ORs in facilities that adopted team training had a lower rate of deaths for

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1 Patient safety VA study shows fewer patient deaths after OR team training ORs in facilities that adopted team training had a lower rate of deaths for surgical patients than facilities that had not yet had training, in a large new study from the Veterans Health Administration. The 74 VA facilities that had team training saw an 18% decrease in their annual surgical mortality rate compared with a 7% decrease in facilities that had not, a significant difference. Moreover for every quarter of additional training, surgical deaths fell still further by 0.5 per 1,000 procedures. The training, based on the aviation model, instructed clinicians in working as a team, challenging each other when they identified safety risks, and conducting checklist-guided preoperative briefings and postoperative debriefings. This is about more than a checklist that s the clear message. We did this in a structured way where each team developed its own briefing and debriefing tools, James Bagian, MD, PE, a coauthor of the report in the October 20, 2010, JAMA, told OR Manager. The aim, he says, is for the briefings not to be a rote exercise but a richer conversation that brings the team together to prepare for the operation. Some facilities also chose to measure indicators such as operative time and on-time first case starts and saw gains in those areas as well (table). The team training was piloted in 2003, rolled out nationally in 2006, and mandated for all 130 VA facilities that perform surgery in What this paper documents is the results not with the volunteers but with the full rollout, Dr Bagian adds. Director of the VA s National Center for Patient Safety during the study, he is now director of the Center for Health Engineering at the University of Michigan, Ann Arbor. (Stories of good catches and improvements resulting from the training are in the sidebar, p 11.) More than a time-out Having the briefing be a conversation is real important, Julie Freischlag, MD, the author of an accompanying JAMA editorial with Peter Pronovost, MD, PhD, told OR Manager. She is surgeon-in-chief at Johns Hopkins and editor of the Archives of Surgery. At Johns Hopkins, where briefings were introduced in 2003, the briefing is not simply a time-out. It s more having a conversation about the patient what are the issues, what is specific to this patient, what are you worried about, what equipment do you need? Dr Freischlag says she and Dr Pronovost were impressed with the culture created by the training in the VA that was reinforced as teams continued to talk about and improve their processes. 1

2 Improvements reported by VA s medical team training facilities Reported No. (%) of facilities improvements n = 74 Communciation among OR staff 35 (47.2) Staff awareness 34 (46.0) Overall efficiency 49 (66.2) Equipment use during surgery 44 (59.9) Reduced length of procedures 15 (20.3) Improved first-case start times 30 (40.5) Other types of efficiency improvements a 6(8.0) a For example, reduced delays for surgical consent, decreased turnover time between cases, reduction in staff overtime hours. Source: Copyright Neily J, Mills P D, Young-Xu Y, et al. JAMA. 2010;304: Reprinted with permission. What team training includes These are elements of the VA s team training program. 2 months before the training day, a conference call was held by the trainers with each facility. Each OR selected an implementation team with champions from surgery, anesthesia, nursing, surgical technology, and the sterile processing department (SPD). The facility measured its baseline OR team climate with the Safety Attitudes Questionnaire (SAQ), a validated tool for measuring attitudes about safety, teamwork, and working conditions. The ORs were closed for a 4-hour mandatory team training session attended by all disciplines. In the training, the participants learned communication skills such as recognizing red flags, stepping back to reassess a situation, and effective communication during care transitions. Participants then worked in small groups to develop checklists for their own situations. Facilities that received the training were required to implement briefings and debriefings with the intent to improve communication and patient safety. Four structured interviews were held with the facilities for 1 year to support, coach, and assess the team training implementation. Surgeon leads briefing At the Phoenix VA Health Care System in Arizona, which conducted team training in 2008, the attending or primary surgeon leads the briefing, as directed by the chief of surgery. The briefing is held in the OR with the patient involved. A laminated poster on the wall of each OR guides the discussion (illustration, p 10). 2

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4 With the surgeon leading the briefing, the plan for the procedure is clear, and more attending surgeons are arriving on time, notes Lisa Warner, RN, MHA, CNOR, nurse manager for perioperative services. I think the nurses have looked at this as a positive opportunity to talk with the anesthesia provider and the surgeon and ask questions, she adds. For example, teams learn before the case if equipment isn t available so the case can be canceled before the patient is anesthetized. There have also been good catches. In one case, a wrong-side hand surgery was prevented. The patient had had previous surgery on one hand, and the team initially thought the case was a reoperation. But in re-examining the x-ray during the briefing, they realized the surgery was on the opposite hand. Though some complained about taking time for the training, Warner thinks the discussions that took place were beneficial and helped even the playing field among the disciplines. The tone needs to be set early on, she says. All players in the perioperative arena need to be involved. Tips for training Asked for tips on introducing a similar program, Dr Bagian suggested starting with volunteers. Our plan in any patient safety activity has always been to go to volunteers first prove the concept and show that it works. That creates a buzz. After the VA s pilot projects started, he says, other facilities began asking for the training. By the end of the pilots, we had a majority demanding to do it next, he says. Other facilities were beginning to hear about the results, not only for patient outcomes but also for operational improvements such as more first cases starting on time. Do the briefings take extra time? Dr Bagian responds, We showed a decrease in overall intraoperative time. In a lot of cases it doesn t take any additional time. Or instead of talking about the baseball playoffs, maybe you could talk about the case. Measuring outcomes Patient outcomes from team training were measured through the VA s Surgical Quality Improvement Program (VASQIP), which the authors say provides a reliable, valid, risk-adjusted means for tracking 30-day mortality rates for major noncardiac surgery performed at VA facilities. VASQIP was adopted by the American College of Surgeons (ACS) as the first nationally validated, risk adjusted outcomes-based program to measure and improve the quality of surgical care and is now called ACS NSQIP, Dr Bagian notes. The VA was able to conduct this outcomes study because of its substantial investment in health information technology and quality assurance processes, the editorial notes. The VA has an integrated outpatient electronic health record and administrative tools that enable it to capture and analyze large databases for its patient population. References Neily J, Mills P D, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:

5 Pronovost P J, Freischlag J A. Improving teamwork to reduce surgical mortality. Editorial. JAMA. 2010;304: Sexton J B, Helmreich R L, Neilands T B, et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. Stories from team training Stories shared by VA facilities that conducted OR team training. For one patient, they discovered the number on the blood band was wrong. They had to redraw the blood and correct the band. The briefing allowed them to discover and correct the problem. One day, the OR schedule for cataracts was rearranged because the patient needed potassium redrawn. There was potential for error because this was the first patient, but the second patient was moved up to be the first case. The team used the briefing process to make sure they had the correct patient and correct lens for each patient that day. In a hip replacement case, the team needed a unique instrument. Since they didn t carry it, they had to get it from another facility. When the instrument came in, it was marked single-use only and was not packaged. This was discovered far enough in advance not to be problematic. In the past, it would have been a later discovery. The OR staff feels that the medical team training holds the surgeons accountable. Staff are told of the surgeons needs before the case. There is less variation in the plan and less uncertainty. This prevents the staff from running in and out of the room accommodating last-minute changes. Copyright OR Manager, Inc. All rights reserved. 800/