This paper shares an overview of communications amongst the surgical team highlighting the impact of both poor and good communication practices and provides methods and tools to improve this process. Please Contact us at www.perspect.ca for more information.

1. SURGICAL TEAM
COMMUNICATION
November 26, 2008
www.perspect.ca

2. Communica>on
Defini>on:
‐ a process by which informa>on is exchanged
between individuals through a common system
of symbols, signs, or behavior

3. Outline
Importance of effec>ve communica>on in surgical

teams
 Current piPalls in OR communica>on
 New communica>on tools
 SBAR
 OR briefings
 Medical team training
Implementa>on


4. Preventable medical errors
Ins>tute of Medicine’s 1999 report “To Err is

Human”
 preventable medical errors result in:
 44,000‐98,000 deaths/year in US hospitals

5. Primary root cause analysis of sen>nel
events
delay in treatment

84% ‐ breakdown in communica>on

wrong site surgery

> 50% ‐ breakdown in communica>on between surgical team members

and the pa>ent and family
opera>ve and post‐op complica>ons

66% ‐ failure in communica>on

ven>lator‐related deaths and injuries

70% ‐ communica>on breakdown

infant death and injury during delivery

72% involved communica>on issues (with 55 percent ci>ng

organiza>on culture as a barrier to effec>ve communica>on and
teamwork)
Joint Commission on Accredita0on of Healthcare Organiza0ons. Sen$nel event sta$s$cs: Available online
from, hdp://www.jointcomission.ort/Sen>nelEvents/Sen>nelEventAlert/

6. Teamwork in the OR
posi>ve aftudes towards teamwork

 reduced errors in avia>on and ICUs
 increased job sa>sfac>on
 less sick >me used by employees
 decreased employee turnover

7. Teamwork in the OR
Makary et al., J AM Coll Surg, 2006

 surveyed OR personnel regarding aftudes toward
teamwork and collabora>on
 60 hospitals involved
 2769 ques>onnaires
 77.1% response rate
Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L, Pronovost PJ. Opera>ng Room
Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder. J Am Coll Surg 2006; 202:
746‐752

8. Sample survey items
rated on a 5‐point Likert scale

 the physicians and nurses here work together as a well‐
coordinated team
 I am frequently unable to express disagreement with the
staff physicians here
 important issues are well communicated at shij change
 I am sa>sfied with the quality of collabora>on I
experience with (staff physicians/nurses) in this clinical area

9. with respondents during survey feedback presentations
92.7, respectively). In fact, surgeons perceived that
highlighted that nurses often describe good collabora-
everyone in the OR is doing a good job in terms of
tion as having their input respected, and physicians of-
teamwork (Fig. 2). Figures 3A, 3B, and 3C display the
ten describe good collaboration as having nurses who
contrast between surgeons and nurses, surgeons and an-
anticipate their needs and follow instructions. Histori-
esthesiologists, and anesthesiologists and nurses, respec-
cally, there are differences between the expectations that
tively, and Figures 4A and 4B demonstrate interposition
physicians and nurses bring to a communication en-
differences in teamwork among all members of the OR.
counter. Nurses are trained to communicate more holis-
Such differences underscore the disconnect in teamwork
tically, using the “story” of the patient, and physicians
and the methodological barrier in aggregating measures
of teamwork in surgery. are trained to communicate succinctly using the “head-
Table 2. ANOVA Results for Teamwork Ratings by and of Each Operating Room Provider Type
Mean ratings* of teamwork by
OR nurses†
Ratings of df F p Value Surgeons Anesthesiologists CRNAs Overall
Surgeons 4, 2058 41.73 0.001 4.38 4.03 3.72 3.52 3.68
Anesthesiologists 4, 1990 53.15 0.001 4.39 4.80 4.25 3.85 3.96
CRNAs 4, 1571 37.36 0.001 4.37 4.58 4.67 3.94 4.04
OR nurses 4, 2061 12.93 0.001 4.42 4.31 4.10 4.25 4.20
Surgical technicians 4, 2044 6.17 0.001 4.36 4.17 3.95 4.07 4.10
*1 very low; 5 very high.
†
Scrub and circulating.
CRNAs, certified registered nurse anesthetists; df, degrees of freedom; OR, operating room.
!

10. Percentage (rounded) of opera>ng room (OR) caregivers repor>ng a
“high” or “very high” level of collabora>on with other members of the
OR team.

11. Barriers to effec>ve team communica>on
in the OR
OR sefng

 masks
 noise
hierarchical structure

 work overload
 distrac>ng communica>on
 communica>on plan
 accountability

12. Types of Communica>on Failures
Occasion

 occurred too late
Content

 inaccurate or incomplete
Audience

 significant individuals excluded
Purpose

 issues lej unresolved
Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E.
Communica>on Failures in the Opera>ng Room: an observa>onal classifica>on of recurrent types and effects.
Qual Saf Health Care 2004; 13: 330‐334

13. Communica>on failures (cont’d)
31% of communica>on events fail

 usually due to >ming or content
one‐third result in immediate effects

 delay
 inefficiency
 team tension
May lead to false sense of security and migra>on

into poten>al danger zone

14. Crew Resource Management
history

 originated 1979
 NASA research showed that majority of avia>on
accidents were caused by human error
 specifically failures of communica>on, leadership and
decision‐making

15. CRM Training
encompasses knowledge, skills and aftudes

 includes:
 communica>on
 leadership
 problem‐solving
 situa>onal awareness
 decision‐making
 teamwork skills
 conflict resolu>on

16. CRM in Medicine
SBAR

 Opera>ng Room Briefings
 Medical Team Training

17. SITUATION
 What is going on with the pa>ent?
BACKGROUND
 What is the key clinical background or
context?
ASSESSMENT
 What do I think the problem is?
RECOMMENDATION
 What do I think you should do and when?

18. SBAR
communica>on technique providing a framework

for a discussion about a pa>ent
 uses a standardized format
 enhances clarity and efficiency of communica>on

19. Possible uses of SBAR
anesthesia hand‐offs

 crisis management
 reques>ng a consult
 hand‐overs at shij change or for ward transfers
 nurse‐physician communica>ons regarding pa>ent
status

20. Example of SBAR
Dr. Jones, this is Nurse McDonald, I am calling from

ABC Hospital about your pa>ent Jane Smith.
Situa&on: Here's the situa>on: Mrs. Smith is having

increasing dyspnea and is complaining of chest pain.
Background: The suppor>ng background informa>on

is that she had a total knee replacement two days ago.
About two hours ago she began complaining of chest
pain. Her pulse is 120 and her blood pressure is
128/54. She is restless and short of breath.
Assessment: My assessment of the situa>on is that

she may be having a cardiac event or a pulmonary
embolism.
Recommenda&on: I recommend that you see her

immediately and that we start her on 02 stat.

21. Opera>ng Room Briefings
also called a team checklist

 addresses safety issues by:
 decreasing reliance on memory
 standardizing processes
 increasing access to informa>on
 providing feedback

22. Development and pilot implementa>on of
a checklist
Lingard et al. 2005

 developed own checklist
 studied its use in 18 vascular surgery procedures
 elicited feedback from par>cipants
Lingard L, Espin S, Rubin B, White S, Colmenares M, Bager GR, Doran D, Grober E, Orser B, Bohnen J, Reznick
R. Gefng Teams to Talk: development and pilot implementa>on of a checklist to promote interprofessional
communica>on in the OR. Qual Saf Health Care 2005; 14: 340‐346

24. Development and pilot implementa>on of
a checklist
dura>on

 averaged 3.5 minutes (range 1‐6 min)
>ming (number of checklists done)

 before pa>ent arrival 9
 ajer arrival, before induc>on 5
 ajer induc>on 4
loca>on

 in OR 13
 in hallway 4
 in holding area 1

25. Development and pilot implementa>on of
a checklist
Pros Cons
not >me consuming or inconvenient to surgeons
 
onerous interrupted workflow

increased nursing if too late, redundant
 
knowledge of history and
plan
improved OR efficiency

reduced equipment delays


26. Study of pre‐opera>ve checklist to reduce
communica>on failures
13 month prospec>ve study

 # of communica>on failures pre‐ and post‐
checklist interven>on
 func>onal u>lity of checklist
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evalua>on of a
Preopera>ve Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in
Communica>on. Arch Surg 2008; 143: 12‐17

27. Study of pre‐opera>ve checklist to reduce
communica>on failures
observed 302 checklist briefings

 1 – 4 minutes
 8% before pa>ent arrival to OR
 34% ajer pa>ent arrival, before induc>on
 47% ajer induc>on of general anesthesia
 (11% >ming was not documented)

28. Study of pre‐opera>ve checklist to reduce
communica>on failures
observed 86 each pre‐ and post‐ interven>on

procedures
 # of communica>on failures per procedure
 3.95 before introduc>on of checklist
 1.31 ajer introduc>on of checklist
 P < 0.001

30. Func>onal u>lity of checklist briefings
34% (100/295) showed some func>onal u>lity

 iden>fied a problem
 revealed an ambiguity
 exposed a cri>cal knowledge gap
 provoked a change in plan
 prompted a follow‐up ac>on
44% had a direct impact on pa>ent care


31. Implementa>on
BARRIERS ASSETS
OR professionals engaging team
 
accustomed to members
independence  stake‐holder mee>ngs
 “individual excellence  surgeon “champions”
should be sufficient”
 overwhelmed and
may priori>ze other
du>es

35. Medical Team Training
uses interdisciplinary team training

 surgical teams work in a high‐stress, high‐
workload, >me‐pressured environment
 need flexible, open communica>on
 must an>cipate other members’ needs
GOAL:
 to transform a team of experts into an
“expert team”

36. Medical Team Training
team training focuses on non‐technical skills

 leadership
 decision making ability
 situa>on awareness
 communica>on
 team skills
 coordina>on
 vigilance

37. Approaches to Team Training
CLASSROOM‐BASED MEDICAL SIMULATION
TEACHING
high‐fidelity simulated
lectures 

OR
 videos
 prac>ce new protocols
 case‐reviews
in work sefng
 problem‐solving
 exams

38. Approaches to Team Training
CLASSROOM‐BASED MEDICAL SIMULATION
TEACHING
hands‐on prac>ce
no expensive 

equipment  deploy new skills in
complex environment
 teach many staff
simultaneously  enhance cross‐role
understanding
 can update and orient
new staff as needed  immediate feedback

39. Medical Team Training
difficult to cause permanent change with only a

single interven>on
 people need repe>>ve training and prac>ce to
change behaviours
 workplace re‐inforcement is beneficial
 “champions” of the new behaviours are ideal
 classroom teaching and medical simula>on could
be used together

40. WHO’s “Safe Surgery Saves Lives”
began in January 2007

 officially launched June 2008
 iden>fied four areas requiring improvement in
order to increase pa>ent safety during surgery
 surgical site infec>on preven>on
 safe anesthesia
 safe surgical teams
 measurement of surgical services

41. Pilot evalua>on of WHO “Surgical
Safety Checklist”

42. Pilot evalua>on of WHO “Surgical
Safety Checklist”
1000 pa>ents

 8 sites worldwide
 adherence to proven standards of surgical care
 has increased from 36% to 68%
 reduced complica>ons and deaths
World Health Organiza0on. Safe surgery saves lives. Available online from, hdp://www.who.int/
pa>entsafety/safesurgery/tes>ng/pilot_sites/en/index.html

43. one in 5000 chance of death. With improvements in knowledge and basic
standards of care the risk has dropped to one in 200 000 in the developed
Safe Surgical Teams
world — a 40-fold improvement. Unfortunately the rate of anaesthesia-associated
mortality in developing countries appears to be 100–1000 times higher, indicating
a serious, sustained lack of safe anaesthesia for surgery in these settings.
• Safe surgical teams: Teamwork is the core of all effectively functioning systems
involving multiple people. In the operating room, where tension may be high
and lives are at stake, teamwork is an essential component of safe practice. The
quality of teamwork depends on the culture of the team and its communication
patterns, as well as the clinical skills and situational awareness of the team
members. Improving team characteristics should aid communication and reduce
patient harm.
!
• Measurement of surgical services: A major problem in surgical safety has
been a shortage of basic data. Efforts to reduce maternal and neonatal mortality
during childbirth have been critically reliant on routine surveillance of mortality
rates and systems of obstetric care to monitor successes and failures. Similar

44. Global support and endorsements
Accredita>on Canada

American Academy of Orthopaedic Surgeons/ American Associa>on of

Orthopaedic Surgeons
American Academy of Otolaryngology‐Head & Neck surgery

American Associa>on of Neurological Surgeons (AANS)

American College of Surgeons

American Orthopaedic Associa>on

American Society of Anesthesiologists

Anesthesia Pa>ent Safety Founda>on

Canadian Anesthesiologists' Society

Canadian Associa>on of General Surgeons

Canadian Medical Associa>on

Canadian Pa>ent Safety Ins>tute

Royal College of Physicians and Surgeons of Canada


45. Framework for Harm Preven>on

46. Bodom Line
IOM and JCAHO have both recommended

adop>on of avia>on safety principles
 WHO supports improved surgical safety and use of
an OR checklist
 the WHO ini>a>ve is endorsed worldwide

47. Next Steps…
How best to implement and maintain new

ini>a>ves?
 Par>cipa>on is crucial – consider becoming a
champion
 Next mee>ng of OR safety commidee is January
21, 2009
 Contact Dr. Craig Bosenberg for further
informa>on

48. Contact:
Dr. O McAllister BSc, MD, FRCP(C)
Managing Partner
Colin McAllister PEng, PMP, MBA
Managing Principal
Perspect Management Consulting
www.perspect.ca (Contact Us)