Northwell Pioneers Black Boxes in Operating Rooms for Performance Improvement

Operating room black boxes collect video and audio of the OR staff as well as images of the surgical field.

Black boxes not only help ensure airliner safety, but they are now used to ensure the quality and safety in Northwell Health operating rooms.

In February 2019, the Manhattan-based health system became the first in the nation to deploy OR Black Box, technology developed at Surgical Safety Technologies in Toronto, Canada. At Northwell, OR Black Box has been used to examine adverse events in granular detail, to assess teaching in ORs, and to look for improvement opportunities.

Northwell is piloting the black box technology with laparoscopic urologic and colon surgical teams at Long Island Jewish Medical Center, says Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at the health system. "It takes several inputs from the room—the physiology, audio from microphones, video of the staff, and the digital image from the scope to make certain that the gradings of the surgical technique and the teaching going on are analyzed."

OR Black Box is designed to record laparoscopic procedures, which is why urologic and colon procedures were chosen to pilot the technology, he says. "We wanted laparoscopic surgery because it depends on the digital feed from the camera of the actual surgery."

Northwell also picked urologic and colon surgical teams to be the first ORs with the black box technology because there were eager physician champions willing to pioneer the initiative, Jarrett says. "It required a physician champion with a team in the OR that would feel comfortable doing this."

The OR Black Box computer packages the scope video with video and audio collected from the OR staff as well as physiology data collected from the patient such as heart rate, pulse, blood pressure, and oxygen level. Then all the time-synched data is sent electronically to Surgical Safety Technologies for analysis.

"It pays for all of us to do the analysis centrally—it leads to more reliability and validity. By doing the analysis centrally, we can also share information between hospitals. For example, if Northwell does 150 urology cases and five other medical centers do 150 urology cases each, we can have 900 cases analyzed. That will give us better information in terms of things that happen frequently and infrequently. Maybe there is a near miss that happens once every 300 cases," Jarrett says.

The cost of the black box equipment is $100,000 per OR.

How Northwell uses black box technology in operating rooms

At Northwell, all black box data collected in an OR is de-identified, he says.

"It's the team approach that we look at. Everything is de-identified. The cameras blur out the faces of the OR team members. The purpose is to look for system issues—not individual people issues. That was important because one of the fears of people was having Big Brother watching over them. We are not looking to get anyone in trouble. What we are looking for is system issues that we can correct to protect the patients. It's about taking a proactive approach based on the data."

De-identifying the data also protects patient privacy, Jarrett says.

Taking a team approach for analysis of OR Black Box data is a key element of capitalizing on the new technology for OR performance improvement, he says.

"Outcomes are not totally dependent on the surgeon. They are also dependent on the interplay between all the nurses in the room, the anesthesiologist, the problems that occur no matter how good the surgeon is, and how those problems are addressed. All those things can be looked at because the technology uses digital algorithms much like a black box in a plane."

Northwell is also generating surgical technique and teaching gains from the black box technology, Jarrett says.

"When we do the analysis of the video for technique, we can give scores for it and we can show what happened. We can use this information at conferences to show how a surgeon approached a problem and achieved a great outcome. So, you can use this information for teaching. For residents who rotate into a service for four months, you can see whether there is improvement in performance or not to assess the quality of the teaching program."

And the black box technology is well-suited to analyzing adverse events, he says.

"Adverse outcomes can occur even when nobody does anything wrong—it can be the anatomy of the patient. However, when we analyze the surgery, we can ask whether there was any way to anticipate the anatomy was different than expected and how the situation was addressed. Was it addressed in a timely fashion? Did the surgeon communicate that there was a problem and what was needed to address it? Was all the right equipment in the room?"

Jarrett says "it's too early in the game" to measure the impact of OR Black Box at Northwell, but the pilot program is focusing on an area for improvement—distractions. "There are a lot of distractions in the OR. Not all of them are bad, but there are more distractions than we realized, which is one of the reasons we are studying their impact."

A major distraction identified in analyzing the black box data is people leaving and entering the OR, he says.

"Some people go out of the room for breaks, some people go out of the room to get special equipment, but the question is do we need to have that happening all the time? We may want to limit people going in and out of the OR, and the black box technology can tell us whether that kind of a rule makes a difference. We want to base decisions about our protocols on real data rather than assumptions."

Adapting to black box technology

The OR teams that have worked with OR Black Box have acclimated to the technology, Jarrett says. "Now that we have been doing this for a year, the first team performs like it doesn't even know the black box is there. They turn it on at the beginning of a case, turn it off at the end of a case, and work as if it wasn't even there. They get used to it."

Northwell is considering whether to install the black box technology at more hospitals in the health system, and several other U.S. health systems are contracting for OR Black Box with Surgical Safety Technologies this year, he says.