Challenge

In Australia, 22 percent of surgeries suffer from incidents known as ‘adverse events’. Whilst most events are minor and cause no permanent harm, 13 percent result in some form of disability for the patient 18 months later. 48 percent of adverse events are preventable and as many as 70 percent of these are due to communication failures.

Communication failures can also affect efficiency and staff engagement in the operating theatre.

With this in mind, the SWANS (Surgical Work-team Advanced Non-technical Skills) team have come up with a fresh approach to making operating theatres more efficient, staff more engaged and surgery safer for patients.

Pre-surgical briefings are introduced prior to entering the operating theatre and are designed to set the tone to bring the various professional groups together, allow for proactive planning, create a coherent mental model for the day, and ensure staff feel comfortable to speak out if they see a potential issue.

One of the biggest challenges the research team faces is changing the mindset of surgical staff and hospital management in believing that their program will work in producing tangible benefits to patients, theatre staff, and the hospital.

The project aims to reach the following goals on a national scale:

• Help embed pre-surgical list briefings into hospital practice around Australia, resulting in improved communication of surgical teams.
• Improve theatre efficiency by working smarter, not harder.
• Reduce medical error due to communication and coordination failures.
• Create engaged operating teams where staff can thrive at work.

This innovative project began with Dr Stewart Flemming, UWA School of Surgery, observing surgeon fatigue. With safer surgery in mind, he looked for research in team working and communication improvements and made contact with Sharon Parker and Joseph Carpini (PhD candidate), UWA Business School. Thus the SWANS project began.

In 2014, a pilot study was undertaken at Kaleeya Hospital, with exciting results. The project now continues at Fiona Stanley Hospital where briefings have been introduced as a standard practice.

Solution

Whilst pre-surgical briefings are happening in hospitals overseas, the practice is sporadic and lack empirical evidence. The SWANS team are confident of the benefits gained by correct implementation of their project and aim to support the national implementation of briefings through providing rigorous evidence-based guidance.

The SWANS project expands on the already widely practised World Health Organisation (WHO) policy of team time out. The WHO surgical checklist is completed when the patient is brought to theatre prior to surgery and again before the patient leaves the operating theatre. While the WHO checklist has been shown to improve the quality of patient care, there are several important limitations which include: the checklist does not always engage the various professional groups and encourage them to share relevant information, nor does it allow teams to effectively plan for challenges in advance. Thus an opportunity to do things differently exists.

How the briefings work:

It is not uncommon for briefings to occur within a discipline (e.g. doctor to doctor), but with the SWANS method, briefings include all disciplines involved: surgeons, anaesthetists, nurses and theatre technicians, and occur prior to the surgical list commencing.

Briefings can be as short as five minutes and provide:

• a quick introduction of each person in the surgical team.
• planning what is going on, and what equipment will need to be available.
• clarification on who is doing which task, bringing role delineation and personal responsibility.
• a chance to ask questions, including expressing any foreseeable concerns.
• team engagement and feelings of trust.

Something as simple as ensuring a piece of equipment is available at the right time, or re-arranging a surgical list can provide quick efficiencies and a shared mental model going into the operating theatre.

Since commencing their research, the SWANS team have observed over 300 surgical procedures in the operating theatre. They have listened to the concerns of operating theatre staff and gathered valuable (de-identified) information about how surgical teams have worked, adverse events, staff engagement, whether the team believed the briefings were of value, as well as “hard” data related to theatre efficiency.

The team are also passionate about ensuring the ongoing success of the program, so in addition to training and coaching sessions, the team will provide materials, such as videos of role plays, to support ongoing training for management and medical professionals.

The idea of pre-work briefings can be adapted to other areas within the hospital and indeed other industries. It would suit rostered ward staff, prior to starting a new shift or in regional centres. There has been interest from colleagues in India who are keen to implement the SWANS process in their institutions and interest has also come from the mining sector, aviation industry and military where effective team functioning and communication are essential for safety and productivity.

In partnership with The Anatomy of Complications Workshop held in Perth, the team are also conducting research using simulations to further understand and measure team processes and the impact of briefings on communication between surgeons.

SWANS research is being funded by the State Health Research Advisory Council (SHRAC) which will help the team take their findings and offer their broad use in a way that can be implemented to realize real impact on, such as training videos, workshops and ongoing support services. Joseph’s PhD is supported by the Social Sciences and Humanities Research Council of Canada (SSHRC).

Impact Pathway

The evidence of the pilot studies so far indicate that team briefings are an effective means of not only reducing medical error, but also increasing operating theatre efficiency, and theatre staff engagement.

The preliminary results can be divided into three categories:

1. Efficiency in theatre. A significant improvement in the time it took for procedures to be executed, including reducing the time taken to anaesthetise a patient and turn theatres around.
2. Patient safety. A marked improvement in safety, with better communication between different medical professionals during surgery, leading to better quality outcomes for the patient.
3. Staff Engagement. Medical professionals in these demanding jobs are generally under enormous amounts of stress. With the briefing included, surgical teams became more satisfied with their team and with their performance and with their own job as a whole. If staff are happier, they are less stressed and perform at their best.

If each member feels an equal and important part of the process, the briefings can provide significant benefits.

Whilst some surgeons may have initially been opposed to the pre-surgical briefings, the study has shown that they have greatly benefitted and some are now amongst the greatest advocates with overwhelming support from those who have adopted the pre-surgical briefings.

Similarly, nurses, anaesthetists and technical staff and have reported feeling like a more cohesive team and with open sharing of information, they feel more informed and engaged in their work. Enjoyment of work leads to less staff turnover and absenteeism for hospitals.

The Australian health system will benefit from surgical procedures that are more efficient, with less chance of adverse events. As a consequence, patients will experience better health outcomes.

Hospitals will see real economic efficiencies. Based on figures in the pilot study at Kaleeya Hospital, if the program was consistently adopted by all surgical teams at Fiona Stanley Hospital, in one year the efficiencies would equal $17 million.

Professor Sharon Parker

With such positive economic, health and public impacts, the practice of pre-surgical briefings will be instrumental in creating a stronger safety culture in the operating theatre and better health outcomes for all involved.

Impact in Action:

Prior to a colorectal surgery in Perth, a surgeon had asked a nurse to ensure that a piece of equipment be available for the procedure. The nurse later went on a tea break and neither he, nor the equipment could be found during surgery. It took 45 minutes for him to return and reveal the item in one of the operating theatre draws. Every minute lost cost over $1,000. This delay cost $45,000. With a pre-surgical briefing, every person present would have known where the equipment was.

Survey response: ‘This project has significantly contributed to an improved culture of communication in theatre in our hospital. The briefings definitely improves efficiency, avoid problems and improve the work of the team.’ (Anth.Con)

Survey response: ‘Briefings personally changed my perspective on being a surgeon as before I felt just like a contract labourer doing my job, but briefings helped me to express and connect with my workplace a lot better.’ (Surgeon210)