AAOS Now

Published 8/1/2016
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Terry Stanton

Beyond the Technique: Patient Safety and the Core Competencies

In an Annual Meeting symposium focusing on surgical safety core competencies for orthopaedic residents, William J. Robb III, MD, asked how many residents in the audience had  nontechnical" surgical skills education and whether their programs had an identified safety expert. "Unfortunately," he said, surveying the result, "everyone's hand should be in the air."

Dr. Robb, past chair of the AAOS Patient Safety Committee, noted that an estimated 1 million adverse events occur every year in surgical patients resulting in more than 100,000 deaths and costing $5 billion to $6 billion annually. Most of these adverse events are preventable, he said.

Adverse events, including wrong-site/side/procedure/level/implant/patient surgeries (wrong-event surgeries [WES]), occur across all orthopaedic specialties. Dr. Robb said that during their careers "one in two spine surgeons will perform wrong-level surgery, one in five hand surgeons will perform wrong-site or wrong-procedure surgery, and one in ten arthroscopic knee surgeons will perform the wrong-site or wrong-procedure surgery.

"This undoubtedly underestimates the true incidence of these WES," he noted. Focusing on WES is important because it is a preventable occurrence, and these events are symptomatic of badly broken surgical care systems. They are the tip of the iceberg."

Surgical safety is a fundamental component of the "value equation," Dr. Robb said. "All surgical care must be safe. Lapses in safety lead to decreased patient satisfaction, poorer outcomes, and greater costs. As surgical care bundles emerge as alternative payments models, safety errors negatively affect surgeon scorecards and reimbursements and undermine professional satisfaction. Now, when patient harms occur, we directly bear the burden of these adverse events—professionally and financially."

Defining surgical safety
Dr. Robb defined surgical safety as "a component of surgical care that emerges from the knowledge, skills, attitudes, abilities and teamwork of multiple providers." Optimal surgical safety extends beyond surgical technique. "If an operation is not performed technically well, a poorer outcome may be a result," Dr. Robb said. "Most current surgical education is focused on improving surgical technical skills, but most adverse surgical events are actually rooted in deficient nontechnical surgical skills such as communication, leadership, and teamwork. Technical errors represent only 30 percent to 50 percent of adverse surgical events (ASEs)." These non-technical surgical core competencies include the following:

  • prioritization of the prevention of patient harm supporting a "culture of safety"
  • effective regular use of non-technical skills including:
    • patient communication
    • team communication
    • standardized safety processes, including regular use of checklists, briefings, timeouts, debriefings, and handoffs
    • systematic safety data collection
    • safety performance analysis and benchmarking
  • committed surgeon leadership modeling effective team behaviors

"Unfortunately, shortcomings in nontechnical skills lead to technical errors." Dr. Robb said. "Impaired situational awareness, poor communication, ineffective leadership, and lack of teamwork undermine both technical and nontechnical team performance, often resulting in adverse events."

Dr. Robb said that an ASE is defined as an avoidable or unavoidable event during the episode of surgical care that directly or indirectly risks or causes harm to the patient resulting in an adverse outcome or death. ASEs are "the shared responsibility of the surgeon, the surgical team, and the surgical facility," he said.

"It is critical that the concept of shame-and-blame be removed," he continued, "because it oversimplifies or ignores complex system issues." ASEs can be prevented through continuous team and system-based evaluation and improvement.

Addressing ASEs
Hardware and implant failures often are often the focus in discussions of adverse events, but other ASEs are equally important to consider in designing systems leading to prevention of events such as surgical site infections (SSIs), urinary tract infections, venous thromboembolism, confusion/delirium, and falls.

The Centers for Disease Control and Prevention estimates that orthopaedic SSI rates vary from 2 percent to 21 percent. This much variation indicates that SSI is an ASE that can be addressed and improved. The Surgical Care Improvement Project (SCIP), for example, is a Joint Commission initiative to address SSI prevention through the regular use of standardized evidence-based protocols including antibiotic choice, timing, and dosage; glycemic control; and surgical site skin preparation.

"One study showed that compliance with one or several of the SCIP measures did not actually change SSI rates," Dr. Robb said, "but compliance with all seven SCIP measures reduced SSIs by 50 percent. This finding implies that compliance with individual measures is less important than compliance with the entire system of care with supportive team behaviors to actually improve patient safety."

Another example of the impact of system-wide compliance comes from Minnesota. In 2003, Minnesota mandated reporting of all WES. By 2008 the number of WES had more than doubled. A human factors study was undertaken to analyze use of the surgical timeout and identify safety process variations, including site marking and patient identification.

A key finding of this safety study was that "surgeon leadership is critical," Dr. Robb said. To improve surgical care, a standardized surgical safety model was introduced in 2009 with consistency as a goal to reduce unacceptable observed variation. The Minnesota timeout module included the following:

  • participation of all surgical team members
  • training with specific roles for all surgical team members
  • 'All-Stop' and 'All-Quiet' in the operating room during the timeout
  • supportive shared surgeon and facility safety leadership

Minnesota provided education and training for all operating rooms in the state. By 2014, the incidence of WES had decreased by 50 percent.

To improve safety, details matter. Safety program implementation must be constantly measured and analyzed. Culture change, said Dr. Robb, is difficult to implement and maintain. "You have to be persistent to change the culture."

Competencies and safety
The competencies that lead to improvement in safety place patients at the center of care and draw support from the whole surgical team. "We know that surgeon leadership is critical but the surgeon must lead with a deference to situational expertise among all team members," said Dr. Robb.  This is a 'high reliability' concept that requires that all members of the team be involved and willing to speak up if they see something that isn't best for the patient."

He listed the six basic nontechnical skills and behaviors as the "Cs of Safety" (Table 1). Dr. Robb noted that healthcare facilities can learn from other high-risk industries such as nuclear power plants and aviation that have adopted the following high-reliability organizational principles to reduce errors and successfully avoid disasters:

  • a preoccupation with failure
  • a reluctance to simplify (and an embrace of complexity)
  • a sensitivity to operations with empowerment of the front line
  • a deference to expertise
  • a commitment to resilience

"Resilience is a characteristic of individuals, teams, and organizations maintaining the ability to function in the face of disruptions to normal routines," Dr. Robb said. "Equally important, they must be able to maintain vigilance and adaptability during routine operations. Deference to expertise means getting away from the concept of authority and ceding leadership to those with the most appropriate skills for the situation at hand. Organizations that do this are safer."

Barriers to safety include the following:

  • time constraints risking variations created by surgeon or facility demands for productively
  • limited English proficiency and/or health literacy of the patient, which can be effectively addressed with effective surgeon-patient-team communication, shared decision making, and patient-centered care
  • surgical patient-based medical factors, including modifiable risk factors such as nutrition, smoking, obesity, diabetes, and disease and medications management.

In summary, Dr. Robb said, "Don't look to the past for behavior and values that will improve safety. Don't expect that surgeon-centered processes will deliver safe care. Look to structured and standardized processes to improve safety. Look for leadership training, team training, regular use of standardized evidence-based safety processes such as briefs, timeouts, debriefs, and handoffs, systematic data collection, and team member reporting. Expect that you will professionally lead effective surgical teams supporting a culture of safety. Become a safety leader and a safety champion."

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org