Dr. Ring:


Published 4/1/2018

Universal Protocol Is a Team Responsibility

Pre-op huddles, timeouts just before incision, and post-op debriefs can improve patient safety

The AAOS Patient Safety Committee continues to address important issues with its series of roundtable discussions. The following roundtable focuses on how to use universal protocol more effectively by including the surgical team as active participants in the process and how doing so can lead to a safer and more efficient operating room (OR).

Moderator David Ring, MD, PhD, Patient Safety Committee chair, led the discussion, which included Michael Archdeacon, MD; Dwight W. Burney III, MD; Andrew Grose, MD; Ramon Jimenez, MD; Michael R. Marks, MD, MBA; Michael Pinzur, MD; and Alan Reznik, MD.

Let’s talk about using pre-op huddles, timeouts just before incision, and post-op debriefs. Some refer to these actions as the universal or World Health Organization protocol for safer procedures—a system intended to catch errors before they cause harm as well as prepare the team for potential adverse events.

Dr. Marks: After we do the time out, I always make a point of asking, “What are your concerns?” I do not ask, “Do you have any concerns?” which is a closed-ended question. “What are your concerns?” is an open-ended question that invites a response.

Dr. Burney: We need to avoid sending messages that come off like “Here is what I think,” and “I’m saying the only things that are important to hear.” It should be a clear invitation for everyone to speak their mind and contribute. To speak up if they’re wondering about something is critical.

Dr. Jimenez: It seems most people approach the timeout as a facility obligation. They put up with it, but they don’t use it to protect the patient.

Dr. Ring: How do you get surgeons to want to do it?

Dr. Marks: A lot of surgeons are naysayers. They say, “Look, we’ve been doing these timeouts, and we see we’re still having the same number of wrong site surgeries that we had 20 years ago.” And it’s true. Just having a piece of paper and a checklist doesn’t address the issue. It has to be a humanistic process—engaged and mindful.

Dr. Ring: We know that the checklist isn’t enough. The checklist is a reminder for you to turn your mind on, be a Kahneman Type 2 thinker, and get past your intuition’s potential errors. How do we get people to look forward to the checklist and to feel strange and uncomfortable when they do not do it?

Dr. Reznik: I suggest stories of fear, love, and guilt. For instance, you can talk about how a timeout kept you out of a courtroom. For love, you can talk about how patients enjoy the fact that you care about them. I make sure to do the timeout in front of them when they are awake. If it’s guilt, try, “Everyone else is doing the timeout. You should be doing it, too.”

Dr. Ring: The pre-op huddle and the post-op debriefs save time in the OR, because everyone is prepared. For instance, you get the correct equipment.

Dr. Burney: A lot of our Team Strategies and Tools to Enhance Performance and Patient Safety (or commonly known as STEPPS) workshops are done in multidisciplinary groups. Within a surgical team, you can ask the nurses, “Who are the people who really make the team run?” And they will often say, “Oh, the orderlies and the nursing assistants. We couldn’t operate without them.” Or they’ll say, “The sterile supply people.” But when you ask any of the surgeons if they have ever been to the sterile supply, they respond, “What building is that in?”

Dr. Archdeacon: My OR team runs in this safe way, and it works. For a decade, I’ve not been able to get my partners to buy into it, even though my rooms run fluid, and we run on time.

Dr. Marks: One of my partners was getting frustrated with the trays not being set up correctly. I told him about my experience with the pre-op huddle and the post-op debrief and how they worked for me. I walked into his OR as he was finishing up the surgery, and I made him do a debrief. He was pleasantly surprised. “Wow. They heard me,” he said. And then his next case went better. It’s the process improvement of it. It’s not going to help that case. That case is done. It’s the next case that will be better if we stop to talk about what we can do to improve.

Dr. Ring: You’re telling your colleagues that this is good for efficiency: “You’re going to like the results.”

Dr. Archdeacon: The common dissent is, “I don’t want to get there a half hour early. They’re still not going to have this stuff. We’re still going to start late due to anesthesia.”

Dr. Ring: One of the ways to make this process more compelling and appealing is to say, “You might not see the value of it, but your team sees it. You don’t want to be that jerk who doesn’t care about the nurses, techs, equipment people, and orderlies. I know it’s not your thing, but can you do it for them?” I think that might work for a lot of people.

When they’re trying to do a quick turnover and the scrub has a whole bunch of stuff to open and organize, I help them open it. When they need to turn the table and reset the hand table and the tourniquet, I help them. It is what you do in any other circumstance: When you see somebody that needs help, you help them.

Dr. Pinzur: Our head nurse came up to me a few months ago and said, “Why is it that your room requires the most work, is the most physically demanding, does a lot of cases with a lot of equipment, and, yet, I have nurses waiting in line to work with you?” It’s all the things we’re talking about. From the OR director’s perspective, surgeons that pitch in and understand the team concept, motivate staff to work better as well as get more personal enjoyment from their work.

Dr. Marks: The challenge in some institutions is that if you work efficiently, you get additional cases. You need to think through the incentives.

Dr. Grose: When we analyzed the influence of team dynamics, the teams that worked well had people who spoke up. It wasn’t simply the leader of the team saying, “Here’s the plan.” Everyone’s input was valued and heard.

Dr. Ring: Just the fact that you were sharing responsibility shows respect.

Dr. Grose: All you do is say, “This is what we are about today. This is what we’re after. These are the things that we should be concerned about. What are your questions and/or concerns?” Boom, you’re done, and the team performs better. It is really remarkable.

Showing my trauma surgeons the data on good catches by the team was really compelling to them. We don’t see all the messy stuff that we just got away with, but when you show them what the team notices, you’re saying, “These are peers watching you work and helping catch errors before they cause harm. No one’s out to get you.” We’re sharing in a transparent way. That’s really, really helpful.