David M Lawrence, MD, Chairman's Patient Safety Award Winner
Our patients and their families reasonably expect us to maintain patient safety in the medical environment. Until recently, however, this critical component of medical care did not receive the attention it deserves. Against a background of increased mass media attention to hospital errors, such as performing wrong procedures or performing procedures on the wrong anatomic site or wrong patient as reported in the Institute of Medicine's 1999 report, "To Err is Human"1 and in Lucien Leape's landmark article, "Error in Medicine,"2 the medical profession has finally realized that safety is an integral part of the health care that we deliver. These trends, coupled with three wrong-site surgeries and several near misses in the previous year, prompted the Kaiser Permanente (KP) Orange County Service Area (OCSA) to embrace a fundamental cultural change that emphasized safety as part of clinical quality standards of defining the care experience for our health care providers and patients.
Other industries, most notably the aviation industry, have long known the importance of human factors in the etiology of errors and have sought to identify and address human factors that result in errors. KP OCSA already followed several patient safety policies and procedures in the surgical suite, such as use of the Patient Procedure Site Marking Verification Form, to meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO) regulations. However, the Safety, Human Factors, and Preoperative Safety Briefing project was intended to supplement and to add another dimension to patient safety practices by creating a culture whereby team members are formally identified and create a shared mental model by focusing on the patient minutes before the surgical procedure. The project was designed and implemented by a team consisting of surgeons, operating room nurses, anesthesiologists, nurse anesthetists, scrub technicians, quality coordinators, risk managers, and administrators (Table 1).
According to the JCAHO, breakdown in communication is the primary cause of serious sentinel events in the healthcare setting; 75% of these events result in patient death.3 On the basis of this and other human factors analysis and design, a Preoperative Safety Briefing for surgical teams in the KP OCSA was developed: a document and procedure very similar to the preflight checklist used by pilots. The purpose of the briefing is to maximize the ability of health care providers to effectively identify and manage human error and other threats to patient safety. Important elements of the project design included creation of a climate of improved communication, collaboration, teamwork, and situational awareness in the perioperative setting.
Human Factors, and Preoperative Safety Briefing project focused on these
five specific objectives:
Developing the Preoperative Safety Briefing
The project centered around the Preoperative Safety Briefing, a brief activity in which the members of the surgical team discuss the background of the case, assess threats and risks, and offer any other relevant information. A one-page document reminds team members of key relevant questions regarding patient safety (Figure 1). The briefing is required after induction and before a surgical procedure. Briefings are also encouraged at handoffs and other special situations (eg, training new team members). Although simple, the briefing design encourages and requires collaboration and consensus from each member of the perioperative team. In addition, the check-in procedure fosters a more collegial atmosphere, which encourages monitoring, facilitates cross-checking, and empowers all team members to be proactive about patient safety in the perioperative setting.
The Human Factors Steering Committee presented the original concept to key members of the operating staff, anesthesia department, and surgical services at the KP Anaheim Medical Center in October 2001. Components of the Preoperative Safety Briefing were designed by a team consisting of operating room and anesthesia staff and surgeons from different disciplines, who then met monthly to develop and later to refine the design used in training their staff and colleagues until the pilot started in February 2002. Quantitative results of monthly surveys during the pilot helped the team to improve the design, identify other safety supplements and tools (such as a training module), and offer rapid feedback to operating suite staff and physicians about the influence of the briefing on safety and teamwork climate. Anonymous suggestions collected in a box outside the Perioperative Services Department Administrator's office provided qualitative data. Both sets of information allowed the team to quickly identify and resolve concerns during the pilot period. For example, one anonymous suggestion proposed placing a whiteboard in each of the operating rooms to list the four primary roles and the name of each person in that role for the current case. Studies have shown that knowing the names of other team members greatly improves prevention of adverse outcomes. This simple addition to the Preoperative Safety Briefing added tremendous value; more important, this type of rapid cycle change process provided the global framework for problem-solving in the operating suite.
Preoperative Safety Briefing Pilot
The Preoperative Safety Briefing six-month pilot beginning in February 2002 consisted of several steps.
Although risk reduction was inherent in design of the project, the data were minimally reviewed at each monthly pilot project team meeting to safeguard against unrecognized negative impacts or unintended consequences.
Safety Attitudes Questionnaire
The SAQs used in our pilot were developed by the Center of Excellence for Patient Safety Research and Practice at the University of Texas7 and have been used in more than 450 hospitals and their departments in the United States, Europe, Australia, and New Zealand. SAQs are designed to assess the following factors that are linked to risk-adjusted patient mortality and nursing turnover:4 job satisfaction, perceptions of management, teamwork climate, safety climate, stress recognition, and working conditions. Participants read a series of statements and are asked to respond with "Agree Strongly," "Agree Slightly," "Neutral," "Disagree Slightly," or "Disagree Strongly." Table 2 shows sample SAQ statements; responses to this subset of statements were used to measure the perceived safety climate of the participant's clinical area. An SAQ was administered in the OCSA in August 2001, which was six months before project design began, and again in September 2002, after completion of the pilot. Each participant was given a survey and asked to return the completed survey in a sealed envelope to the charge nurse. Response rate for the prepilot SAQ was 75% and for the postpilot SAQ was 88%; 59 operating suite staff and 60 surgeons at KP Anaheim Medical Center were surveyed. In addition, a subset of questions from the SAQ was administered to participants monthly during the pilot to track progress.
Improved Safety Indicators
Quality Management monitored the number of reports of near misses and of faulty or missing equipment to measure change in situational awareness and nurturing of a blame-free environment. An increase in the number of near misses reported was assumed to signal that operating suite staff and surgeons were becoming more willing to admit errors; the number of near misses reported increased from zero in 2001 to 5 in 2002. Compared with 2001, reports of faulty or missing equipment and instrumentation decreased slightly in 2002, but the frequency at which operating suite or anesthesia time was extended or cases were delayed or canceled subsequent to issues with equipment may have decreased and is being evaluated. These results suggest that the Preoperative Safety Briefing facilitates early reporting of equipment issues and that this reporting leads to timely solutions that enhance patient care in the perioperative setting and minimize operational costs.
Improved Safety and Teamwork
The percentage of operating suite personnel who agreed or strongly agreed that the safety climate in the perioperative setting was good increased from 51.1% to 62.9% after completion of the pilot, a substantial increase. Substantial improvement was also seen in operating suite personnel perceived teamwork climate (Figure 2) and in their perception of priority of patient safety in the operating suite, of communication, of their taking responsibility for patient safety, of nurse input being well received, and of medical errors being handled appropriately. In addition, personnel reportedly found it easier to speak up when they identified a problem in patient care and found it easier to discuss mistakes. Throughout the reporting period, the perception of teamwork was somewhat influenced by the discipline and job of participants; physicians consistently gave nurses higher teamwork scores than nurses gave physicians (Figure 3).
Minimal Cost and Change
to Organizational Structure
As an organization that cares about its members and employees, KP has a responsibility to create and maintain a culture of safety, because "Safety comes first, before quality, service, and profit." Injuries and errors such as wrong-site surgeries have tremendous personal cost to the patient and employee and are a significant financial liability for KP. In addition, the factors that enable severe errors also lead to decreased morale and poor staff retention rates. Human Factors principles provide a straightforward method for preventing errors by improving team communication and collaboration. Creating a team with a healthy balance between vertical and lateral communication allows team members to identify variation in processes and to develop system modifications to reduce inappropriate variation, which ultimately empowers everyone---surgeon, anesthesia and operating room staff alike--to act as an agent for change.
In 2002, KP Orange County personnel reported that briefings were approximately 1.5 times more common than the year before, and respondents who reported good teamwork climate nearly doubled during this time. Team identification, communication, and collaboration have increased substantially, potential problems are identified and resolved preoperatively, and situational awareness has been heightened as shown by increased reporting of near-miss situations.
After its introduction in 2002, the Preoperative Safety Briefing potentially improved the safety of every patient who had a procedure done in the operating suite at the KP Anaheim Medical Center. In 2002, OCSA membership was more than 340,000, and of the 16,042 operating suite procedures performed in Orange County in 2002, 6795 (43%) were done at the KP Anaheim Medical Center.
A small investment was necessary for designing and implementing the change, but the resource allocation was easily absorbed into the existing cost structure and required a minimal, shared commitment among the perioperative team members. The rewards of this change were a clear, shared focus on the patient. The goal was achieved of lessening the gap between positive perception of teamwork by physicians rating nurses and somewhat lower positive perception of teamwork by nurses rating physicians. Greater satisfaction among operating suite staff was indicated by decreased nurse turnover. Increased operational efficiency was indicated by reduced delays in receiving operating suite equipment and reduced case delays or cancellations and an overall heightened awareness of patient safety initiatives.
Toward Continued Safety Improvement
The Preoperative Safety Briefing has become the safety standard norm in the KP Anaheim Medical Center operating suites and will become the norm in our contract hospital operating rooms throughout the OCSA. The project has transitioned from pilot mode to process improvement mode. The goal is to add additional components to the Preoperative Safety Briefing to continue to build the safety culture in the perioperative setting. For example, the team is currently developing and implementing a Postoperative Debriefing and determining how to strengthen briefings at handoffs and breaks. The Regional Coordinating Chief of Anesthesia continues to work with the Chiefs of Anesthesia, Perioperative Department Administrators, and Joint Anesthesia Management Committee (JAMCO) to support local implementation throughout the region.
Both the specific implementation of a Preoperative Safety Briefing and the general concept of using Human Factors principles to improve patient safety are highly transferable. Within KP, the Physician Champion, Dr James DeFontes, MD, who is also the Regional Coordinating Chief of Anesthesia, has formally presented the Preoperative Safety Briefing concept at the Perioperative Summit for KP Southern California, the Regional Anesthesia Symposium, the Regional Anesthesia Chiefs of Service Meeting, the Perioperative Departmental Administrators Meeting, and the Anesthesia Departmental Administrators Meeting. Through his discussions with JAMCO and the Chiefs of Anesthesia, an SAQ was administered throughout the KP Southern California Region. On the basis of these results, the Chiefs of Anesthesia and JAMCO supported the recommendation to work collaboratively on opportunities for safety improvements at their local sites and agreed to conduct another survey within a year after improvements were made.
To date, the concept of the Team Briefing has been institutionalized regionally as part of the Procedural Sedation Policy in the KP Medical Care Program, Southern California Region, Policies & Procedure Manual (P&P#: 03-167-01). Similarly, Dr Mark Gow, MD, who is also the KP Orange County Director of Patient Safety, has formally presented to the medical staff at Panorama City and will continue to share successful practices with his colleagues in other service areas. Application of the Preoperative Safety Briefing and Human Factors principles are expected in other perioperative settings in other service areas across the region.
The Preoperative Safety Briefing concept has been applied to other services within the OCSA, such as the Departments of Labor and Delivery and of Radiology, with support from the quality management coordinators. The briefing concept is also part of the Regional Labor Management Initiative, because it is one of the annual goals for JAMCO this year.
Interest has also been expressed from outside KP; inquiries have been received from Harvard University, the University of Michigan, and other health care institutions. Dr Gow and the Perioperative Department Administrator are working with our contract hospitals and other private hospitals, such as the City of Hope, to share this tool with their peers in the community. The project team is also committed to spreading these ideas and practices to other KP Regions.
A healthy team environment serves as the foundation for a conducive environment for change. In OCSA, the net effect of this project has been to transition the operating suite culture away from one of individual advocacy to one of an integrated team mentality that mitigates risks to patients, attains optimal operational efficiency, and empowers all participants to leverage improvements beyond patient safety.
Michael W Leonard, MD, Anesthesia, KP Colorado Franklin Medical Center; Suzanne M Graham, RN, PhD, KP California Regions Patient Safety Practice Leader; and Doug Bonacum, MBA, Vice President, Safety Management, provided training. Mark Alan Monroe, RN, KP National Environmental Health and Safety Department, provided statistical analysis.
From the University of Texas, J Bryan Sexton, PhD, assisted with data analysis; and William R Taggart, Human Factors Research Project, assisted with training.