Team Resource Management in the OR What s it all about? A surgeon s perspective Peter Blair March 9, 2010
Surgical Safety Checklist The third phase of the new culture of improved patient safety
Team Resource Management Surgical Site marking Surgical safety checklist Surgical pause
Social Organizations Agonic or dominance hierarchies Hedonic or Egalitarian societies
Dominance Hierarchies Baboons and macaques..individuals...keeping their distance from dominant ones...ready to avoid punishment...from threats dealt out down the rank order...submissive and appeasing gestures... Reynolds and Luscombe 1976: 105
Egalitarian Society Great apes: Live closely together in groups Share food and parenting Mutual grooming Silverback: the leader
...mutual grooming in the OR
Dominance vs Egalitarian Social Organizations Great apes have better health than baboons
Social Gradient of Health Health and longevity increase with wealth Sense of control and autonomy increase with wealth
Social Structure in the Work-Place Dominance hierarchy Strong ranking of workers Each level fears the one above Fear of making the wrong move Fear of retribution No creativity Culture of keeping one s head down Cover your...
Social Structure in the Work-Place Egalitarian Workers feel they are on a team Each worker feels valued No fear of voicing opinion Everyone wants to contribute to success Less stress by individuals More creativity
Social Structure in the Operating Room What is the social organization in your OR Dominance hierarchy or Egalitarian?
Traditional relationships in the OR Surgeon is the king/queen Anesthesiologist works quietly in the background minding his/her own business (keeping the patient alive) Nurses do what they do and what the surgeon tells/asks them to do Assistants do as surgeon bids them
Surgeon of old.
Advantages of traditional OR hierarchy Surgeon can concentrate on his/her game plan without having to process distracting advice Surgeon can feel like a king Surgeon could scold staff Surgeon could throw instruments
Disadvantages of traditional OR hierarchy OR personnel afraid to question surgeon s commissions or omissions No involvement in the surgery beyond basic job description Nurses felt demeaned? Nurses felt inadequate? Nurses felt frustrated? Nurses suffer burn out?
Team Approach Abolish the hierarchy-level the field Still need a leader Common goal: successful operation Engage all OR staff in reaching the goal Everyone has a skill set for the team Everyone is a member of the team Briefing and debriefing to engage team
Team Approach: goals Change dynamics of OR staff relationships Operation run more smoothly Fewer omissions Improve patient outcome Fewer near misses or worse
What is team approach? Surgical pause and then some
Team Approach: the briefing Surgical pause Describe the patient and the problem Outline the goal Discuss requirements of success Review checklist preop and intraop Introduce personnel White board with team member names
The Pause
Surgical Safety Checklist For complex activities by complex groups NASA launches Aviation take off and landing Anaesthetic induction Surgical procedures...a no brainer
Baguio, Philippines Jan 2009
The Checklist.. What should it contain When should it be done Who should lead
After the operation: Debriefing Label specimen Review wound classification How did the operation go? Any questions about what we did? Anything we could do better? Do we need to change the instrument checklist? Specific post op orders Anesthesiologist concerns
OR relationships with team approach
Team approach: spin offs More job satisfaction Less burn out Better morale Better retention of staff
Surgeon s perspective Opportunity to teach Engagement of OR personnel in surgery Less pressure on surgeon to remember Errors of omission reduced Operation runs more smoothly Meaningful interaction with OR personnel More likely to have a nice day
Challenges to Implementation Time constraints: takes 5 minutes Surgeon factors old school threatened loss of control Need strong surgical leadership mandated by legislation
Our goal: a happy team