Published 2/1/2008
Robert L. Brooks, MD, PhD, MBA

HRST Training: The next step in patient safety?

Team dynamics contribute to the highly reliable surgical team

Team dynamics should be part of the training for all operating room (OR) crew members, especially those who, like orthopaedic surgeons, have the responsibility to assume a leadership role. Last fall, the AAOS leadership discussed the concept of training surgeons in techniques that would enable them to better manage surgical teams to reliably achieve safety and excellence.

Thomas Barber, MD, secretary of the AAOS Board of Councilors; Paul Preston, MD, an anesthesiologist and regional patient safety educator for the Kaiser Permanente San Francisco Medical Center, and I delivered the message of surgical safety and “Highly Reliable Surgical Team” (HRST) training.

Leadership styles matter
Research performed on command structure in military patrols, and expanded in industries such as flight control where team performance is essential, has shown that certain leadership styles and techniques improve results, while other methods disrupt team function, possibly resulting in mission failure.

Poor communication, chaos, stress, and fatigue all contribute to adverse surgical events. Although these factors cannot be eliminated from emergency situations, their risks can be minimized by strategies to manage chaos, improve active communication, and cope successfully with fatigue and stress. The result is the HRST.

Crew resource management
The aviation industry introduced formalized training for flight crews more than 20 years ago. Later, the healthcare industry recognized the relevance of these principles, frequently called Crew Resource Management (CRM), to the practice of medicine.

Other industries and managerial schools have enlarged the principles into Highly Reliable Organizations (HRO), which decrease errors by training in “human factors” engineering. For more than 10 years, the Kaiser Permanente Medical Centers have been applying these team-training techniques in their labor and delivery suites. The Veterans’ Administration National Center for Patient Safety has produced a program, Medical Team Training, which has been conducted at more than 54 facilities for more than 3,000 surgeons, nurses, and anesthesiologists. Many leading academic centers have recently made similar training a requirement for renewal of surgical staff privileges.

The impact on outcomes
Studies have demonstrated a direct correlation between OR teams that exhibit HRST behavioral markers and patient outcomes. A study conducted by Kaiser Permanente in Southern California revealed that communication and teamwork interrelated with surgical outcomes, especially during intermediate- and high-risk procedures. Since its implementation in 2002, the Perioperative Safety Briefing Project resulted in a statistically significant increase in the perception of safety climate in the OR by the staff as well as the physicians, and only one wrong-site surgery (
Table 1). Effective implementation of such programs would definitely be a cost savings to institutions and/or practices.

Although creating HRO and Crew Resource Management programs have associated costs, the cost is minimal compared to the expensive ramifications of errors. For example, a study conducted by Agency for Healthcare Research and Quality found that surgical teams leave instruments inside patients 2,700 times per year—a total annual cost of $36 million.

Surgeons must rely on teams to successfully help their patients. Most surgeons recognize that certain dysfunctional leadership behaviors can disrupt the smooth operation of a team and increase the chances for adverse events. Perceptions of teamwork, such as team members feeling that they are heard by leaders, can have tremendous impact on a team’s functioning (Table 2). The study of team dynamics shows that methods of leadership behavior are learnable, and implementing improved behaviors increases reliable results, improves patient safety, and increases the professional satisfaction of the surgeon and every other team member.

Orthopaedic surgeons should be aware of this rising trend in surgical safety and discuss the possibility of implementing team training with other OR leaders in their institutions. By beginning with AAOS initiatives such as Sign-Your-Site, time-outs, and preoperative checklists and applying them more broadly to improve all OR safety, orthopaedic surgeons can make a clear contribution to building a highly reliable surgical team. As AAOS Past President James H. Herndon, MD, urged us, we can do one more “Turn of the Wrench” for the safety of our patients by advocating for surgical team training.

The role of the AAOS
The AAOS may also have a role in developing educational programs and material to support surgical team training. The provision of educational materials and programs would help decrease the number of surgical errors, infections, and malpractice lawsuits, while improving employee retention and adverse event reporting. Proposed topics include the following: how and why teams function or fail; the science of errors; shared “mental models”; communication techniques; situational awareness; management of fatigue, stress, and work load; and improving individual performance on teams.

Robert L. Brooks, MD, PhD, MBA, is chair of the AAOS Patient Safety Committee.

He can be reached at bobbrookster@gmail.com