Improving surgical teamwork & communication

Improving surgical teamwork & communication - surgical safetyHow does Surgical teamwork and communication contribute to surgical safety?

During a surgical procedure and the pre and post-operative period, patient care depends on the expertise, teamwork, communication and co-ordination of the multi-disciplinary Surgical Team. Research suggests that teamwork and communication failures are at the core of many medical errors and adverse events.

Patients who undergo a surgical procedure are at increased risk for complications and death. However, enhancing the teamwork and communication of the team will provide safer surgery for the patient, reduce the likelihood of harm, and improve patient outcomes.

Why is teamwork and communication important in Surgery?

Surgical procedures, and the peri-operative care of patients involves complex coordination within the surgical team, including surgeons, anaesthetists, nurses and support staff.

To provide the safest most effective care for patients, there needs to be established evidenced-based practices around safety checklists, team communication and co-ordination.

The Health Quality Safety Commission (HQSC), through its Safe Surgery New Zealand programme, has developed a number of interventions aimed at reducing peri-operative harm and improving patient outcomes. These interventions are supported by research around the world demonstrating reductions in surgical mortality and complications.

What specific interventions target teamwork and communication in Surgery?

1. World Health Organization (WHO) Surgical Safety Checklist

The WHO Surgical Safety Checklist was developed to ensure that the correct surgical procedures are carried out on the correct patients. The checklist has three parts, where different details are checked in theatre by the team at three different points of time. Using the checklist means that the Surgical Team performs key safety checks, and it also aims to increase verbal communication in the operating theatre.

2. Surgical Briefings and Debriefings

As an adjunct to the Surgical Safety Checklist, WHO recommends structured Briefings and Debriefings take place to further enhance team communication in the operating theatre.

A surgical briefing is a standardised communication tool used at the start of a session in the operating theatre. It enables the team to discuss the operative plan for all procedures, potential hazards are highlighted, and a check is made that all equipment required for the day is available. Briefings promote teamwork and communication as all team members gain an improved understanding of the plan for the day, and are encouraged to raise any potential issues or concerns.

A surgical debriefing, at the end of an operating list, allows teams to discuss what went well or didn’t go to plan. The debriefing provides an opportunity for improvement as teams can identify solutions to any issues encountered.

3. Surgical Safety Culture Survey

The Harvard Surgical Safety Culture Survey is a recently validated questionnaire, which collects data around staff perceptions and attitudes about various aspects of their work and work environment. Areas covered, specific to the operating theatre environment, include staff opinions related to the quality of communication, teamwork, and safety practices in the operating theatre and also the facility's readiness for change.

This questionnaire may be used as tool to measure perceptions before and after implementation of processes such as the Surgical Safety Checklist and Briefings and Debriefings.

4. Communication tools

There are a number of tools available to improve communication in operating theatres. Two of the tools promoted by the HQSC are Closed-Loop Communication and ISBAR.

  • Closed-loop communication ensures the ‘sender’ of information knows that the ‘receiver’ of their information has heard and understood their instructions. It minimises the risk of misinterpretation.
  • ISBAR is a framework for communicating information in a clear logical way. It involves communication by using the following framework:
    dentify – Situation – Background – Assessment – Recommendation
    ISBAR is particularly useful when sharing patient information between team members and ensuring that everyone has the same level of understanding.

What have we done?

We have already implemented many of the Safe Surgery NZ interventions, and are one of the first DHBs in New Zealand to roll-out them out.

1. World Health Organization (WHO) Surgical Safety Checklist

We implemented use of the Surgical Safety checklist over 2011-12 and have refined the process by developing a Waitemata DHB specific checklist, and also moving to a paperless checklist. Having the checklist as a chart on the wall allows all members of the team to see what will be asked and use it as a discussion guide for all three parts.

2. Surgical Briefings and Debriefings

A staged process involving education and training of staff around Briefings and Debriefings was undertaken across all three of our surgical sites over the course of 2016. We are one of the first DHBs in New Zealand to implement Briefings and Debriefings in our operating theatres.

3. Surgical Safety Culture Survey

We obtained permission from the Harvard group to use their Surgical Safety Culture Survey to collect baseline data prior to implementation of Briefings and Debriefings. The survey was administered at all three of our surgical sites over the course of 2016.

Response rates of over 90% were achieved from Surgical, Anaesthetic, Nursing, and theatre support staff. The survey has provided useful information about overall perceptions of staff, and differences between professional groups, in relation to surgical culture. Areas with the greatest potential for improvement were identified.

4. Communication tools

A project team is currently promoting and implementing the use of the ISBAR framework across the entire DHB, including operating theatres.

Where to from here?

Refinement of existing interventions, and implementation of new approaches is ongoing.

1. World Health Organization (WHO) Surgical Safety Checklist

Trained auditors are monitoring and assessing use of the WHO Surgical Safety Checklist in our theatres, and there is ongoing training in checklist use.

2. Surgical Briefings and Debriefings

Training in Briefings and Debriefings in operating theatres is ongoing, and tools are being developed to assess its use across Waitemata DHB sites.

3. Surgical Safety Culture Survey

The Surgical Safety Culture Survey is to be repeated at all three of our surgical sites to assess any changes or improvements after implementation of Briefings and Debriefings in operating theatres. Remaining areas for improvements will be highlighted, and it will be determined what additional interventions are required to address these.

4. Communication tools

Ongoing process of training staff and promoting use of communication tools throughout the DHB.