crew
resource management training is in the airline industry. I always have the
thought that everybody that forms the team when the plane takes off stays on it
till it lands, right? Over the years we've created a whiteboard structure in
the room. That has everybody's name and role on it and a few other key pieces
of information. There's a there's a very short handoff that's done, whether
it's circulated or circulator or scrub to scrub. It goes on in the back of the
room. I was saying it has incomplete penetrance but our process rules are that
you ask before you change. You can't start changing the circuit. It's sometime
during the case when you can afford to have that break in concentration from
your teammate and they always know that they don't always ask, but they often
do and usually do, I guess. Obviously, all the counting goes on as part of the
handoff, right? And they gotta redo the counts. That’s partly why it's
important to put that in in a time in the operation, when it's OK to do that,
right. We do that through the White Board, which has had several evolutions of
data that's on it. Based on instances we've had where the holes in the Swiss
cheese lined up that we had a communication break now and we've added it, added
different things to the to the White Board.
BUILDING A SURGICAL SAFETY PROGRAM
LIPSHY
In 2016, the American College of
Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS)
hosted the first National Surgical Patient Safety Summit (NSPSS)
Program. 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." (Summary
located at: http://crisislead.blogspot.com/2016/08/national-surgical-patient-safety-summit_8.html ).
The topic frequently turned towards our constant shift in medicine to create
aviation crew H.R.O. models to improve patient safety.
After that, in 2017, LD Britt
and I discussed some of the concepts that came out of this meeting.
I asked him how do we deal with the public pressure regarding the concerns that aviation has reduced fatal incidents and near misses using crew resource management but medicine had not yet seen those same results almost two decades later. Is it unrealistic to have an assumption that simple checklists and CRM training will work due to the fact that health care is substantially more complicated. Dr. Britt did not hesitate, and said we have to start somewhere and that place is to work with the CRM concepts and not focus on the differences between aviation and medicine as a reason not to improve, but as a reason to excel.
In 2015, I spoke with several members of the 2015 South Carolina Surgical Safety program regarding the inconsistency of full completion of their goals. I even contacted members of the South Carolina Hospital Executive Group to discuss this with me. Universally they revealed that failures were due to this being a surgeon driven process in sites who succeeded and an executive driven process where if failed. You have to have a surgeon and or nurse manager and other anesthesiologists. They have to band together and say enough is enough.
MEREDITH:
This is really a model that
takes surgery, anesthesia and nursing to form this bond and make it happen. With
other hospitals in our system approach us and saying we would like to start a Wake
Wings program. The first thing we do is go find out if there's going to be
sufficient surgeon champions and anesthesia champions to pull it off, and if
they're not there, we don't do it and we help them fine. There would be there
would be champions and then we coach those people on it and then we then they
start becoming train the trainers, they take the course so then they or they
take and then they take the instructor course and we spread it. But we, won't
do it without champions.
We had external consultants of that, that came from life wings in Nashville. They
spent several days with us. First with five critical people and then 15
critical people. Then we worked for two days with 45 or 50 thought leaders in
the operating room going through the course, taking it and then going through
the design process, starting with building a common mental model of what wake
wings was going to be.
That still started with a little bit of a Big Bang, right?
We had lots of champions who knew understood the plan. There wasn't just one,
just me or one other one person, one around selling it to 1400 people, right. We
had 50 or 60 champions.
Many of them alternated and became instructors and were former first wake wing
steering committee members.
It's still a lot of work to
keep it maintained.
Ken, you keep saying this “culture where you have built” but I how would admonish you to think of this in terms of this culture you are trying to build. This culture you are working on. Because I don't think this is not a one and done. I know we're not there we're not where we need to be. Where I would like to see us be but we're putting one foot in front of the other all the time and trying to work on it yeah.
LIPSHY:
Some large institutions note that the process of having annual team training unfortunately does not produce enduring results. They recommend ongoing training. But several consider ongoing, to mean asynchronous learning modules. I believe we know that asynchronous, 1:1 computer modules do not have lasting results and that face-to-face case-based scenario/simulation models work in the long run.
MEREDITH:
We have not figured out how
to do that here at scale. we can have segments of it where we take a time that
we are already have set aside for learning. Our department and orthopedics and
urology have this their educational modules but it’s hard to get a
multidisciplinary team free all at one time and in one place.
But having said that, those
residents graduate and carry that skill with them.
My mentors used to say you're just one generation away from the Stone Age all
the time.
Everybody, on Earth forgot
all that. We knew we'd be back in the Stone Age immediately if this was not
continuous. That's a challenge, it's going to turn out, for us to do everybody
they worked in the operating room at one time. It costs us some money in terms
of trainers and people that we paid to do it, but the time of people that will
were there came to work that day and their job that day was to go to weaklings
training for half a day was hundreds and hundreds of thousands of dollars for
that one day for us to do it right.
For me, that's a big thing,
for us to do.
On the other hand, I think
there's a lot of payback on the other end of it.
LIPSHY
Well, you know that's I think your institution has recognized and you already
said this once that the payback is, you know, not necessarily in terms of
dollars, but you know the prevention of a patient safety incident, the ability
of y'all to have a shared mental model.
HELPING THE SECOND
VICTIMS:
LIPSHY
Wayne, when you become aware of a highly emotionally triggering event, does Wake Forest Have a process to help individuals process and heal?
General Surgery News recently posted a testimonial of a Surgeon who endured a tragic death of one of his patients, and his story concluded that he was left to his own accord for counseling and help. He recounted that when they published his first account, many surgeons contacted him to thank him for his honesty as the vast majority of surgeons feel as though they are on an island when such events happen. In fact, a recent LinkedIn editorial comments that many physicians constantly feel all alone.
It was the same time Balch and a couple of others wrote a paper for the college about burnout and subsequent risk for suicide, alcoholism and other things. Prior to that the ASA published a study that revealed that it rare that someone in anesthesia was given time off after witnessing an enormous critical event death on the table or something similar. Severe, irreversible neurological deficit due to something that happened and it was it was it.
I interviewed several law
enforcement officers asking how does their department handle that situation and
they told me that have people that will respond on the scene and talk to
someone and they'll talk to the people involved and decide if they're equipped
to come back to work or if they need to be reevaluated before they return to
duty.
You want to be sure that when something wrong does happen, you're not losing staff in the midst of this, and staff who are distracted by something that occurred that they have no way to resolve it internally, they will eventually create another mistake that leads into my last question for you.
MEREDITH
It was eye opening to me when I realized the number of staff who are involved in that incident, who had to go to work on that case, right and you know, and just the thought that in medicine we don't really have a process and most scenarios to find a way to alleviate that person who now has been traumatized to that team.
LIPSHY
Do you have a team that comes in and works with them to get them fit for duty?
MEREDITH
We send them some to pay
anonymous place.
Individually to work through
that, and then they have to be signed off on to be fit for duty.
If they're still bothered by
and it's way more than just a case, an operating room, workplace violence- someone
that's beaten up in the office or the holding room.
It is surprising how many of
those people years ago were affected. How seriously and what they need?
How much additional support
they needed from the institution to get back to good to go again?
It's really you can't just
seal team six your way through some of those tough things.
They're hard to do and I
think that's actually true for us as surgeons as well.
We need to be mindful of when
we have been put through the wringer of a case that you feel guilty about. Get
it off your chest and wait.
M&M is not the answer for
that, even if you confess your sins at M&M's that's not the answer You need
to go through a process of describing what you're feeling more than and sorting
out how to get back to resilient.
I do think it's an important
skill.
For trauma surgeons in
particular.
But everybody will have one,
right?
I think it's very important
to develop the skill set to that, elite athletes do.
If you watch some of these
documentaries or talk to some of those people there, there's an ability to put
aside the bad play right now and finish the game.
And then after the game… Confer
with your friends and partners teammates and go over it and hate it. Feel lost
from it. Feel remorse about it, then stop feeling that way.
Learn from it and go out and
start getting ready for the next game.
And it's a great lesson
performing athletes have to have that ability, or eventually they all gets in
their head and it messes them up and they can't.
They can't do the game right
and so and I've listened to lots of those.
I've read lots of books about
uh people talking to.
Talking to the G.O.A.T.s is
great book and he and he talks to, you know, Tom Brady, and he talks about his
time with Muhammad Ali and the goats.
They all take responsibility
maybe more than they should but they all take responsibility and they all go
through this process of internalizing it, grieving at learning from it and then
ending it and then being done with it.
that's a hard-fought skill
set to learn.
And I think it takes help, right?
I mean, those guys have learned that since there were playing pop Warner,
right?
They have been trying to practice dealing with loss.
They're dealing with loss
that you're responsible for or dealing with injury.
Has truly elite people have
been practicing the mental discipline of doing that and they have.
They have mental discipline
coaches on their teams, right?
They have physical coaches on
their teams and they have mental discipline coaches on their teams look at a
golf pro.
If they can afford it t, that
and some of them are just more psychologists, we don't.
We don't do enough that I
have seen some mentoring programs written about where senior surgeons go into
the operating room with another senior surgeons and they just observed them and
then they tell them .. here's some tricks that I observe from watching you.
Not blaming not anything like
that, but just having an external eye.
Observe what you're doing and
then go over it is.
Yeah, and I get called in a
lot to help other surgeons and we will almost and I will push very hard to
debrief those cases with the learners and without the learners.
And I've tried to debrief on
the pieces that they saw in what I was doing.
What did you learn from what I was doing and what did you learn not to do?
LIPSHY:
Well Wayne we have covered 45 minutes about a very broad range of topics
Dr. Meredith is the Richard T. Myers Professor and Chair of the Department of Surgery, Chief of Clinical Chairs and Chief of Surgery at Wake Forest Baptist Health. He graduated from Wake Forest School of Medicine in 1978. Amongst his many surgical society leadership roles, he recently served as the President American College of Surgeons from 2020 to 2021.
Kenneth A. Lipshy, MD is
ACOS Surgery Salisbury VA Healthcare System (Charlotte, Salisbury, Kernersville).
Associate Professor Surgery Wake Forest
University.
(Welcome to Crisis Management Leadership).
DISCLAIMER OF REPRESENTATION:
The content of this editorial
represents the opinions of the authors and correspondents noted herein and does
not represent the opinion of the United States Federal Government or Department
of Veterans Affairs or Veterans Health Administration
SEE FURTHER DISCUSSIONS BELOW REGARDING OTHER INTERVIEWS WITH SURGICAL LEADERS FOUND IN “CRISIS MANAGEMENT LEADERSHIP: Training to Survive the Critical Moment © Sept 2021 ISBN: 978-0-578-98323-3”
·
“THE SOUTH
CAROLINA SAFE SURGERY 2015 INITIATIVE” ADJUNCTS AND BARRIERS TO IMPLEMENTING A
STATEWIDE SURGICAL SAFETY CHECKLIST FU Interview with William Berry
· http://crisislead.blogspot.com/2016/09/the-south-carolina-safe-surgery-2015.html?m=1
· THE SOUTH CAROLINA SAFE SURGERY 2015 INITIATIVE- ADJUNCTS AND BARRIERS TO IMPLEMENTING A STATEWIDE SURGICAL SAFETY CHECKLIST (conversation with the Harvard and SCHA groups). http://crisislead.blogspot.com/2016/08/the-south-carolina-safe-surgery-2015.html
· DISCUSSION ON ACS COMMUNITY RE. POST NSPSS INTERVIEW WITH AIRLINE PILOTS REGARDING AVIATION CREW TRAINING REQUIREMENTS. http://crisislead.blogspot.com/2016/08/discussion-on-acs-community-re-post.html
·
HOW DO WE
IMPROVE PATIENT SAFETY? A LOOK AT THE ISSUES AND AN INTERVIEW WITH DR. BRITT
KENNETH A.
LIPSHY, MD, FACS AND L.D. BRITT, MD, MPH, D.SC(HON), FACS, FCCM, FRCSENG(HON),
FRCSED(HON), FWACS(HON), FRCSI(HON), FCS(SA)(HON), FRCSGLASG(HON)
PUBLISHED
FEBRUARY 1, 2017 • PRINT-FRIENDLY
CRISIS MANAGEMENT LEADERSHIP: Training to Survive the Critical Moment © Sept 2021
WHY AREN’T PATIENT SAFETY
INITIATIVES WORKING UNIVERSALLY?
One major hurdle for patient
safety initiative implementation has been lack of staff buy-in. Staff
frequently are hindered by 'checkbox fatigue'. As a result, staff simply may go
through the motions. However, as Berg’s
meta-analysis of surgical safety checklist studies concluded, implementation of
checklists is more than checking off boxes.
In a review of the implementation of the World Health Organization (WHO) Checklist in the U.K., Russ and colleagues concluded successful implementation of the WHO Checklist required the following: Modification to suit the local context to ensure integration into existing programs and enhance buy-in. Education tailored to the needs of each stakeholder. Identification of local champions to promote safety in clinical work areas. Executive leadership support. A system of accountability for “improper” behavior or noncompliance. Careful auditing.
STAFF BUY IN-Staff Buy-in is
absolutely essential. Richard Karl, MD, FACS, a commercial pilot for JetSuite
Irvine CA and Chairman Emeritus, Department of Surgery, University of South
Florida, Tampa, stated that though medicine is far more complicated than
aviation, many tools
associated with improved air travel safety could be used for error reduction and improved outcomes in health care if implemented properly. However, "you can't just slide a checklist under the operating room door and expect it to work," he said (personal communication July 2016).
RETHINKING TEAM CONCEPTS: Douglas Paull, MD, MS, [director,Patient Safety Curriculum and Medical Simulation National Center for Patient Safety (NCPS)] suggested (personal communication July 2016) that considering the dynamic state in which medical teams function, health care organization should introduce the Amy Edmondson's concept of the action of ”teaming.” (Edmondson). According to Edmondson, health care are not static groups. The members have different levels of training and competence. Furthermore, team composition is dynamic, with different members performing different responsibilities in the course of care or of a procedure. Moreover, several leadership units are often at play in an OR, including nursing, anesthesia, and surgery. Team training in health care, therefore, needs to account for the dynamic interactions between units or special teams. (Edmondson). As surgeons, we ultimately have responsibility for our patients’ outcome and experience. We set the tone for a safety culture.
WHO IS LEADING THE WAY? In addition to
communication failures, a lack of leadership is a key driver of sentinel and
adverse events. As Dr. Paull said, "Leaders set the tone for safety
culture...leaders by their words and actions develop an environment that
rewards people for speaking up with safety concerns." While the captain-of-the-ship model in
medicine may no longer be applicable, physicians must take the helm and steer
this patient safety process. Leadership is vital to ensuring the team remains
focused and on target.
The concept of
"oversight of the entire process" would suggest that surgeons should
be invested in the entire patient safety venture. However, surgeons frequently
become disinterested in an educational program as soon as they hear it is
non-technical in nature.
In 2015, Russ and colleagues noted: that “the most common barrier to checklist
implementation, reported by 51% of the sample was active resistance or passive
non-compliance from individuals on the OR team, most frequently (84%) from
senior surgeons and/or anesthesiologists. This often made it challenging for the person leading the checks (often a
nurse) to complete them in the intended manner, or without feeling personally
attacked.”
Often only after something untoward occurs, do
surgeons take interest.
(RUSS) Edmondson recently noted that in a prior study on the development of minimally invasive cardiac surgery (MICS) programs, the key to success hinged on how the lead surgeon viewed their stance as a member of the team. In the instances where the lead surgeon viewed themselves as part of a partnership aimed at the benefit of their team and patients, the project succeeded. These surgeons tore down the silos and ensured everyone had an equal role in the success and failure of the project. However, when the lead surgeon practiced authoritarian (top-down) leadership and simply expected everyone to execute their job as directed, the project failed. (Edmundson)
RETHINKING HRO PRINCIPLES IN HEALTHCARE:
One final area of contention is the continued use
in the scientific community of James Reason’s "Swiss Cheese Model" as
a model for healthcare HRO’s.
(REASON) However, this model, which suggests that that there are stepwise processes where errors occur and are easily detected, may be too simplistic for use in health care. In complex systems such as medicine multiple cogs move simultaneously. The process that we believe we have put into check may change the second we move onto the next task. (Cook and Rasmusen)
RELATIONSHIP OF ERRORS ON STRESS, FATIGUE, BURNOUT,
ALCOHOLISM, AND SUICIDE
Balch et al. related that burnout and other measures of surgeon distress correlate directly with increasing work hours over eighty hours a week and nights on call over twice a week among American surgeons. They noted that “when physicians are in distress, their performance in delivering care can be suboptimal” which increases risk for a home-work conflict and lapse in judgment. In patient care (and especially surgery) there is always the expectation of a quick success. As Bosk reminds us in “Forgive and Remember: Managing medical Failure” the first question asked after any failure is, “what did you do wrong?” On top of that, unfortunately, most of us harbor maladaptive behavior in times of failure or significant change.
A recent American College of Surgeons survey on
burnout revealed a tight relationship between causing a patient error and
stress, fatigue, burnout, alcoholism, and suicidal ideation. In this survey,
8.9% reported committing a medical error within the preceding three months. The majority of these
contributed this to a lapse in judgment, fatigue, lack of concentration, and
other distractions. Further assessment of the responders noted that a prior
medical error was independently predictive of high alcohol use and suicide ideations.
Similar findings are noted above from a recent ASA study on the effects of negative outcomes in the operating room on anesthesia providers.3
Bernstein’s group at the University of Toronto conducted a survey in 2015 assessing the mechanisms whereby residents learn to recover from a traumatic impact during their residency. The study confirms that residents are still distraught over the lack of formal mechanisms around to assist them in that recovery process. That is, the idea of helping the second victim, does not appear to be universal. (Balogun et al). Thus, anything that reduces errors reduces distractions from the team and creates a safer environment for patients and staff.
84% experienced more than 1 unanticipated death or serious injury
over career.
70% experienced guilt, anxiety, and reliving of
the event (88% requiring time to recover emotionally & 19% never fully
recovered, 12% considered a career change).
67% believed that their ability to provide patient care was
compromised in the first 4 hours subsequent to the event.
Only 7% were given time off.
CONCLUSION: A perioperative catastrophe may have a profound and lasting
emotional impact on the anesthesiologist involved and may affect his or her
ability to provide patient care in the aftermath of such events.
