Pilots and flight crews have long relied on the use of checklists and brief huddles to prevent errors and the concept has made its way to healthcare, particularly in operating rooms. But the patient safety protocols proved so successful at one South Florida healthcare system that it has implemented the processes in all of the procedural areas of its six hospitals.
Despite initial misgivings by physicians, the Hollywood, Florida-based Memorial Healthcare System introduced "crew resource management" within its operating rooms in 2008. The model involves mandatory briefings and debriefings for surgeries as well as the use of checklists, structured handoffs and communication scripts.
Surgeons worried at first that the processes would add time to the procedures, but they actually had the opposite effect. The briefings and debriefings actually streamlined surgeries because OR staff spent less time leaving the sterile environment to retrieve forgotten equipment. And clinicians appreciate the extra safeguards and system-wide culture that truly lives by the rule that patient safety comes first, Joseph Loskove, M.D., chief of anesthesia for the system and regional medical director for Sheridan Healthcare, (pictured) told FierceHealthcare in an exclusive interview.
"One of my biggest fears is a human error and operating on the wrong person, or the right side instead of left side," Loskove said. "I feel better when I go to an OR, and know I have the right person and am about to operate on the correct side. That to me is very comforting. Professionally, I sleep better at night."
The OR process calls for the surgeon to follow a script, making sure to identify all team members and go over the operation and specific concerns. The team works through the details of the surgery before they begin. And if any team member has a concern during the surgery, he or she has the power to stop the procedure by simply saying, "Delta," Loskove explained. Once the surgery is completed, the team debriefs and talk about what went right, what went wrong and any concerns.
"The ability to make that safety statement and stop an operation,…that's really novel," he said. "Twenty years ago in the world of surgery there as a mentality that the surgeon was the captain of the ship and everyone else was deck hands and that wasn't always a good thing. To have the ability to stop and force everyone to talk as a group is a unique thing."
If a nurse or technician invokes a 'Delta' and the surgeon ignores it, Loskove said the team member can immediately go up the chain of command to the operating nurse, chief nursing officer, director of medical affairs, even the CEO of the hospital. "If someone wants to stop the operation for a patient safety concern, it's taken seriously," he said.
The success of the protocols led the system to incorporate them into all procedural areas of its six hospitals, including the cath lab, ICU, critical care units, labs, pathology, radiation, labor and delivery and interventional radiology. Each procedural area has its own checklist that it uses in the briefing process to address the unique concerns of the setting. The hospitals also conduct monthly crew resource management training for new staff.
The system doesn't have statistics to demonstrate the success of the program, mainly because the types of those adverse events (wrong patient, wrong operation,wrong side) are such infrequent occurrences, Susan Klett, R.N, director of crew resource management, organizational development for the system, told FierceHealthcare.
"We didn't measure prior to implementation," she said. "The only thing as hard data that they looked at is retaining foreign objects and that number went from five to zero. We looked at it retrospective once we introduced the program."
However, Klett said that team members report better communication and a more collegial partnership among physicians, nurses and ancillary staff since they implemented the protocols. "It's very difficult to measure something that doesn't happen," she said. "But the training process empowers staff to speak up and it was a definite cultural change."
The system has trained more than 1,000 physicians and 5,000 staff on crew resource protocols, according to Klett. Physicians who want to receive privileges at the system's hospitals must participate in a training class within six months of coming on staff.
"We make sure everybody has the same thought in mind, starting with the checklist, always do the same thing, the same way," she said. "The other piece is everyone understands they have a vital role, therefore they have the ability to speak up at any time. That's huge. It was huge in aviation and it's huge in healthcare. They shouldn't keep their mouth shut, even if someone in the room has huge credentials, and is considered a lot smarter. They may have piece of information someone doesn't have."
OR 'black box' may help to reduce errors, teach surgeons
Quick huddle in the OR prior to sugery improves teamwork, communication
Surgical safety checklists may not improve patient outcomes after all
Hospitals get 10 more checklists to keep patients safe
Surgeon-led mortality review can improve patient outcomes
Hospital avoid high-risk procedures to lower publicly reported mortality rates