Perioperative Safety Culture

Contents

Foreword: Patient Safety in 2023: Developing a New Science in a Postpandemic

World xv
Lee A. Fleisher

Preface: Perioperative Safety Culture: Principles, Practices, and Pragmatic

Approaches xvii
Matthew D. McEvoy and James H. Abernathy III

Change Management and Health Care Culture 693

Maxamillian Solow and Tjorvi E. Perry
Change management in health care is the process of implementing new
policies, procedures, and practices in order to improve the quality of pa-
tient care. It involves understanding the need for change, identifying the
stakeholders involved, and developing a plan to implement and manage
the change. Change management in health care requires a comprehensive
and collaborative approach to ensure that changes are properly imple-
mented, communicated, and monitored. It is essential for health care pro-
viders to be aware of the current trends in health care and to stay up to
date with the latest technology in order to provide the best care possible.

Building Cultures of High Reliability: Lessons from the High Reliability

Organization Paradigm 707
Kathleen M. Sutcliffe
Safety models from disciplines outside of health care have begun to dif-
fuse into the health care safety arena. This article explores high reliability
organizing (HRO) theory, which privileges culture as means to adaptively
learn and reliably perform. A brief history of the HRO paradigm and factors
that contribute to cultures of high reliability is provided, followed by review
of existing research to discern which HRO ideas have diffused into re-
search on anesthesiology and perioperative care. High reliability research
is growing and concepts seem useful; but there is a long way to go before
the benefits of HRO are fully realized.

The Cognitive Basis for Human Error and the Best Practices to Reduce Error 719
Joyce A. Wahr
A great deal of knowledge exists about how to make health care safer than
it is currently. The tools exist but all too often, they are not implemented. All
anesthesia providers need to understand what safety best practices are
and continue to advocate for them in their workplaces.
x Contents

Just Culture: How Do We Address Risky and Unprofessional Behaviors that Lead to
Errors? 731
Amanda J. Rhee
Unprofessional behavior in the procedural arena is associated with worse
patient outcomes. This is thought to be due to breakdowns in communica-
tion structures and team dynamics. Behavioral issues are often uncovered
during the investigation of serious event reports. Understanding differen-
ces in behavior deviations enables leadership to best address each type
with an appropriate response. This allows institutions to address reckless
behavior and unprofessionalism, while concomitantly creating a culture
that fosters trust to promote self-reporting and sharing of information.
These are characteristics of high-reliability organizations that produce sus-
tained excellence in patient outcomes.

Patient Safety and Clinician Well-Being 739

Jina L. Sinskey, Joyce M. Chang, Amy C. Lu, and May C. Pian-Smith
Clinician well-being and patient safety are intricately linked. We propose
that organizational factors (ie, elements of the perioperative work environ-
ment and culture) affect both, as opposed to a bidirectional causal rela-
tionship. Threats to patient safety and clinician well-being include
clinician mental health issues, negative work environments, poor team-
work and communication, and staffing shortages. Opportunities to miti-
gate these threats include the normalization of mental health care, peer
support, psychological safety, just culture, teamwork and communication
training, and creative staffing approaches.

Perioperative Environment Safety Culture: A Scoping Review Addressing Safety

Culture, Climate, Enacting Behaviors, and Enabling Factors 755
Ellen J. Bass and Bat-Zion Hose
While there is an increasing interest in patient safety and in transforming safety
culture in the perioperative environment, it is not clear what methods are being
used to understand, assess, and influence safety culture and climate. This ar-
ticle seeks to uncover what instruments and measures are used to assess
safety culture and investigates how these measures are applied in baseline as-
sessments and interventions in the perioperative environment to enhance/
support safety culture. Study investigators are encouraged to collect and an-
alyze data about engaging in behaviors that prevent, respond to, or resolve
safety issues, and related factors that support understanding their effects.

Team Dynamics in the Operating Room: How Is Team Performance Optimized? 775
Scott C. Watkins and Nadia B. Hensley
Health care requires the effort of a team, and nowhere is this more evident than
in the care of the surgical patient. No single clinician can perform all aspects of
the continuum of surgical care. The basic operating room (OR) team consists
of nurses, technicians, surgeons, and anesthesiologists with unique and well-
defined roles and expertise in perioperative care. The modern OR team con-
tinues to grow and evolve in size, diversity, and complexity to meet the needs
of growing patient and procedural complexity. This growing complexity
makes achieving optimal team performance paramount and challenging.
 Contents xi

Safety in Health Care: The Impact of Operating Room Design 789

Timothy L. Heinke, Anjali Joseph, and David Carroll
The science of operating room design has grown over the past 20 years
due to the realization that the physical environment influences health
care provider performance and patient outcomes. Medical errors occur
when the normal workflow in an operating room is disrupted as providers
must overcome sub-optimal conditions. All aspects of the physical envi-
ronment can impact operating room flow. Studying the layout, contents,
ergonomics, and environmental parameters of the operating can lead im-
proved work conditions resulting improved patient and provider safety. At
the forefront of operating room design science is the use of simulation and
the evaluation of new technologies.

Nontechnical Skills for Intraoperative Team Members 803

Michael R. Mathis, Allison M. Janda, Steven J. Yule, Roger D. Dias,
Donald S. Likosky, Francis D. Pagani, Korana Stakich-Alpirez, Fiona M. Kerray,
Megan L. Schultz, David Fitzgerald, David Sturmer, Milisa Manojlovich,
Sarah L. Krein, and Matthew D. Caldwell
Nontechnical skills, defined as the set of cognitive and social skills used by
individuals and teams to reduce error and improve performance in com-
plex systems, have become increasingly recognized as a key contributor
to patient safety. Efforts to characterize, quantify, and teach nontechnical
skills in the context of perioperative care continue to evolve. This review
article summarizes the essential behaviors for safety, described in taxon-
omies for nontechnical skills assessments developed for intraoperative
clinical team members (eg, surgeons, anesthesiologists, scrub practi-
tioners, perfusionists). Furthermore, the authors describe emerging meth-
ods to advance understanding of the impact of nontechnical skills on
perioperative outcomes.

Coaching to Improve Individual and Team Performance in Anesthesiology 819

Laura Berenstain, Scott D. Markowitz, Samuel D. Yanofsky, and
Jamie McElrath Schwartz
In addition to medical knowledge and psychomotor skills, anesthesiology
practice requires the ability to work within a complex system, navigate so-
cial situations, manage conflict, and lead teams. Coaching has founda-
tions in psychology and adult learning theory and uses a process of
inquiry, reflection, and shared discernment to discover values, goals,
and solutions. There is increasing use and evidence for coaching in med-
icine and anesthesiology to support personal and professional growth. In-
dividual and group coaching for anesthesiologists may improve
anesthesiologists’ ability to communicate, collaborate and solve prob-
lems, improving well-being, culture, and plausibly, patient outcomes.

Systems of Care Delivery and Optimization in the Preoperative Arena 833

Elena J. Koepke, Cheryl Hilty Orr, and Jeanna Blitz
Key elements of an effective preoperative process include the following:
history-taking, risk assessment, shared decision making, effective inter-
disciplinary communication, preoperative optimization of modifiable
xii Contents

conditions, longitudinal care coordination, contribution to population

health aims, and collection of outcomes-driven metrics. Perioperative
medicine tenets can be applied by health systems of all sizes and demo-
graphics to improve quality and safety.

Systems Anesthesiology: Systems of Care Delivery and Optimization in the

Operating Room 847
Laure Cochand, Mark G. Filipovic, Markus Huber, Markus M. Luedi,
Richard D. Urman, and Corina Bello
Anesthesiology presents a challenge to a traditional simplifying approach
given the ever-increasing amount of medical data and a more demanding
environment. Systems anesthesiology is a modern approach to perioper-
ative care, integrating the complexity of multifactorial knowledge and data
to achieve a more adequate representation of reality, while including both
patient-related medical aspects as well as economic and organizational
challenges. We discuss the value of some innovative technologies such
as the emergence of anesthesia information systems, the use of tele-med-
icine, predictive monitoring, or closed-loop systems as it pertains to the
changes in the current standards of care in anesthesiology. Furthermore,
we highlight the importance of systems anesthesiology in operating
room planning, anesthesia research, and education.

Systems of Care Delivery and Optimization in the Intensive Care Unit 863
Christopher Patrick Henson and Sheena M. Weaver
As the volume and complexity of patients requiring intensive care grows,
so do the barriers and challenges to the delivery of that care. This article
summarizes these challenges, outlines strategies used to overcome
them, and presents new developments and concepts within the care of
the ICU patient.

Systems of Care Delivery and Optimization in the Postoperative Care Wards 875
Connor Snarskis, Arna Banerjee, Andrew Franklin, and Liza Weavind
A third of all patients are at risk for a serious adverse event, including
death, in the first month after undergoing a major surgery. Most of these
events will occur within 24 hours of the operation but are unlikely to occur
in the operating room or postanesthesia care unit. Most opioid-induced
respiratory depression events in the postoperative period resulted in death
(55%) or anoxic brain injury (22%). A future state of mature artificial intelli-
gence and machine learning will improve situational awareness of acute
clinical deterioration, minimize alert fatigue, and facilitate early intervention
to minimize poor outcomes.