Promoting Teamwork and Surgical Optimization: Combining TeamSTEPPS With a Specialty Team Protocol SHEILA MARIE TIBBS, DNP, RN, ACNS-BC, CNOR; JACQUELINE MOSS, PhD, RN, FAAN
ABSTRACT This quality improvement project was a 300-day descriptive preintervention and postintervention comparison consisting of a convenience sample of 18 gynecology surgical team members. We administered the Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPSÒ) Teamwork Perception Questionnaire to measure the perception of teamwork. In addition, we collected data regarding rates of compliance (ie, huddle, time out) and measurable surgical procedure times. Results showed a statistically significant increase in the number of team members present for each procedure, 2.34 m before compared with 2.61 m after (P ¼ .038), and in the final time-out (FTO) compliance as a result of a clarification of the definition of FTO, 1.05 m before compared with 1.18 m after (P ¼ .004). Additionally, there was improvement in staff members’ perception of teamwork. The implementation of team training, protocols, and algorithms can enhance surgical optimization, communication, and work relationships. AORN J 100 (November 2014) 477-488. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.01.028 Key words: teamwork, TeamSTEPPSÒ, protocol, algorithm, surgical workflow.
H
uman error caused by poor communication and lack of teamwork is the leading cause of patient harm in the surgical environ1 ment. In 2008, The Joint Commission reported that more than two-thirds of adverse events occurring in the OR were a result of poor communication.2 To reduce errors, studies have recommended using team training, checklists, and standardized protocols.3,4 Our facility, a large military medical center and major training site, began an organizationwide rollout of Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPSÒ)
training in 2010. TeamSTEPPS is an evidence-based teamwork system designed to produce highly effective health care teams by optimizing the use of information, people, and resources to achieve the best clinical outcomes for patients.5 We conducted a process improvement project that examined whether the use of TeamSTEPPS training combined with a team protocol and algorithm could optimize surgical workflows for the gynecology surgical specialty team (GSST). This article reports on the results of using the TeamSTEPPS principles of team structure,
http://dx.doi.org/10.1016/j.aorn.2014.01.028
Ó AORN, Inc, 2014
November 2014
Vol 100
No 5
AORN Journal j 477
November 2014 Vol 100
No 5
leadership, communication, mutual support, and situation monitoring to develop and implement a process improvement initiative for the GSST.5 BACKGROUND As the number one training site for the US Army Medical Command (AMEDD), the perioperative services department hosts more than 300 students daily, including perioperative nurses, surgical residents and interns, surgical technicians (ie, scrub persons), anesthesiology residents, and certified registered nurse anesthetists (CRNAs). The miliary facility deploys the largest number of medical personnel to support several military missions throughout the world. To promote stability and patient care continuity in perioperative services, staffing plans include the use of civilian personnel to supplement military medical personnel. Civilian personnel possess a wide variety of surgical experience, from novice to expert, and they may fill permanent and temporary staffing roles. A surgical services team traditionally comprises surgeons and an assigned group of anesthesia professionals, RN circulators, and scrub personnel who work together most of the time. The issue at our facility is that assigned team members seldom end up working on their specialty team or with their team members. Instead, the assignments coordinator routinely places team members in different rooms and assigns nonteam personnel to work on the specialty service procedures. Multiple factors contribute to this situation to include training needs of students and efficient use of civilian and contract personnel. Military members are added to any unassigned rooms as needed, rotating among the surgical service specialties. This method of assigning personnel to rooms and procedures impeded team cohesiveness and caused dissatisfaction among the surgeons because it resulted in personnel being assigned who may have lacked procedural knowledge and surgeon familiarization. To prevent patient care problems related to inadequate personnel experience, most hospital units colocate patients with like illnesses or medical 478 j AORN Journal
TIBBSdMOSS or surgical conditions, thus allowing nurses to specialize in providing care to patients with similar medical conditions, equipment needs, and providers.6 These practices contribute to effective communication and teamwork.6 From the retrospective review of staffing data from January 2012 to July 2012, we determined that the time specialty team members spent working with two or more team associates averaged less than 30% compared with an average of 67% by surgical procedure staffing reports in civilian hospital perioperative departments.7 According to the 2012 Surgical Optimization Standardization dashboard measurements from the AMEDD report,8 our facility ranked 13th among the 14 largest military medical facilities in turnover time at an average of 58 minutes between procedures; additionally, it ranked 13th for first case (FC) in room on time. Initial assessment of these results together with the staffing issues led to the theory that addressing perceptions of teamwork among surgical team members could optimize team function and surgical workflows (eg, improve surgical procedure times). The perioperative staff members’ familiarity with the TeamSTEPPS system framework prompted the project coordinators to combine that framework with the use of a surgical specialty team algorithm (Figure 1) and protocol (Table 1). The GSST was chosen because of the high number of complaints from surgeons regarding staffing, equipment, and supplies. Both the GSST manager and the main OR clinical leader supported the selection. SETTING This project took place in our surgical department at one of the largest military facilities in the United States. More than 1,200 surgical procedures are performed each month in its 28 OR suites. There are 120 surgeons working within 14 surgical specialties. The gynecology (GYN) surgical department has eight surgeons across three subspecialties, and additional GSST members include five RN circulators (including the team manager), three
TEAMWORK AND SURGICAL OPTIMIZATION
www.aornjournal.org
Figure 1. This algorithm provides assignment personnel with a visual cue of the steps to be performed, the order of occurrence, and what to do if a problem arises when performing the GSST protocol. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
surgical technicians, and three anesthesia professionals. Approximately 250 GYN procedures are performed each month. Three OR suites are blocked for GYN procedures three days per week. Two rooms are located in the A core close to their equipment storage room, and the third is in the D core. OBJECTIVES The primary objective of this project was to determine whether implementation of a team protocol and algorithm could improve n
surgical times, n compliance with performing time outs and huddles, and n the perception of teamwork among members of the GSST.
The secondary objective was to assist GSST members with improving teamwork by identifying contributing factors to poor team performance and improving the facility’s ranking of surgical times among other military medical centers. LITERATURE REVIEW Collaboration and communication are the backbone of teamwork in the OR.9 The Joint Commission encourages team training to enhance communication and leadership support, which was the catalyst for this project. 10 AORN also endorses team training models to improve communication, optimize workflow, and potentially decrease surgical errors.11 Human factors, such as perceptions of trust and teamwork, staffing patterns, and the AORN Journal j 479
November 2014 Vol 100
TIBBSdMOSS
No 5
TABLE 1. Gynecology Surgical Specialty Team (GSST) Protocol Instructions Preoperative protocol n The OR room coordinator makes staff room assignments and assigns GSST members to the gynecology team room the day before. n The patient arrives at 5:45 AM. The preoperative hold RN performs the preoperative assessment; verifies consent, laboratory results, and NPO status; and completes the preoperative prep (eg, provides surgery gown, places identification and other appropriate bracelets [eg, allergies, fall status] on the patient, starts IV). n All OR personnel at work review the surgery schedule for assignments and changes and then report to assigned rooms to start setting up. n Team members (eg, surgeon, anesthesia professional, RN circulator, scrub person) scheduled in the team room perform a brief team huddle. n The RN circulator initiates the Universal ProtocolTM in the preoperative area, during which he or she asks the patient to verify the planned surgical procedure and operative site marking. n The assigned RN circulator and scrub person perform the initial count and complete the setup of instruments and equipment. Intraoperative protocol n The anesthesia professional and surgeon or RN circulator transport the first patient into the OR by 7:30 AM or within 20 minutes of the previous out-of-room time. n The surgeon reports to the room with the patient or within 5 minutes of the patient’s arrival in the room. n Team members position the patient for surgery, perform the surgical skin prep, and set up any required special equipment. n The surgeon leads all team members in the surgical time out and brief. n The surgeon starts the surgical procedure. n The team manager or an available team nurse checks the next assigned case cart, gathers supplies and equipment, and sends for and interviews the next patient. n The surgeon starts to close the surgical wound. n The RN circulator and scrub person scan the room and then perform the first closing and final counts. n The surgeon conducts the postoperative brief with all surgical team members, during which team members verify the procedure performed and specimen collected. n The anesthesia professional extubates the patient. n The RN circulator records the surgical end time and pages for housekeeping personnel to prepare for room turnover. n The RN circulator and anesthesia professional transport the patient to the postanesthesia care unit. n The scrub person prepares the room for turnover. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
presence of a respectful culture, can affect communication and team building.11 Additionally, principles for optimizing workflow and teamwork, such as the use of patient briefs, checklists, readbacks, callouts, and time outs, can minimize patient risk, improve communication, and enhance the quality of patient care. The project coordinators considered errors related to human factors and principles of optimization during the creation of the interventions for this project (eg, algorithm, protocol list, definitions of terms, training, reviews, reminders).
480 j AORN Journal
Optimization Wolf et al7 performed a detailed analysis of 4,863 procedures in their study about the efficacy of medical team training (MTT) in improving team performance and decreasing OR delays. Personnel completed MTT, an evidence-based tool centered on aviation crew resource management. After MTT training, OR procedure delays decreased by 23%, a change that was sustained at a 24-month review. Hand overs, equipment issues, low-procedure scores, and adherence to prophylactic antibiotic timing guidelines also improved.7
TEAMWORK AND SURGICAL OPTIMIZATION Mills et al12 examined the perceptions of teamwork among 300 surgical clinicians as part of a patient safety implications study. The researchers scored “perception of communication,” and physicians scored higher than nurses and anesthesia professionals combined. Findings suggest that the MTT was instrumental in identifying n
hidden communication problems among disciplines in the surgical setting and n efforts to improve communication and teamwork.12 Teamwork Paige et al6 improved OR teamwork in a rural community hospital by using the Structured Assessment Fostering Enhanced Teamwork Yield Preparation (SAFETY Prep) program. They used MTT processes and tools developed from randomized clinical trials and evaluated their effectiveness by using preintervention and postintervention questionnaires. Although the researchers noted improvements in the preoperative briefing and team interaction, they were unable to obtain statistical significance because of the small sample size. Implementation of a preoperative briefing enhanced team communication and interactions. These findings suggest that teamwork and patient safety can be improved in the perioperative environment, especially through effective use of the preoperative briefing.6 Awad et al3 also used the MTT evidence-based model developed from randomized clinical trials, and a change team implemented the training. To record and measure the effectiveness of team communication, researchers administered a survey to team members two months after the training was completed. The researchers noted improvement in communication between the anesthesia professional and surgeon. Findings from this study suggest that MTT using crew resource management principles can improve communication in the OR, thereby helping to ensure a safer environment and decrease adverse events. In addition, survey tool questions can aid in assessing the role of team communication in
www.aornjournal.org
reducing errors, improving surgical optimization, and eliminating patient risk by highlighting communication problems in the department.3 METHODS The following paragraphs discuss the design of the project, human protections guidelines, and sample size and composition. Additionally, the reliability and validity of the TeamSTEPPSeTeamwork Perception Questionnaire (T-TPQ) as well as data collection, analysis, and interventions are reviewed. Design This project was a descriptive preintervention and postintervention comparison of the perception of teamwork among GSST members. To measure the perception of teamwork and the effectiveness of TeamSTEPPS training, we used the T-TPQ, a selfreport tool that measures teamwork perception within a team, unit, or department. This instrument allowed GSST members to anonymously score performance measures related to perceptions of teamwork. Furthermore, the following performance measures could be used to compare changes in surgical optimization preintervention and postintervention: n n n n n
huddle and time-out compliance, the number of team members present, the first procedure in-room times, incision times, and turnover times.
This comparison was used to note improvements, address areas of concern, and compare with data from other military medical centers. The questionnaires had specific headings that identified the role of the team member (eg, surgeon, nurse). This identifier was helpful for grouping and comparing responses to identify whether a specific team role was experiencing challenges related to team skills or behavior that needed to be addressed. Terms associated with surgical procedure times in the OR (eg, turnover, in room, case times) may vary according to each institution’s definition. Our collected list of metrics for this project was developed and based on the literature review and AORN AORN Journal j 481
November 2014 Vol 100
TIBBSdMOSS
No 5
recommendations.11 We reviewed the measurable surgical procedure terms defining surgical times with GSST members to assist with capturing measurements accurately (Table 2). Next, we compared these data points with dashboard measurements from the 2014 Surgical Optimization and Standardization (SOS) report that highlighted surgical procedure times (ie, turnover time, in-room time, prime time minutes) for several military medical centers.8 There were no statistically significant differences between results from the project and any measures listed on the SOS report.
provided the study participants with a verbal and written description of the project, after which participants voluntarily provided their consent for participating. To meet IRB requirements for obtaining a Health Insurance Portability and Accountability Act waiver and informed consent, we provided participants with a written instruction sheet without requesting a signature or collecting identifiers. The project coordinators stored completed questionnaires in a secure file and placed data analysis on a password-encrypted computer, both of which were maintained in a locked office.
Human Protections We obtained approval to conduct this study from the University of Alabama Institutional Review Board (IRB) and the medical facility IRB. We
Sample Size and Composition We surveyed a convenience sample of 18 members of the GSST by using the T-TPQ, of which 12
TABLE 2. Procedural Terms and Definitions Used for Intervention Measurements Term In-room time First case
Incision time
Turnover time
Huddle compliance
Definition Time the patient enters the OR The first procedure scheduled for a 7:30 AM start in a room must be in the room before or by 7:30 AM Time of the initial incision
Time between procedures (ie, turning the room over)
Informal brief is performed before the procedure starts Final time-out compliance Reaffirming the surgical procedure, identifying patient information, ensuring availability of important diagnostic test results and interpretation by the appropriate person (eg, radiologist, cardiologist, pathologist) Team members present by The number of GSST members present for and number assigned to the surgical procedure Team Strategies & Tools to TeamSTEPPS system framework increases Enhance Performance and communication between team members and Patient Safety (TeamSTEPPSÒ) promotes patient safety, which includes huddles and preoperative and postoperative briefs TeamSTEPPS Teamwork An instrument that allows respondents to selfPerceptions Questionnaire report perceptions of teamwork within a unit or department
Method of measurement Time of day the patient enters the room Time of day the patient enters the room
Time the patient enters the room to the time the initial incision is made (in minutes) Time the previous patient exits the OR until the next patient enters the OR (in minutes) Yes (1) or no (2) Yes (1) or no (2)
1, 2, 3, or 4 GSST members present Yes (1) or no (2)
1 to 5 points per survey question (Likert scale) with a total of 35 questions (point range: 35 to 175)
TeamSTEPPS is a registered trademark of the US Department of Defense, Falls Church, VA, and the US Department of Health and Human Services, Bethesda, MD.
482 j AORN Journal
TEAMWORK AND SURGICAL OPTIMIZATION
www.aornjournal.org
preintervention (66%) and 14 postintervention (77%) questionnaires were completed and returned. The project participants included GYN surgeons, CRNAs, RN circulators, and scrub personnel. Of the 307 GYN surgical procedures performed during the intervention protocol period, 197 (64%) met the following inclusion criteria. A GYN surgical procedure was included if it
training in health care settings. To assess the effectiveness of this training, these organizations also developed the T-TPQ, an instrument for assessing five constructs related to teamwork: team structure, leadership, communication, mutual support, and situation monitoring. These organizations tested and refined the T-TPQ through cognitive interviews, a small group trial, and a field test followed by application of standard item statistics. The Cronbach alpha reliability coefficients for constructs ranged from 0.88 (communication) to 0.95 (leadership).5 The T-TPQ for our quality initiative consisted of questions for respondents to rank using a 5-point Likert scale (ie, “strongly agree” to “strongly disagree”). We administered the T-TPQ before and after the intervention period. The margin of error calculated for 12 participants was 28.3% with a mean of 0.50 (SD, 0.28; 95% CI, 0.22-0.78). To analyze the T-TPQ score responses, we used a hypothesis test rather than margin of error. Because one or more variables were not normally distributed with equal variances, we repeated the analysis using the nonparametric Mann-Whitney rank sum test for the T-TPQ responses.
n
was performed by a GYN surgeon; n had at least one GSST member present, which was usually the surgeon; n was scheduled as an elective procedure; and n was performed Monday through Friday between 7 AM and 5 PM. The data were documented into an inpatient electronic health record system by the RN circulator and into the surgery scheduling system (S3) by the statistical assistant. The S3 system is where the assistant inputs times from the nurse documentation. The statistical assistant provided us with a printout of GSST procedures without patient identifying information at the end of the project period for all procedures that met the criteria. All other surgical personnel and surgical procedures were excluded. We used a two-tailed independent sample t test to analyze the data. This test compares one group of the same subjects for a before-and-after intervention on one tail of the t distribution (ie, improve personnel perception of teamwork and optimize surgical workflow). The project coordinators used the IBMÒ SPSSÒ SamplePower version 2.0 to estimate the sample size needed for a power of 80% with a level of confidence of 95%. We estimated mean turnover time as 45 minutes from the 14 largest military treatment facilities listed on the SOS report, and the project coordinators determined that a 33% (15-minute) decrease in turnover time would be a significant improvement. Reliability and Validity In 2006, the Agency for Healthcare Research and Quality and the Department of Defense released TeamSTEPPS as the national standard for team
Data Collection The project coordinators collected surgical procedure times and compliance data during the 60-day protocol period from the electronic perioperative record documented by the RN circulator into the inpatient electronic health record system and the surgery scheduling system by the department’s statistical assistant. They verbally instructed the GSST members on the nature of the process improvement initiative and provided them with a written handout about the protocol. They also determined whether team members completed initial TeamSTEPPS training during the hospitalwide rollout or individual training during their hospital in-processing. All members of the GSST completed the T-TPQ in the seven days immediately preceding and following the intervention period. Members of the project team hand-delivered questionnaires to each GSST member and facilitated AORN Journal j 483
(2:29) (0.50) (0.38) (11.81) (21.36) (0.82)
> .05 > .05 .004 > .05 > .05 .038b
their return to a secured box located in the OR. The statistical assistant provided surgical times and compliance adherences at the end of the study for all included procedures during the 60-day protocol period. The project coordinators coded the data appropriately and entered it into SPSS.
(2:23) (0.50) (0.22) (13.70) (40.99) (0.74)
7:21 1:00 1:00 6:00 0:00
minutes minutes minute minutes minutes 1
16:33 minutes 2:00 minutes 2:00 minutes 81:00 minutes 81:00 minutes 4
10:17 AM 1.56 1.18 32.91 20.96 2.61
Data Analysis In this project, the independent variable was performance relative to an intervention (ie, before or after). The dependent variables were times measured in minutes (ie, in-room time, turnover time, surgery start time, incision time) and events (ie, time out, huddle) recorded as binomials (ie, yes/no). The number of team members present for each procedure also was noted. The expected outcome, as computed by descriptive statistics, was that there would be an improvement in time measurement and the number of team members present.
b
a
P values are for an independent sample t test unless otherwise noted. Mann-Whitney test.
9:51 AM 1.53 1.05 31.70 26.36 2.34 16:12 minutes 2:00 minutes 2:00 minutes 101:00 minutes 307:00 minutes 4 minutes minute minute minutes minutes 1 7:24 1:00 1:00 6:00 0:00
Minimum
TIBBSdMOSS
No 5
In-room time First case Final time out Incision time Turnover time Number of team members present
P valuea Minimum
Maximum
Mean (SD)
484 j AORN Journal
Maximum
Mean (SD)
Range Range
Before intervention (n ¼ 88)
TABLE 3. Comparison of Surgical Times Before and After Process Intervention
After intervention (n ¼ 109)
Significance
November 2014 Vol 100
Interventions As discussed, the interventions for this project were a specialty team protocol and algorithm. We reviewed the algorithm and protocol several times with the GSST members and OR assignment coordinator before the protocol start date. The protocol was explained to the surgeons, leaders, and management personnel and focused on obtaining their acceptance and support. Additionally, all OR personnel received inservice training on the protocol and algorithm. The project coordinators also placed a copy of the protocol and algorithm in each of the three GYN surgical suite binders. Using the algorithm and protocol as guides, the OR assignment coordinator made room assignments the day before, assigning any available GSST team member to the GYN room and the GSST manager to the core A or D. At the beginning of the shift, the surgical coordinator/operations officer reviewed patient data to ensure the patients met inclusion criteria indicated by the protocol and that the GSST manager was assigned to the core A or D to assist with setups, turnovers, and review of GSST case
TEAMWORK AND SURGICAL OPTIMIZATION carts. The project coordinators reminded the schedulers daily to assign as many GSST members as possible to GYN specialty procedures, which was necessary because of the frequent changes of personnel assigned to complete the staff assignment task. To overcome this challenge, members of the project team attached an updated list of GSST team members to the staffing scheduling sheet.
RESULTS The results of independent sample t tests for beforeand-after procedure times and Mann-Whitney test for total number of team members present (TMPNUM) are shown in Table 3. The variance between the group means was significantly different for final time out (P ¼ .004). The results shifted compliance documentation to the right, which resulted from a clarification of the definition and compliance standards for this measure. In addition, there was a statistically significant difference between groups in the number of team members present according to the results obtained from the Mann-Whitney rank sum test (P ¼ .038). The OR staff scheduler increased the use of specialty teams by placing more GSST members in their specialty room for GYN specialty procedures, which promoted teamwork, communication, optimization, and patient safety. The distribution graphs for final time out and team members present are shown in Figures 2 and 3, respectively. There was no statistically significant difference between groups (ie, before, after) for any items on the questionnaire. However, we identified two areas of improvement in core components in the perception of teamwork: staff members met to reevaluate goals when the situation changed (m ¼ 3.08 vs 3.64, P ¼ .126) and staff members corrected each other’s mistakes (m ¼ 3.42 vs 4.0, P ¼ .236). We noted the following changes regarding teamwork after the 60-day protocol period: n
GSST members described the experience as rewarding and voiced fewer complaints about their work environment.
www.aornjournal.org n
GSST members expressed a desire to continue using the algorithm and protocol. n We observed an increase in assistance between members during room procedure setup and breakdown.
Figure 2. Before the intervention, the number of times the final time out (FTO) recorded by the RN circulator as meeting compliance was 95.2%; after the intervention, the number meeting compliance dropped to 82.2%, which was statistically significant (P [ .004). This finding indicates that the intervention led to proper documentation of the FTO process.
Figure 3. The number of gynecology surgical specialty team members present for a gynecology procedure increased after the intervention, and this difference was statistically significant (P [ .038). This finding indicates that the OR staff scheduler increased the use of specialty team members, which promoted teamwork, communication, optimization, and patient safety.
AORN Journal j 485
November 2014 Vol 100
TIBBSdMOSS
No 5
KEY TAKEAWAYS FOR CLINICAL PRACTICE Using a Surgical Specialty Team Protocol and Algorithm Improves Turnover Time and Communication Why Did We Do This Research? n We conducted this quality improvement project to determine whether using a surgical team protocol and algorithm combined with TeamSTEPPSÒ could improve staff member perceptions of teamwork and improve gynecological surgical workflows.
What Did We Find? n The process improvement led to decreased turnover time between procedures. n Staff members had better perceptions of teamwork after the process improvement than they did before. n For each procedure, there were more team members present during procedures after the improvement process compared with before because the OR staff scheduler increased the use of specialty teams by placing more gynecology surgical specialty team members in their specialty room, which promoted teamwork, communication, optimization, and patient safety.
n Compliance with the final time out decreased after the
intervention, but we found that this was because team members better understood the definition of “final time out” as part of the process improvement and were more often documenting this compliance correctly. How Can Clinicians Use These Results? n Clinician: Perioperative team members should participate in team training, protocols, and algorithms to help make surgical processes more efficient and improve communication and work relationships for the perioperative team. n Manager: Managers should consider implementing team training, protocols, and algorithms as a way to optimize surgical processes as well as enhance communication and work relationships. n Educator: Educators should help personnel understand the components of and the reasons behind the use of huddles and time outs and work with them to find ways to improve these processes and patient care.
Tibbs SM, Moss J. Promoting teamwork and surgical optimization: combining TeamSTEPPS with a specialty team protocol. AORN J. 2014;100(5):477-488. Copyright Ó AORN, Inc, 2014.
n
Team members demonstrated more positive communication among themselves. n Complaints from the surgeons decreased from almost daily to two or fewer per week. n Other OR personnel voiced support of the specialty team concepts. Overall, the measures for turnover time are skewed because of the use of a stagger room model resulting in turnover time being reported as zero minutes. The expected outcome, as computed by descriptive statistics, was that there would be an improvement in time measurement and the number of team members assigned. The project coordinators determined that a 15-minute decrease in turnover time would be a clinically significant improvement for our facility because it was 50% less than our current average and could result in increased prime-time use of our surgical rooms and OR staff. 486 j AORN Journal
DISCUSSION Using a surgical specialty team protocol and algorithm, the GSST was able to decrease turnover time and improve communication between nursing personnel and surgeons. When the surgeons realized that they had specific team members assigned to their service, they did not want anyone else in their room. Project leaders and participants faced many challenges from instructors and the OR educator, who wanted their students and new employees to be assigned to those rooms to acquire more OR experience during the postintervention period. The project coordinators decided to remove the anesthesia professionals from the GSST because of their complex work schedules after the first two weeks of the postintervention period. Getting the same anesthesia professional for two consecutive days was nearly impossible. Based on the findings of this project, the OR leaders agreed to require the staff
TEAMWORK AND SURGICAL OPTIMIZATION scheduler to place members assigned to specialty teams in their team room whenever possible. To promote teamwork, GSST personnel were allowed time to attend GYN clinic meetings and training sessions to enhance team-building concepts. This was a great hit, especially with scrub personnel, because it improved knowledge and confidence. Despite all the planning, military training pulled away our GSST manager for two weeks and the anesthesia section chief could not support the GSST assignment with the same two providers for the entire protocol period.
www.aornjournal.org
Church, VA, and the US Department of Health and Human Services, Bethesda, MD. IBM SPSS SamplePower version 2.0 is a registered trademark of IBM, Armonk, NY. Disclaimer: The opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Air Force, Department of Defense, or the United States Government.
References
CONCLUSION Although the RN circulator’s and GSST manager’s ultimate goal is to provide a safe surgical environment, the findings from this project confirm that the perception of teamwork and communication are critical elements in promoting patient safety. Unfortunately, we are finding it almost impossible to implement the process initiatives (ie, protocol, algorithm) throughout perioperative services because of our military mission and 24-hour operation, which require perioperative personnel to provide OR support during a variety of surgical procedures 24 hours a day, seven days a week. The project won leadership support; however, management team members expressed a fear of violating union rules and contract inclusions if they altered the schedule or work assignments without proper notification. Nevertheless, everyone involved in this project agreed that we should continue to work toward implementing the process and using surgical specialty teams within the constraints of our facility’s mission. Acknowledgment: The authors thank John A. Ward, PhD, Department of Clinical Investigation, Brooke Army Medical Center, JBSA Fort Sam, Houston, TX, for his assistance with statistical data analysis and tabular formatting. Editor’s notes: TeamSTEPPS is a registered trademark of the US Department of Defense, Falls
1. Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg. 2009;198(5): 675-678. 2. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-142. 3. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5): 770-774. 4. Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010;145(6): 582-588. 5. TeamSTEPPSÒ: Strategies and Tools to Enhance Performance. Agency for Healthcare Research and Quality. http://www.ahrq.gov/teamsteppstools. Accessed July 12, 2014. 6. Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. Improved operating room teamwork via SAFETY prep: a rural community hospital’s experience. World J Surg. 2009;33(6):1181-1187. 7. Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Ann Surg. 2012;252(3):477-483. 8. Surgical Optimization and Standardization Dashboard. Washington, DC: US Army Medical Department; 2012. 9. Cvetic E. Communication in the perioperative setting. AORN J. 2011;94(3):261-270. 10. Universal protocol for preventing wrong site, wrong procedure, wrong surgery. The Joint Commission. http:// www.jointcommission.org/standards_information/up.aspx. Accessed July 12, 2014. 11. Human factors in health care tool kit. AORN, Inc. https:// www.aorn.org/Clinical_Practice/ToolKits/Human_Factors_ In_Health_Care_ToolKit/Human_Factors_in_Health_Care_ Tool_Kit.aspx. Accessed July 12, 2014. 12. Mills P, Neily J, Dunn E. Teamwork and communication in surgical teams: implications for patient safety. J Am Coll Surg. 2008;206(1):107-112.
AORN Journal j 487
November 2014 Vol 100
No 5
Sheila Marie Tibbs, DNP, RN, ACNS-BC, CNOR, Lt Col, USAF, NC, is the operating room services element chief for the 959th Medical Operations Squadron (AETC) of the Joint Base San Antonio at Fort Sam Houston, TX. Dr Tibbs has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
488 j AORN Journal
TIBBSdMOSS
Jacqueline Moss, PhD, RN, FAAN, is a professor and chair of the School of Nursing, Adult/Acute Health, Chronic Care and Foundations, at the University of Alabama at Birmingham. Dr Moss has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
ABSTRACT This quality improvement project was a 300-day descriptive preintervention and postintervention comparison consisting of a convenience sample of 18 gynecology surgical team members. We administered the Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPSÒ) Teamwork Perception Questionnaire to measure the perception of teamwork. In addition, we collected data regarding rates of compliance (ie, huddle, time out) and measurable surgical procedure times. Results showed a statistically significant increase in the number of team members present for each procedure, 2.34 m before compared with 2.61 m after (P ¼ .038), and in the final time-out (FTO) compliance as a result of a clarification of the definition of FTO, 1.05 m before compared with 1.18 m after (P ¼ .004). Additionally, there was improvement in staff members’ perception of teamwork. The implementation of team training, protocols, and algorithms can enhance surgical optimization, communication, and work relationships. AORN J 100 (November 2014) 477-488. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2014.01.028 Key words: teamwork, TeamSTEPPSÒ, protocol, algorithm, surgical workflow.
H
uman error caused by poor communication and lack of teamwork is the leading cause of patient harm in the surgical environ1 ment. In 2008, The Joint Commission reported that more than two-thirds of adverse events occurring in the OR were a result of poor communication.2 To reduce errors, studies have recommended using team training, checklists, and standardized protocols.3,4 Our facility, a large military medical center and major training site, began an organizationwide rollout of Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPSÒ)
training in 2010. TeamSTEPPS is an evidence-based teamwork system designed to produce highly effective health care teams by optimizing the use of information, people, and resources to achieve the best clinical outcomes for patients.5 We conducted a process improvement project that examined whether the use of TeamSTEPPS training combined with a team protocol and algorithm could optimize surgical workflows for the gynecology surgical specialty team (GSST). This article reports on the results of using the TeamSTEPPS principles of team structure,
http://dx.doi.org/10.1016/j.aorn.2014.01.028
Ó AORN, Inc, 2014
November 2014
Vol 100
No 5
AORN Journal j 477
November 2014 Vol 100
No 5
leadership, communication, mutual support, and situation monitoring to develop and implement a process improvement initiative for the GSST.5 BACKGROUND As the number one training site for the US Army Medical Command (AMEDD), the perioperative services department hosts more than 300 students daily, including perioperative nurses, surgical residents and interns, surgical technicians (ie, scrub persons), anesthesiology residents, and certified registered nurse anesthetists (CRNAs). The miliary facility deploys the largest number of medical personnel to support several military missions throughout the world. To promote stability and patient care continuity in perioperative services, staffing plans include the use of civilian personnel to supplement military medical personnel. Civilian personnel possess a wide variety of surgical experience, from novice to expert, and they may fill permanent and temporary staffing roles. A surgical services team traditionally comprises surgeons and an assigned group of anesthesia professionals, RN circulators, and scrub personnel who work together most of the time. The issue at our facility is that assigned team members seldom end up working on their specialty team or with their team members. Instead, the assignments coordinator routinely places team members in different rooms and assigns nonteam personnel to work on the specialty service procedures. Multiple factors contribute to this situation to include training needs of students and efficient use of civilian and contract personnel. Military members are added to any unassigned rooms as needed, rotating among the surgical service specialties. This method of assigning personnel to rooms and procedures impeded team cohesiveness and caused dissatisfaction among the surgeons because it resulted in personnel being assigned who may have lacked procedural knowledge and surgeon familiarization. To prevent patient care problems related to inadequate personnel experience, most hospital units colocate patients with like illnesses or medical 478 j AORN Journal
TIBBSdMOSS or surgical conditions, thus allowing nurses to specialize in providing care to patients with similar medical conditions, equipment needs, and providers.6 These practices contribute to effective communication and teamwork.6 From the retrospective review of staffing data from January 2012 to July 2012, we determined that the time specialty team members spent working with two or more team associates averaged less than 30% compared with an average of 67% by surgical procedure staffing reports in civilian hospital perioperative departments.7 According to the 2012 Surgical Optimization Standardization dashboard measurements from the AMEDD report,8 our facility ranked 13th among the 14 largest military medical facilities in turnover time at an average of 58 minutes between procedures; additionally, it ranked 13th for first case (FC) in room on time. Initial assessment of these results together with the staffing issues led to the theory that addressing perceptions of teamwork among surgical team members could optimize team function and surgical workflows (eg, improve surgical procedure times). The perioperative staff members’ familiarity with the TeamSTEPPS system framework prompted the project coordinators to combine that framework with the use of a surgical specialty team algorithm (Figure 1) and protocol (Table 1). The GSST was chosen because of the high number of complaints from surgeons regarding staffing, equipment, and supplies. Both the GSST manager and the main OR clinical leader supported the selection. SETTING This project took place in our surgical department at one of the largest military facilities in the United States. More than 1,200 surgical procedures are performed each month in its 28 OR suites. There are 120 surgeons working within 14 surgical specialties. The gynecology (GYN) surgical department has eight surgeons across three subspecialties, and additional GSST members include five RN circulators (including the team manager), three
TEAMWORK AND SURGICAL OPTIMIZATION
www.aornjournal.org
Figure 1. This algorithm provides assignment personnel with a visual cue of the steps to be performed, the order of occurrence, and what to do if a problem arises when performing the GSST protocol. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
surgical technicians, and three anesthesia professionals. Approximately 250 GYN procedures are performed each month. Three OR suites are blocked for GYN procedures three days per week. Two rooms are located in the A core close to their equipment storage room, and the third is in the D core. OBJECTIVES The primary objective of this project was to determine whether implementation of a team protocol and algorithm could improve n
surgical times, n compliance with performing time outs and huddles, and n the perception of teamwork among members of the GSST.
The secondary objective was to assist GSST members with improving teamwork by identifying contributing factors to poor team performance and improving the facility’s ranking of surgical times among other military medical centers. LITERATURE REVIEW Collaboration and communication are the backbone of teamwork in the OR.9 The Joint Commission encourages team training to enhance communication and leadership support, which was the catalyst for this project. 10 AORN also endorses team training models to improve communication, optimize workflow, and potentially decrease surgical errors.11 Human factors, such as perceptions of trust and teamwork, staffing patterns, and the AORN Journal j 479
November 2014 Vol 100
TIBBSdMOSS
No 5
TABLE 1. Gynecology Surgical Specialty Team (GSST) Protocol Instructions Preoperative protocol n The OR room coordinator makes staff room assignments and assigns GSST members to the gynecology team room the day before. n The patient arrives at 5:45 AM. The preoperative hold RN performs the preoperative assessment; verifies consent, laboratory results, and NPO status; and completes the preoperative prep (eg, provides surgery gown, places identification and other appropriate bracelets [eg, allergies, fall status] on the patient, starts IV). n All OR personnel at work review the surgery schedule for assignments and changes and then report to assigned rooms to start setting up. n Team members (eg, surgeon, anesthesia professional, RN circulator, scrub person) scheduled in the team room perform a brief team huddle. n The RN circulator initiates the Universal ProtocolTM in the preoperative area, during which he or she asks the patient to verify the planned surgical procedure and operative site marking. n The assigned RN circulator and scrub person perform the initial count and complete the setup of instruments and equipment. Intraoperative protocol n The anesthesia professional and surgeon or RN circulator transport the first patient into the OR by 7:30 AM or within 20 minutes of the previous out-of-room time. n The surgeon reports to the room with the patient or within 5 minutes of the patient’s arrival in the room. n Team members position the patient for surgery, perform the surgical skin prep, and set up any required special equipment. n The surgeon leads all team members in the surgical time out and brief. n The surgeon starts the surgical procedure. n The team manager or an available team nurse checks the next assigned case cart, gathers supplies and equipment, and sends for and interviews the next patient. n The surgeon starts to close the surgical wound. n The RN circulator and scrub person scan the room and then perform the first closing and final counts. n The surgeon conducts the postoperative brief with all surgical team members, during which team members verify the procedure performed and specimen collected. n The anesthesia professional extubates the patient. n The RN circulator records the surgical end time and pages for housekeeping personnel to prepare for room turnover. n The RN circulator and anesthesia professional transport the patient to the postanesthesia care unit. n The scrub person prepares the room for turnover. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
presence of a respectful culture, can affect communication and team building.11 Additionally, principles for optimizing workflow and teamwork, such as the use of patient briefs, checklists, readbacks, callouts, and time outs, can minimize patient risk, improve communication, and enhance the quality of patient care. The project coordinators considered errors related to human factors and principles of optimization during the creation of the interventions for this project (eg, algorithm, protocol list, definitions of terms, training, reviews, reminders).
480 j AORN Journal
Optimization Wolf et al7 performed a detailed analysis of 4,863 procedures in their study about the efficacy of medical team training (MTT) in improving team performance and decreasing OR delays. Personnel completed MTT, an evidence-based tool centered on aviation crew resource management. After MTT training, OR procedure delays decreased by 23%, a change that was sustained at a 24-month review. Hand overs, equipment issues, low-procedure scores, and adherence to prophylactic antibiotic timing guidelines also improved.7
TEAMWORK AND SURGICAL OPTIMIZATION Mills et al12 examined the perceptions of teamwork among 300 surgical clinicians as part of a patient safety implications study. The researchers scored “perception of communication,” and physicians scored higher than nurses and anesthesia professionals combined. Findings suggest that the MTT was instrumental in identifying n
hidden communication problems among disciplines in the surgical setting and n efforts to improve communication and teamwork.12 Teamwork Paige et al6 improved OR teamwork in a rural community hospital by using the Structured Assessment Fostering Enhanced Teamwork Yield Preparation (SAFETY Prep) program. They used MTT processes and tools developed from randomized clinical trials and evaluated their effectiveness by using preintervention and postintervention questionnaires. Although the researchers noted improvements in the preoperative briefing and team interaction, they were unable to obtain statistical significance because of the small sample size. Implementation of a preoperative briefing enhanced team communication and interactions. These findings suggest that teamwork and patient safety can be improved in the perioperative environment, especially through effective use of the preoperative briefing.6 Awad et al3 also used the MTT evidence-based model developed from randomized clinical trials, and a change team implemented the training. To record and measure the effectiveness of team communication, researchers administered a survey to team members two months after the training was completed. The researchers noted improvement in communication between the anesthesia professional and surgeon. Findings from this study suggest that MTT using crew resource management principles can improve communication in the OR, thereby helping to ensure a safer environment and decrease adverse events. In addition, survey tool questions can aid in assessing the role of team communication in
www.aornjournal.org
reducing errors, improving surgical optimization, and eliminating patient risk by highlighting communication problems in the department.3 METHODS The following paragraphs discuss the design of the project, human protections guidelines, and sample size and composition. Additionally, the reliability and validity of the TeamSTEPPSeTeamwork Perception Questionnaire (T-TPQ) as well as data collection, analysis, and interventions are reviewed. Design This project was a descriptive preintervention and postintervention comparison of the perception of teamwork among GSST members. To measure the perception of teamwork and the effectiveness of TeamSTEPPS training, we used the T-TPQ, a selfreport tool that measures teamwork perception within a team, unit, or department. This instrument allowed GSST members to anonymously score performance measures related to perceptions of teamwork. Furthermore, the following performance measures could be used to compare changes in surgical optimization preintervention and postintervention: n n n n n
huddle and time-out compliance, the number of team members present, the first procedure in-room times, incision times, and turnover times.
This comparison was used to note improvements, address areas of concern, and compare with data from other military medical centers. The questionnaires had specific headings that identified the role of the team member (eg, surgeon, nurse). This identifier was helpful for grouping and comparing responses to identify whether a specific team role was experiencing challenges related to team skills or behavior that needed to be addressed. Terms associated with surgical procedure times in the OR (eg, turnover, in room, case times) may vary according to each institution’s definition. Our collected list of metrics for this project was developed and based on the literature review and AORN AORN Journal j 481
November 2014 Vol 100
TIBBSdMOSS
No 5
recommendations.11 We reviewed the measurable surgical procedure terms defining surgical times with GSST members to assist with capturing measurements accurately (Table 2). Next, we compared these data points with dashboard measurements from the 2014 Surgical Optimization and Standardization (SOS) report that highlighted surgical procedure times (ie, turnover time, in-room time, prime time minutes) for several military medical centers.8 There were no statistically significant differences between results from the project and any measures listed on the SOS report.
provided the study participants with a verbal and written description of the project, after which participants voluntarily provided their consent for participating. To meet IRB requirements for obtaining a Health Insurance Portability and Accountability Act waiver and informed consent, we provided participants with a written instruction sheet without requesting a signature or collecting identifiers. The project coordinators stored completed questionnaires in a secure file and placed data analysis on a password-encrypted computer, both of which were maintained in a locked office.
Human Protections We obtained approval to conduct this study from the University of Alabama Institutional Review Board (IRB) and the medical facility IRB. We
Sample Size and Composition We surveyed a convenience sample of 18 members of the GSST by using the T-TPQ, of which 12
TABLE 2. Procedural Terms and Definitions Used for Intervention Measurements Term In-room time First case
Incision time
Turnover time
Huddle compliance
Definition Time the patient enters the OR The first procedure scheduled for a 7:30 AM start in a room must be in the room before or by 7:30 AM Time of the initial incision
Time between procedures (ie, turning the room over)
Informal brief is performed before the procedure starts Final time-out compliance Reaffirming the surgical procedure, identifying patient information, ensuring availability of important diagnostic test results and interpretation by the appropriate person (eg, radiologist, cardiologist, pathologist) Team members present by The number of GSST members present for and number assigned to the surgical procedure Team Strategies & Tools to TeamSTEPPS system framework increases Enhance Performance and communication between team members and Patient Safety (TeamSTEPPSÒ) promotes patient safety, which includes huddles and preoperative and postoperative briefs TeamSTEPPS Teamwork An instrument that allows respondents to selfPerceptions Questionnaire report perceptions of teamwork within a unit or department
Method of measurement Time of day the patient enters the room Time of day the patient enters the room
Time the patient enters the room to the time the initial incision is made (in minutes) Time the previous patient exits the OR until the next patient enters the OR (in minutes) Yes (1) or no (2) Yes (1) or no (2)
1, 2, 3, or 4 GSST members present Yes (1) or no (2)
1 to 5 points per survey question (Likert scale) with a total of 35 questions (point range: 35 to 175)
TeamSTEPPS is a registered trademark of the US Department of Defense, Falls Church, VA, and the US Department of Health and Human Services, Bethesda, MD.
482 j AORN Journal
TEAMWORK AND SURGICAL OPTIMIZATION
www.aornjournal.org
preintervention (66%) and 14 postintervention (77%) questionnaires were completed and returned. The project participants included GYN surgeons, CRNAs, RN circulators, and scrub personnel. Of the 307 GYN surgical procedures performed during the intervention protocol period, 197 (64%) met the following inclusion criteria. A GYN surgical procedure was included if it
training in health care settings. To assess the effectiveness of this training, these organizations also developed the T-TPQ, an instrument for assessing five constructs related to teamwork: team structure, leadership, communication, mutual support, and situation monitoring. These organizations tested and refined the T-TPQ through cognitive interviews, a small group trial, and a field test followed by application of standard item statistics. The Cronbach alpha reliability coefficients for constructs ranged from 0.88 (communication) to 0.95 (leadership).5 The T-TPQ for our quality initiative consisted of questions for respondents to rank using a 5-point Likert scale (ie, “strongly agree” to “strongly disagree”). We administered the T-TPQ before and after the intervention period. The margin of error calculated for 12 participants was 28.3% with a mean of 0.50 (SD, 0.28; 95% CI, 0.22-0.78). To analyze the T-TPQ score responses, we used a hypothesis test rather than margin of error. Because one or more variables were not normally distributed with equal variances, we repeated the analysis using the nonparametric Mann-Whitney rank sum test for the T-TPQ responses.
n
was performed by a GYN surgeon; n had at least one GSST member present, which was usually the surgeon; n was scheduled as an elective procedure; and n was performed Monday through Friday between 7 AM and 5 PM. The data were documented into an inpatient electronic health record system by the RN circulator and into the surgery scheduling system (S3) by the statistical assistant. The S3 system is where the assistant inputs times from the nurse documentation. The statistical assistant provided us with a printout of GSST procedures without patient identifying information at the end of the project period for all procedures that met the criteria. All other surgical personnel and surgical procedures were excluded. We used a two-tailed independent sample t test to analyze the data. This test compares one group of the same subjects for a before-and-after intervention on one tail of the t distribution (ie, improve personnel perception of teamwork and optimize surgical workflow). The project coordinators used the IBMÒ SPSSÒ SamplePower version 2.0 to estimate the sample size needed for a power of 80% with a level of confidence of 95%. We estimated mean turnover time as 45 minutes from the 14 largest military treatment facilities listed on the SOS report, and the project coordinators determined that a 33% (15-minute) decrease in turnover time would be a significant improvement. Reliability and Validity In 2006, the Agency for Healthcare Research and Quality and the Department of Defense released TeamSTEPPS as the national standard for team
Data Collection The project coordinators collected surgical procedure times and compliance data during the 60-day protocol period from the electronic perioperative record documented by the RN circulator into the inpatient electronic health record system and the surgery scheduling system by the department’s statistical assistant. They verbally instructed the GSST members on the nature of the process improvement initiative and provided them with a written handout about the protocol. They also determined whether team members completed initial TeamSTEPPS training during the hospitalwide rollout or individual training during their hospital in-processing. All members of the GSST completed the T-TPQ in the seven days immediately preceding and following the intervention period. Members of the project team hand-delivered questionnaires to each GSST member and facilitated AORN Journal j 483
(2:29) (0.50) (0.38) (11.81) (21.36) (0.82)
> .05 > .05 .004 > .05 > .05 .038b
their return to a secured box located in the OR. The statistical assistant provided surgical times and compliance adherences at the end of the study for all included procedures during the 60-day protocol period. The project coordinators coded the data appropriately and entered it into SPSS.
(2:23) (0.50) (0.22) (13.70) (40.99) (0.74)
7:21 1:00 1:00 6:00 0:00
minutes minutes minute minutes minutes 1
16:33 minutes 2:00 minutes 2:00 minutes 81:00 minutes 81:00 minutes 4
10:17 AM 1.56 1.18 32.91 20.96 2.61
Data Analysis In this project, the independent variable was performance relative to an intervention (ie, before or after). The dependent variables were times measured in minutes (ie, in-room time, turnover time, surgery start time, incision time) and events (ie, time out, huddle) recorded as binomials (ie, yes/no). The number of team members present for each procedure also was noted. The expected outcome, as computed by descriptive statistics, was that there would be an improvement in time measurement and the number of team members present.
b
a
P values are for an independent sample t test unless otherwise noted. Mann-Whitney test.
9:51 AM 1.53 1.05 31.70 26.36 2.34 16:12 minutes 2:00 minutes 2:00 minutes 101:00 minutes 307:00 minutes 4 minutes minute minute minutes minutes 1 7:24 1:00 1:00 6:00 0:00
Minimum
TIBBSdMOSS
No 5
In-room time First case Final time out Incision time Turnover time Number of team members present
P valuea Minimum
Maximum
Mean (SD)
484 j AORN Journal
Maximum
Mean (SD)
Range Range
Before intervention (n ¼ 88)
TABLE 3. Comparison of Surgical Times Before and After Process Intervention
After intervention (n ¼ 109)
Significance
November 2014 Vol 100
Interventions As discussed, the interventions for this project were a specialty team protocol and algorithm. We reviewed the algorithm and protocol several times with the GSST members and OR assignment coordinator before the protocol start date. The protocol was explained to the surgeons, leaders, and management personnel and focused on obtaining their acceptance and support. Additionally, all OR personnel received inservice training on the protocol and algorithm. The project coordinators also placed a copy of the protocol and algorithm in each of the three GYN surgical suite binders. Using the algorithm and protocol as guides, the OR assignment coordinator made room assignments the day before, assigning any available GSST team member to the GYN room and the GSST manager to the core A or D. At the beginning of the shift, the surgical coordinator/operations officer reviewed patient data to ensure the patients met inclusion criteria indicated by the protocol and that the GSST manager was assigned to the core A or D to assist with setups, turnovers, and review of GSST case
TEAMWORK AND SURGICAL OPTIMIZATION carts. The project coordinators reminded the schedulers daily to assign as many GSST members as possible to GYN specialty procedures, which was necessary because of the frequent changes of personnel assigned to complete the staff assignment task. To overcome this challenge, members of the project team attached an updated list of GSST team members to the staffing scheduling sheet.
RESULTS The results of independent sample t tests for beforeand-after procedure times and Mann-Whitney test for total number of team members present (TMPNUM) are shown in Table 3. The variance between the group means was significantly different for final time out (P ¼ .004). The results shifted compliance documentation to the right, which resulted from a clarification of the definition and compliance standards for this measure. In addition, there was a statistically significant difference between groups in the number of team members present according to the results obtained from the Mann-Whitney rank sum test (P ¼ .038). The OR staff scheduler increased the use of specialty teams by placing more GSST members in their specialty room for GYN specialty procedures, which promoted teamwork, communication, optimization, and patient safety. The distribution graphs for final time out and team members present are shown in Figures 2 and 3, respectively. There was no statistically significant difference between groups (ie, before, after) for any items on the questionnaire. However, we identified two areas of improvement in core components in the perception of teamwork: staff members met to reevaluate goals when the situation changed (m ¼ 3.08 vs 3.64, P ¼ .126) and staff members corrected each other’s mistakes (m ¼ 3.42 vs 4.0, P ¼ .236). We noted the following changes regarding teamwork after the 60-day protocol period: n
GSST members described the experience as rewarding and voiced fewer complaints about their work environment.
www.aornjournal.org n
GSST members expressed a desire to continue using the algorithm and protocol. n We observed an increase in assistance between members during room procedure setup and breakdown.
Figure 2. Before the intervention, the number of times the final time out (FTO) recorded by the RN circulator as meeting compliance was 95.2%; after the intervention, the number meeting compliance dropped to 82.2%, which was statistically significant (P [ .004). This finding indicates that the intervention led to proper documentation of the FTO process.
Figure 3. The number of gynecology surgical specialty team members present for a gynecology procedure increased after the intervention, and this difference was statistically significant (P [ .038). This finding indicates that the OR staff scheduler increased the use of specialty team members, which promoted teamwork, communication, optimization, and patient safety.
AORN Journal j 485
November 2014 Vol 100
TIBBSdMOSS
No 5
KEY TAKEAWAYS FOR CLINICAL PRACTICE Using a Surgical Specialty Team Protocol and Algorithm Improves Turnover Time and Communication Why Did We Do This Research? n We conducted this quality improvement project to determine whether using a surgical team protocol and algorithm combined with TeamSTEPPSÒ could improve staff member perceptions of teamwork and improve gynecological surgical workflows.
What Did We Find? n The process improvement led to decreased turnover time between procedures. n Staff members had better perceptions of teamwork after the process improvement than they did before. n For each procedure, there were more team members present during procedures after the improvement process compared with before because the OR staff scheduler increased the use of specialty teams by placing more gynecology surgical specialty team members in their specialty room, which promoted teamwork, communication, optimization, and patient safety.
n Compliance with the final time out decreased after the
intervention, but we found that this was because team members better understood the definition of “final time out” as part of the process improvement and were more often documenting this compliance correctly. How Can Clinicians Use These Results? n Clinician: Perioperative team members should participate in team training, protocols, and algorithms to help make surgical processes more efficient and improve communication and work relationships for the perioperative team. n Manager: Managers should consider implementing team training, protocols, and algorithms as a way to optimize surgical processes as well as enhance communication and work relationships. n Educator: Educators should help personnel understand the components of and the reasons behind the use of huddles and time outs and work with them to find ways to improve these processes and patient care.
Tibbs SM, Moss J. Promoting teamwork and surgical optimization: combining TeamSTEPPS with a specialty team protocol. AORN J. 2014;100(5):477-488. Copyright Ó AORN, Inc, 2014.
n
Team members demonstrated more positive communication among themselves. n Complaints from the surgeons decreased from almost daily to two or fewer per week. n Other OR personnel voiced support of the specialty team concepts. Overall, the measures for turnover time are skewed because of the use of a stagger room model resulting in turnover time being reported as zero minutes. The expected outcome, as computed by descriptive statistics, was that there would be an improvement in time measurement and the number of team members assigned. The project coordinators determined that a 15-minute decrease in turnover time would be a clinically significant improvement for our facility because it was 50% less than our current average and could result in increased prime-time use of our surgical rooms and OR staff. 486 j AORN Journal
DISCUSSION Using a surgical specialty team protocol and algorithm, the GSST was able to decrease turnover time and improve communication between nursing personnel and surgeons. When the surgeons realized that they had specific team members assigned to their service, they did not want anyone else in their room. Project leaders and participants faced many challenges from instructors and the OR educator, who wanted their students and new employees to be assigned to those rooms to acquire more OR experience during the postintervention period. The project coordinators decided to remove the anesthesia professionals from the GSST because of their complex work schedules after the first two weeks of the postintervention period. Getting the same anesthesia professional for two consecutive days was nearly impossible. Based on the findings of this project, the OR leaders agreed to require the staff
TEAMWORK AND SURGICAL OPTIMIZATION scheduler to place members assigned to specialty teams in their team room whenever possible. To promote teamwork, GSST personnel were allowed time to attend GYN clinic meetings and training sessions to enhance team-building concepts. This was a great hit, especially with scrub personnel, because it improved knowledge and confidence. Despite all the planning, military training pulled away our GSST manager for two weeks and the anesthesia section chief could not support the GSST assignment with the same two providers for the entire protocol period.
www.aornjournal.org
Church, VA, and the US Department of Health and Human Services, Bethesda, MD. IBM SPSS SamplePower version 2.0 is a registered trademark of IBM, Armonk, NY. Disclaimer: The opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Air Force, Department of Defense, or the United States Government.
References
CONCLUSION Although the RN circulator’s and GSST manager’s ultimate goal is to provide a safe surgical environment, the findings from this project confirm that the perception of teamwork and communication are critical elements in promoting patient safety. Unfortunately, we are finding it almost impossible to implement the process initiatives (ie, protocol, algorithm) throughout perioperative services because of our military mission and 24-hour operation, which require perioperative personnel to provide OR support during a variety of surgical procedures 24 hours a day, seven days a week. The project won leadership support; however, management team members expressed a fear of violating union rules and contract inclusions if they altered the schedule or work assignments without proper notification. Nevertheless, everyone involved in this project agreed that we should continue to work toward implementing the process and using surgical specialty teams within the constraints of our facility’s mission. Acknowledgment: The authors thank John A. Ward, PhD, Department of Clinical Investigation, Brooke Army Medical Center, JBSA Fort Sam, Houston, TX, for his assistance with statistical data analysis and tabular formatting. Editor’s notes: TeamSTEPPS is a registered trademark of the US Department of Defense, Falls
1. Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg. 2009;198(5): 675-678. 2. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-142. 3. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5): 770-774. 4. Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010;145(6): 582-588. 5. TeamSTEPPSÒ: Strategies and Tools to Enhance Performance. Agency for Healthcare Research and Quality. http://www.ahrq.gov/teamsteppstools. Accessed July 12, 2014. 6. Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. Improved operating room teamwork via SAFETY prep: a rural community hospital’s experience. World J Surg. 2009;33(6):1181-1187. 7. Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Ann Surg. 2012;252(3):477-483. 8. Surgical Optimization and Standardization Dashboard. Washington, DC: US Army Medical Department; 2012. 9. Cvetic E. Communication in the perioperative setting. AORN J. 2011;94(3):261-270. 10. Universal protocol for preventing wrong site, wrong procedure, wrong surgery. The Joint Commission. http:// www.jointcommission.org/standards_information/up.aspx. Accessed July 12, 2014. 11. Human factors in health care tool kit. AORN, Inc. https:// www.aorn.org/Clinical_Practice/ToolKits/Human_Factors_ In_Health_Care_ToolKit/Human_Factors_in_Health_Care_ Tool_Kit.aspx. Accessed July 12, 2014. 12. Mills P, Neily J, Dunn E. Teamwork and communication in surgical teams: implications for patient safety. J Am Coll Surg. 2008;206(1):107-112.
AORN Journal j 487
November 2014 Vol 100
No 5
Sheila Marie Tibbs, DNP, RN, ACNS-BC, CNOR, Lt Col, USAF, NC, is the operating room services element chief for the 959th Medical Operations Squadron (AETC) of the Joint Base San Antonio at Fort Sam Houston, TX. Dr Tibbs has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
488 j AORN Journal
TIBBSdMOSS
Jacqueline Moss, PhD, RN, FAAN, is a professor and chair of the School of Nursing, Adult/Acute Health, Chronic Care and Foundations, at the University of Alabama at Birmingham. Dr Moss has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
