Symposium explores teamwork in the OR
by Stephen J. Regnier, Editor
The Eleventh Symposium on the Operating Room Environment was presented April 30-May 1, 1999, in Chicago, IL, by the American College of Surgeons' Committee on the Operating Room Environment (CORE), in collaboration with the Association of PeriOperative Registered Nurses (AORN), and the American Society of Anesthesiologists (ASA).
The symposium is designed to improve communications among surgeons, operating room nurses, and anesthesiologists in the operating room (OR) environment to the ultimate benefit of the surgical patient. The symposium has been presented every other year since 1979.
This year's program was divided into a keynote address and five sessions that considered a range of issues related to optimizing the quality of the operating room by team participation. The program also included a session that allowed participants to consider OR-related "scenarios" in small-group discussion sessions.
Faculty for the symposium were recruited by the ACS, AORN, and ASA. The theme for this symposium was Optimizing the Quality of the Operating Room by Team Participation. A total of 106 registrants representing OR teams of surgeons, perioperative nurses, and anesthesiologists were in attendance.
Joseph LoCicero III, MD, FACS, associate professor of surgery, Harvard Medical School, Boston, MA, Chair of CORE, and symposium coordinator, welcomed the attendees and provided an overview of program sessions and their panelists.
A quality staff
Jeffrey Doty, MD, FACS, Vice-Chair of CORE, moderated the first session, which considered maintaining a quality OR staff. T. Forcht Dagi, MD, FACS, clinical professor of surgery, The Medical College of Georgia, Atlanta, spoke on conflict resolution in the OR. He outlined a framework for resolving conflict in the OR environment that includes setting priorities, eliciting "buy in" by concerned parties, developing principled approaches, finding creative solutions, and reaching a sustainable solution. "Sustainable solutions are enduring, they are effective—they do the right job—and they are efficient—they do the job right," he said. Dr. Dagi also presented a number of negotiation strategies wherein parties work among themselves, that focus on defining and soliciting needs, distinguishing issues, building relationships, delineating feasible negotiating ranges, exploring options, and working to close a negotiated agreement.
Jean Reeder, RN, PhD, chief of nursing, The Hospital for Sick Children, Toronto, ON, spoke on team decision making. The characteristics of the team decision making process, according to Dr. Reeder, must focus on the patient, sort out who's needs are being met, and clarify, confirm, and communicate decisions to appropriate people and groups. In order to function as an efficient team in the OR, surgeons, nurses, and anesthesiologists must know the purpose of the team and decisions to be made, must recognize and manage conflict, must show up for meetings and participate, must listen to the views of others, and must be willing to compromise. She also acknowledged the intergenerational issues involved with communication between "Baby Boomers" and "Generation X'ers."
Keynote address
Stephen K. Plume, MD, FACS, professor of surgery, Dartmouth Medical School, and president of Hitchcock Clinic, Lebanon, NH, presented the keynote address, titled "Models for Quality Improvement: Using Data to Influence Behaviors."
Dr. Plume noted that every system of data collection is perfectly designed to get the results that it actually gets. "If we want different results, we'll have to use different processes to create them," he said.
Dr. Plume stated that "the ultimate judges of the quality of our work are those we serve." These judges include increasingly well-informed patients, payors, and regulators. "We in the medical professions do not have an exclusive right to police ourselves or to dictate choice of treatment. If we don't figure this out, someone else will," he said.
According to Dr. Plume, collecting too much data related to quality improvement incurs many risks: the work of collection may preclude cooperation from those who have to do it; more data imply more errors collecting and recording it; data collection is expensive; and the credibility and importance of the effort is called into question if those individuals who are allegedly being helped by it see lots of unimportant or irrelevant elements.
"If we are trying to design a more perfect operating room, we simply must get everyone into the game, using process knowledge and quantitative data and simple analyses so that we can make many rapid-cycle, small-scale tests of change. Once we have successfully piloted changes that seem effective in a local setting, we can generalize them across our practices, across our institutions, and across the practice of medicine everywhere," Dr. Plume concluded.
The right products
Kenneth K. Meyer, MD, FACS, Sayre, PA, served as moderator for the third session that focused on getting the right products at the right time, place, and price.
Rosemary Grandusky, RN, CNOR, vice-president/consulting, Higman Healthcare, Rochester, NY, spoke on preference versus procedure cards. She noted that definitions of procedure cards and preference cards are institution- specific, and are key to supply management in the OR. Whether they are automated or manual, the cards should be accurate, comprehensive, logical, timely, and follow a uniform format. Ms. Grandusky discussed protocol development and standardization techniques that result in increased accuracy and cost savings in the OR.
Jeffrey Doty, MD, FACS, clinical associate professor of surgery, Stanford University School of Medicine, San Jose, CA, addressed the ongoing debate surrounding disposable versus reusable supplies in the operating room. Dr. Doty noted that the use and reuse of disposable equipment is a complex and controversial topic involving numerous factors, including patient health and safety, costs, liability, relations with industry, and environmental concerns. "Converting to reusable equipment entails a significant capital investment that may be hard to justify; thus, continued use of disposables that have a lower per item cost is perpetuated. However, as capitation and DRG reimbursement becomes universal, charges for individual items are irrelevant and a long-term perspective on costs is necessary," Dr. Doty said.
Despite the lower cost and improved functionality of modern reusable laparoscopic instruments, for example, Dr. Doty said that many surgeons remain committed to disposables. He believes this commitment is due largely to force of habit—it is not so much an economic or environmental issue but a behavioral one and the challenge is in how to alter the surgeon's behavior.
Dr. Doty noted that as health care reimbursement continues to shrink and patient demand and new technology increase, medical device manufacturers will need to develop instruments that can be reused. "As the consumers/purchasers of medical devices in this era of DRG reimbursement, our continued reliance on single use devices will not be economically feasible," Dr. Doty said. "Manufacturers need to become incentivized and those that develop and produce multiple use devices will have a competitive advantage and it will be more cost- effective for us to use their products," he concluded.
Dr. LoCicero spoke on product standardization, a subject that he believes is a source of constant frustration in the interaction between today's medical staffs and medical administration. He stated that in this age of financial constraints, staying on the cutting edge of medical technology is problematic, especially with the emergence of large purchasing groups that may lessen local autonomy to specify medical equipment in favor of decreasing costs of other medical supplies.
Dr. LoCicero proffered that medical staff and administration must act as partners in evaluating expensive new technology. "A product evaluation committee, composed of many disciplines—including physicians and surgeons, nurses, biomedical engineers, maintenance personnel, and administrators—is an ideal venue for developing the type of teamwork necessary to succeed," he said.
Dr. LoCicero concluded by stating that hospital staffs must become proactive to provide an environment in which all feel that the best and most appropriate equipment is available for proper medical care. When changing to new technology, he believes that the best way to achieve consensus is through a local trial in which all OR staff can fairly evaluate the product or equipment in detail and have the opportunity to report their findings to the hospital administration.
Improving processes
Karen S. Williams, MD, Mitchellville, MD, served as moderator of the fourth program session, which addressed improving processes in the OR.
Ronald C. Merrell, MD, FACS, chief of surgery, Yale-New Haven Hospital, New Haven, CT, spoke on OR time utilization. Dr. Merrill stated that OR time is a valuable commodity that only generates income when it is in use. He described his experience with time utilization at the Yale-New Haven Hospital—a general hospital that is affiliated with the Yale School of Medicine. There are 26 operating rooms at the facility, performing over 23,000 operations a year.
During a seven-year period, the hospital was able to increase caseload, decrease length of stay, use fewer resources, and obtain greater patient satisfaction through a vigorous time utilization program. The program dealt with issues related to access, management of time, monitoring procedures and outcomes, and discipline.
"Our experience showed that it is easier to manage policies than crises, and that successful management is nourished by information, guided by planning, and sustained by reflection," Dr. Merrell said.
Muriel Shewchuk, RN, administrative leader for surgical services, Calgary Regional Health Authority, Calgary, AB, spoke on computerizing the OR. In order to advance to the higher levels of computerized integration,complex interfacing, reporting, statistical analysis, and benchmarking a specific project development process must be used, she said.
The key elements to develop and successfully implement an integrated OR computer program, according to Ms. Shewchuk, include: (1) a steering committee with membership including director of information services(IS) , senior administration, chiefs of surgery and anesthesia, director of surgical services/OR, and project team leader, (2) a project team leader with previous experience in IS project management and excellent communication/team leadership skills, (3) a surgical services/OR director who knows the magnitude of the computerization process and is able to appropriate expert OR staff with committed time to carry through the project, (4) a systems administrator/analyst who fully understands the "business" of the OR, and (5) membership from interdepartmental areas such as admitting, discharge transfer, health records, finance, staffing/workload, anesthesia, central processing, purchasing, and inventory.
Ms. Shewchuk also addressed aspects of vendor selection, scheduling of patients and surgeons, preoperative/intraoperative/postoperative data collection, and establishing benchmarks of best practice.
Cynthia C. Spry, RN, AORN liaison to CORE, New York, NY, spoke on sterilization and instrument processing challenges in today's OR. She noted the development of a sterilization system that is appropriate and safe for endoscopic instrumentation and reduces processing times to a level that permits multiple uses of heat and moisture sensitive items during a single day. OR managers now have options that permit sterilization of endoscopic instrumentation, as opposed to high level disinfection that was used by necessity in the past. Ms. Spry stated that sterilization will increasingly move from:
- low technology, such as dry heat and ethylene oxide, to high technology, such as plasma and ozone;
- long processing times of six hours or ore to shorter processing times of less than one hour;
- high temperatures to low temperature;
- limited material compatibility to improved material compatibility; and
- alkylating chemicals, such as ethylene oxide and Formaldehyde (used in other parts of the world) to oxidizing chemicals, such as hydrogen peroxide, peracetic acid, chlorine dioxide, and ozone.
Ms. Spry described the benefits and disadvantages of the two most recent introductions to the sterilization device market—a liquid peracetic acid sterilizer and a hydrogen peroxide gas plasma sterilizer.
The regulated OR
Jonathan R. Hiatt, MD, FACS, Los Angeles, CA, served as moderator of the fifth session, which examined OR regulations and regulatory agencies.
Nancy M. Quick, a certified industrial hygienist with the Occupational Safety and Health Administration (OSHA), Des Plaines, IL, spoke on current OSHA standards regarding technology and chemical agents in the OR. In particular, she reviewed sections of the OSH Act of 1970, General Duty Clause 5 (a) (1) as they pertain to safety hazards attendant to laser plume.
Robert B. Smith III, MD, FACS, John E. Skandalakis Professor of Surgery, Emory University School of Medicine, Atlanta, GA, and member, board of commissioners, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), spoke on the Joint Commission's standards on environment of care as they pertain to the OR. Dr. Smith said that JCAHO's 500 standards for hospitals has numerous requirements regarding the OR that are grouped within seven functional areas: patient safety, security, hazardous materials and waste, emergency preparedness, life safety (of entire OR unit), medical equipment, and utility systems.
Dr. Smith told the attendees that certain areas of health care organizations will likely receive increased scrutiny by Joint Commission surveyors in 1999. These areas include staffing levels and competencies, control of high- risk medications, oversight of contracted services, and year 2000 preparation. In hospitals, areas most likely to be addressed include orientation of temporary staff, infection control practices, supervision of house staff, and securing and use of information from autopsies.
Karen S. Williams, MD, chief of anesthesia/surgical services, National Institutes of Health, Bethesda, MD, spoke on practical aspects of implementing JCAHO standards. In particular, Dr. Williams outlined the application of standards in three areas of increasing importance to OR personnel: competency- based training, conscious sedation, and securing medications and intravenous supplies.
When attempting to develop practical, consistent applications of JCAHO standards, Dr. Williams said, goals should include not only satisfaction of the intent of the standards, but also policies and procedures to facilitate or improve operational flow and patient care.
Kenneth K. Meyer, MD, FACS, adjunct scientist, Guthrie Foundation for Research, Sayre, PA, spoke on the process for medical device reporting. Dr. Meyer indicated that two processes are involved in medical device failure reporting: (1) tracking, which starts when the device is manufactured, continues with distribution, and culminates with the use of the device in or on a patient, and (2) reporting of an adverse event, which should occur whenever a patient is hurt by a malfunction of the device, regardless of the length of time the device has been implanted or, for support devices, how long they have been in use on the patient.
Dr. Meyer summarized procedures for tracking devices in the OR and for reporting adverse events. All reporting may now be done electronically on the Internet.
Improving patient care
Cynthia Spry moderated the sixth session, which examined improving patient care through participation.
Linda K. Groah, RN, nurse executive, Kaiser Foundation Hospitals, San Francisco, CA, spoke on using feedback for the improvement of performance in the OR. She defined "feedback" as the return of information to the source of a process or action for the purpose of control or correction. With regard to measures of performance in the OR, Ms. Groah discussed issues attendant to availability and timeliness of service, effectiveness of service, continuity of service, patient and staff safety, and involvement of the patient and family in their care and service decisions.
Ms. Groah emphasized that the only reason to collect data is to take action: make informed judgments about existing processes, identify opportunities for improvement, identify areas for more focused data collection, identify the need to redesign processes, and identify if improvements met objectives and were sustained.
Ms. Groah discussed evaluating performance data from three perspectives: (1) internally over time, (2) comparison with data and processes in other like organizations, and (3) benchmarking, or comparing with external sources or information—current scientific literature, practice guidelines or parameters, performance measures, reference databases, and standards form professional organizations.
Kevin Tremper, MD, PhD, professor and chair, department of anesthesiology, University of Michigan Health System, Ann Arbor, MI, spoke on clinical pathways and perioperative evaluations.
Dr. Tremper provided an overview of the progress that has been made over the past decade in implementing various testing protocols for comprehensive preoperative evaluation. He discussed the advantages of using electronic patient questionnaires to assist preoperative evaluation, including the retrieval of data from multiple locations and use of more complex logic than paper forms.
Dr. Tremper noted that incorporating the patient into the process of perioperative evaluation presents a unique opportunity to elicit the patient's preferences regarding perioperative care. Recent studies, he said, have demonstrated that patients' attitudes regarding perioperative care (for example, hospital admission versus home care) are well correlated with their attitudes assessed perioperatively. "As our knowledge of outcome data becomes more comprehensive, it is clear that must be involving the patient more extensively in the choices regarding his or her perioperative care," Dr. Tremper said.
Fran Koch, RN, administrative director of OR, Presbyterian Hospital of Dallas, Garland, TX, spoke on the impact of improving patient care on OR staffing. She provided a historical overview of assistants in surgery, beginning in the mid-1960s when John Kirklin, MD, conceived the idea of physician's assistants.
Ms. Koch stated that although there is an increased demand to assist surgeons in the OR, confusion still exists over who should assist and what duties this individual should have. Issues regarding reimbursement and credentialling of assistants in surgery are still being hashed out at the state level, and there is a paramount need to define the role of the surgical assistant, she said.
Scenarios
Dr. LoCicero moderated the seventh program session, which was devoted to reports by the breakout discussion groups on 16 OR scenarios that were preselected by members of CORE and the CORE liaisons. The scenarios were intended to reflect "real-life" situations encountered in the OR.
The scenarios included: design of a dedicated endoscopic suite, documentation of credentialling, fires in the OR, prioritizing new capital equipment purchases, rain in the OR, cardiac arrest in a freestanding ambulatory surgical center, power failure, wound infection outbreak, high risk in ambulatory surgery, the impaired OR member, surgical gloves, and wrong site surgery.
Creativity/innovation
Dr. LoCicero moderated the eighth and final program session, which featured a provocative presentation by Jane C. Rothrock, RN, professor and director of perioperative programs, Delaware County Community College, Media, PA, who spoke on "Perfection—Maybe. Creativity and Innovation—Definitely."
Ms. Rothrock explored the concept of creativity and energy of innovation, identifying strategies to facilitate creative and inventive opportunities in the OR. "Successful OR teams must strive toward innovation, fresh solutions, and the creative ability to dream up new approaches—it's really not an option anymore," she said.
She described the characteristics of adaptive thinking (follow established patterns, well-organized, goal-focused, work on one task at a time, satisfied when task completed) versus innovative thinking (use different methods to obtain results, appear disorganized, involved with more than one project at a time, value process more than goal).
Ms. Rothrock defined an idea as a new combination of old elements. She outlined four basic steps on how to approach a problem creatively: (1) define the problem, then ask it as a question. Different questions yield different answers and different solutions; (2) ga ther information—it is the springboard of all decision making; (3) search for the idea, condition your mind to consider "unstuck the rut" behaviors; and (4) put the idea into action—if you can think it, you can probably do it.
"The OR team should always wear bifocals: keep their eyes on the road they presently are on while always scanning the horizon for new opportunities," she concluded.
The committee
The current members of CORE are: Joseph LoCicero III (Chair), Boston, MA; Jeffrey E. Doty, MD, FACS (Vice-Chair), San Jose, CA; Ramon Berguer, MD, FACS, Martinez, CA; Quan-Yang Duh, MD, FACS, San Francisco, CA; Donald E. Fry, MD, FACS, Albuquerque, NM; Jonathan R. Hiatt, MD, FACS, Los Angeles, CA; Rene Lafreniere, MD, FACS, Calgary, AB; James T. Lee, MD, FACS, St Paul, MN; Christopher R. McHenry, MD, FACS, Cleveland, OH: Kenneth K. Meyer, MD, FACS, Sayre, PA; H. David Reines, MD, FACS, Newton, MA; Robert V. Rege, MD, FACS, Chicago, IL; Richard J. Shemin, MD, FACS, Boston, MA; and Nathaniel J. Soper, MD, FACS, St. Louis, MO. Senior Members: Maria Allo, MD, FACS, San Jose, CA; James M. Becker, MD, FACS, Boston, MA; Lazar J. Greenfield, MD, FACS, Ann Arbor, MI; Joyce A. Majure, MD, FACS, Lewiston, ID; and Gordon L. Telford, MD, FACS, Milwaukee, WI. Liaison Members: A. Gerson Greenburg, MD, FACS, Providence, RI; Cynthia C. Spry, RN, MA, MSN, CNOR, New York, NY; and Karen S. Williams, MD, Mitchellville, MD.