Surgical Checklist Item No. 1: Improve Your Relationships

In an April 15 webinar hosted by Becker's Hospital Review, experts from Select International discussed the role of behaviors and talent in patient safety and organizational culture. The webinar featured Michael Rose, MD, vice president of surgical services for five-hospital McLeod Health in Florence, S.C., and Ted Kinney, PhD, director of research and development for Pittsburgh-based Select International.

Dr. Rose began the presentation by looking back at safe surgery efforts in the past, such as The Joint Commission's Universal Protocol, which went into effect in July 2004 to better prevent wrong-site, wrong-procedure and wrong-person surgeries. The three primary components of the Universal Protocol include a preprocedure verification, site marking and a timeout. But five years after the protocol went into effect, Dr. Rose spotted an alarming news headline about never-events in surgery: "The horror is far from over."

"Wrong-site surgeries were going up around the country," said Dr. Rose. "In effect, this headline was proof of the failure of the promise we'd made to patients to end never-events." The protocol did not diminish safety violations as robustly as it intended, and Dr. Rose cited previous studies that suggested timeouts — part of Universal Protocol — seemed to increase the odds of a never-event occurring during the surgical procedure.

But then came the 2009 article in the New England Journal of Medicine, "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population" — a game-changer, said Dr. Rose. The article later inspired the oft-cited book "The Checklist Manifesto" by Atul Gawande, MD. When Harvard Business Review published its list of the 10 innovations that will transform medicine, "checklists" sat at No. 1.

"Not only did [the checklist] work, but it seemed to work everywhere they tried it," said Dr. Rose, from third-world operating rooms to academic medical centers. Dr. Rose would eventually see the benefits of a checklist-driven method benefit at his health system — a 40 percent drop in its adjusted surgical mortality rate over three years. But first, he had to improve something else: relationships.  

Second and third priorities
To any member of McLeod's surgical staff, the No. 1 priority was and is patient safety. But what about No. 2 and No. 3? As Dr. Rose found out, his guess was as good as any.   

"Teams underperform when members feel disrespected, unheard or whether there is a lack of clarity about purpose," said Dr. Rose. To re-establish a sense of clarity among surgical team members, he asked hundreds to list their two highest priorities in the OR after patient safety. He found big differences in the No. 2 and No. 3 priorities of most people. For some, it was saving time, being efficient, having respectful communication, having the resources needed to do the job or knowing who was with them on the team, among other concerns.

"Without alignment and clarity of purpose, there was little foundation for relationships between the people. When these conditions exist, people just don't contribute all they can. Some just check out, and in a high-risk environment, we couldn't have that," said Dr. Rose. Armed with this information, Dr. Rose set out to make some changes to the way teams worked together.

First, relationships were built or strengthened on a one-by-one basis. "We would go to one of our colleagues and tell him or her why we were called to work, and then we would ask them about their [calling] and to tell us what their commitment and purpose was," said. Dr. Rose.

Team members then asked one another for commitments. "Would they take three opportunities during each case to hear from each other, hear critical pieces of information the team was accountable for?" Those three points were before anesthesia was applied, before a scalpel touched the skin and before the team placed the patient into the hands of the next care team. Before doing any of these things, the team paused to confirm each member was prepared and confident to do so.

When the case was over, Dr. Rose then asked surgical staff members to "tell us, in your own words, anything that happened that put your patients at risk, made it hard to do your best [or] anything that can help us with the next patient." In exchange, the senior management team would tell the entire team about anything that had been reported the day before. "We let them know they were heard. We used these stories to experience success and show that people would be supportive," said Dr. Rose.

Findings and results
Through this increased transparency about mistakes or concerns, Dr. Rose learned that two, three or four things combined often led to a critical event. There were rarely events when one single thing caused a safety problem. Further, he said there was "almost always" someone on the team who knew, should have known or could have known what was about to happen. The problem was this information was not shared at a point in time when it could have made a difference in the outcome.

With this program in motion, Dr. Rose said the health system's surgical team has "accrued a great deal of learning." The system has had more than 45,000 debriefs, 4,100 events and 100 critical defects in perfection. Half of those critical events have something to do with clinical supplies or technology, whereas another third involved faults in some part of the process of care. Another finding? Errors in the OR most often began far upstream. "Only about one in 10 events had something to do with an individual person's performance, even though in surgery we feel at our best in an OR when we can assign a perpetrator to anything bad that happens," said Dr. Rose.

The relationship building, three-pause checklist process and debriefings have been built into staff members' annual performance reviews and compensation, said Dr. Rose. "This isn't about ticking off boxes, but creating a social change and the development of human behavior and interaction," he said. And it is paying off: In 2013, the system conducted a poll, finding 96 percent of physicians and 92 percent of non-physicians feel that "in the ORs where I work, I feel safe speaking up if I think there's a problem."

Dr. Kinney said there are several remarkable parts to Dr. Rose's approach to patient safety. "First is the discretionary effort model: We are looking for above-and-beyond performance. Dr. Rose talked about zero harm — zero. That's a tough standard to get to. Who goes that far above and beyond? Well, not everyone. Understanding the core psychological attributes that predict above-and-beyond behavior is critical to high-performance outcomes we're all seeking."

Dr. Kinney also brought up checklists, and the question he often hears: Do they work? "My answer always involves words like people, behavior, culture, talent. Without the right people or talents, you're sunk. It all comes back to culture and driving behaviors," said Dr. Kinney. If it weren't for the relationship-centric approach Dr. Rose took to McLeod's patient safety improvement efforts, the results may have played out differently.


View or download the Webinar by clicking here (wmv). We suggest you download the video to your computer before viewing to ensure better quality. If you have problems viewing the video, which is in Windows Media Video format, you can use a program like VLC media player, free for download by clicking here.

Download a copy of the presentation by clicking here (pdf).

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