Team training, locally modified checklists and pre- and post-operative briefings can save lives, according to a study in the October 20 issue of JAMA. But what ultimately makes a difference, according to one of the authors, is improved communications among the surgical team.
In 2006, the Veterans Health Administration implemented a nationwide Medical Team Training program. Clinicians at 74 facilities were trained to conduct checklist-guided pre-operative briefings and post-operative debriefings, and to "implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation, and how to conduct effective communication between clinicians during care transitions."
They were trained to work collaboratively and to "challenge each other when they identify safety risks."
The 74 VA hospitals that had operating room personnel participate in a team-training program reported an 18% decrease in observed mortality, versus 7% in the 34 facilities that had not yet provided the training. Investigators reported a nearly 50 percent greater decrease in the annual surgical mortality rate in the trained group than in the nontrained group.
The checklist-driven pre-operative briefing was a key component in reducing mortality because it provided a chance to identify and correct problems before surgery, the authors note. It also set the stage for how the team would communicate during surgery.
The debriefing gave team members a chance to voice what worked well and what needed improvement. Those lessons were then applied to future cases, explains James P. Bagian, MD, former director, VA National Center for Patient Safety and now at the University of Michigan.
The training encouraged team members—the scrub tech, the nurse, the surgeon, the anesthesiologist, etc.—to speak up if they had a safety concern, but simply telling the surgical team they are free to speak up doesn't mean they will, Bagian, one of the study's authors, notes.
To create changes—in culture, in hierarchy—there needs to be the structure and tools for change. The briefings and debriefings, explicitly guided by purpose-built checklists, provide the structure and tools that drive dialogue, he tells HealthLeaders, adding that mere team training without this structured approach is unlikely to accomplish the same goals.
The checklist—which each team can modify based on its needs and experience—enhances safety and promotes dialogue, but it's "not a magic bullet," warns Bagian. Rather, it is a tool that changes behavior, which ultimately can change culture.
Ultimately, it's about driving conversation, he says—and it's the conversation, not the checklist itself, that drives the changes that lead to enhanced outcomes.
The checklist includes open-ended questions that promote conversation and dialogue. During follow-up interviews, team members reported examples of how the briefing helped them prevent adverse events—such as discovering that a patient was anticoagulated or identifying the need for additional implants that were not currently available.
Bagian says he hopes to see other organizations adopt this approach, and an accompanying JAMA editorial echoes the sentiment.
The editorial calls for wider adoption of team training, briefings and debriefings, and locally modified checklists "to ensure patients receive recommended interventions and to trigger crucial conversations among all team members about risks and ways to reduce risks."
Healthcare, it says, "must have as much improvement in teamwork skills as there has been in technical skills. Physicians and all other members of the health care team have an imperative to improve safety and outcomes and to reduce surgical mortality—patients deserve nothing less."