“Despite implementation and use of the UP, a significant number of wrong-site surgeries occur daily across the country in all orthopaedic settings with little evidence of safety improvements,” said William J. Robb III, MD, chair of the AAOS Patient Safety Committee.


Published 5/1/2014
Maureen Leahy

Steps to Improve Surgical Safety and Quality

Strategies for improvement include new models, data analyses

AAOS has been a leader in the patient safety movement since 1997 when it introduced the “Sign Your Site” surgical safety campaign, which brought national awareness to the issue of wrong-site surgery. In 2004, the AAOS partnered with the Joint Commission (JC) and other medical organizations to develop the Universal Protocol (UP), designed to reduce preventable surgical harm including wrong-site surgery.

Wrong-site surgery is a sentinel reportable event used to track other ‘preventable surgical harm,’ which cumulatively reduce safety and undermine optimal surgical patient outcomes. Use of the UP has been mandated in all JC-accredited hospitals, surgicenters, and office-based surgery facilities since 2005.

Speaking at a symposium that focused on new models and strategies to improve orthopaedic care held during the 2014 AAOS Annual Meeting, Dr. Robb emphasized the importance of surgical safety. “Safety is the core of surgical quality and value. There is no quality or value in orthopaedic care harmed by preventable errors,” he said.

New orthopaedic safety model
Based on analysis of the errors reported to the JC Sentinal Events Data Base, Dr. Robb said that safe surgical care needs to be supported by regular use of three critical elements: (1) structured, effective surgical team communication, (2) validated evidence-based safety processes such as checklists, and (3) systematic safety and quality data collection and analysis.

“Our historic surgical culture is inherently unsafe,” he said. “Team communication is traditionally very hierarchical and processes are traditionally surgeon-centric with little organized data collection. Nontechnical surgical skills education is needed to establish structured communication that shares authority in a team model, that uses surgical processes supported by evidence and consensus, and that uses data to assess performance allowing peer comparison to drive improvement.”

Effective surgical team communication
According to John S. Webster, MD, MBA, MSEL, effective communication and teamwork in the operating room (OR) are essential to reduce errors and optimize patient outcomes.

“Communication is a teamwork skill necessary to provide coordinated care,” Dr. Webster explained. “The Agency for Healthcare Research and Quality’s TeamSTEPPS program teaches surgical team members how to integrate evidence-based teamwork strategies and tools in the OR to advance patient care and safety.”

According to Dr. Webster, orthopaedic surgeons can use the tools and strategies of TeamSTEPPS and take the following actions to improve surgical communication and teamwork and reduce errors:

  • Expand surgical knowledge including nontechnical safety science skills to more effectively communicate with the clinical team and patients.
  • Learn more effective team leadership skills to set the tone for improved surgical team performance supported by transparency and expanded team member authority.
  • Commit to error identification and continuous improvement of surgical team performance and patient outcomes.
  • Use structured communication techniques including briefs and debriefs as a regular part of surgical and clinic/office care.

Validated safety processes
Dr. Robb pointed out that validated evidence- and/or consensus-based surgical processes such as checklists have the potential to increase surgical safety, but only if they are used correctly and consistently.

“There are many different types of surgical checklists—some designed for patients, some for surgeons, and others for surgical teams,” he said. When used properly, these validated surgical processes can do the following:

  • effectively summarize and outline important components of the surgical procedure
  • better format communication
  • level hierarchical power
  • reduce team distractions

“This enables the surgical team to be more effective and improve performance,” he said.

“Despite implementation and use of the UP, a significant number of wrong-site surgeries occur daily across the country in all orthopaedic settings with little evidence of safety improvements,” said William J. Robb III, MD, chair of the AAOS Patient Safety Committee.
During the Annual Meeting Symposium, “Can We Improve Surgical Outcomes for Orthopaedic Patients? A Compelling Need for Change,” panelists, who represented patients, hospitals, payers, and orthopaedic surgeons, called for regular use of effective surgical team communication, reliable safety processes, and systematic safety data collection with analysis.

“However, there is no best practice for safety and quality—the one-size-fits-all approach results only in modest improvements, cautioned Mark Chassin, MD, president of the JC. For example, he noted, the risk for wrong-site surgery has many variable causes and each cause requires different interventions.

“Organizations must first identify and improve the processes—such as checklists—based on site-specific analysis of risk. They must also change the surgical culture to accept and use these processes. Otherwise, they will have no effect,” he explained.

The JC’s Center for Transforming Healthcare has created a Targeted Solutions Tool (TST) to help healthcare organizations create customized solutions for their unique safety and quality issues. The web-based TST is available at no cost to all accredited organizations in the United States.

“TST is entirely educational, voluntary, and completely confidential.” Dr. Chassin said. “It guides organizations through the steps of how to measure a problem, helps them identify their specific risks, and directs them to proven solutions.”

Systematic data collection and analysis
According to Dr. Robb, systematic safety data collection and analyses drive continuous improvement in surgical performance. Sources of safety data include the following:

  • surgical team GLITCH (Gather Little Insights That Can Help) lists to regularly collect technical team performance improvement opportunities
  • hospital- or surgicenter-based confidential surgical error reporting systems
  • payer safety/quality databases
  • national data registries to allow peer comparison and encourage improvements

Similar to debriefing sessions, GLITCH lists are compiled at the end of a surgical procedure. “Surgical teams often work together on a consistent basis. GLITCH lists can be very effective in improving care from one patient to the next,” said Dr. Robb.

Confidential error reporting systems are important to encourage assessment of all types of surgical errors. Surgeons and all team members are encouraged to openly report all errors, but when team members are reluctant to report observed errors, confidential error reporting allows nonpunitive error identification.

The Centers for Medicare & Medicaid Services (CMS) as well as other large healthcare payers collect patient safety data through claims submissions. “CMS requires reporting of some safety data from physicians and hospitals. Data on surgical readmissions, surgical site infections, and mortality rates are now being publicly reported as part of hospital performance. Soon CMS will report individual surgeon performance,” Dr. Robb said.

Registries, such as the American Joint Replacement Registry (AJRR) and American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP), enable healthcare organizations to measure their surgical quality against peer organizations. Assessment of performance through a risk-adjusted outcomes-based surgical database is designed to measure and improve the quality of surgical care. “The ACS has used NSQIP very effectively not only to improve care, but also to help identify and implement national performance measures,” Dr. Robb said.

The AAOS will offer a CME course on Surgical Safety on Oct. 3–4, 2014, in Washington, D.C. Designed for all orthopaedic surgical team members, the course will provide practical safety information and a better understanding of safety science. For more information, visit www.aaos.org/courses

Disclosure information: Dr. Robb—Innomed, Stryker; Dr. Webster—Pfizer, BMJ; Dr. Chassin—no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org