A 1999 Institute of Medicine (IOM) report, To Err Is Human, disclosed that up to 98 000 deaths occurred annu- ally in US hospitals because of medical errors.1 Since that initial report, many organizations, including the World Health Organization, the Joint Commission, the Institute for Healthcare Improvement, and the Accreditation Council for Graduate Medical Education (ACGME), have concurred with the critical need for improved com- munication and teamwork to prevent medical errors and promote patient safety.2-5 The IOM advocated training in team behavior, leadership, and communication, which has been adapted from programs in the aviation industry called crew resource management.

American Journal of Medical Quality 2016, Vol. 31(5) 408 –414 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860615583671 ajmq.sagepub.com

Article

A 1999 Institute of Medicine (IOM) report, To Err Is Human, disclosed that up to 98 000 deaths occurred annu- ally in US hospitals because of medical errors.1 Since that initial report, many organizations, including the World Health Organization, the Joint Commission, the Institute for Healthcare Improvement, and the Accreditation Council for Graduate Medical Education (ACGME), have concurred with the critical need for improved com- munication and teamwork to prevent medical errors and promote patient safety.2-5 The IOM advocated training in team behavior, leadership, and communication, which has been adapted from programs in the aviation industry called crew resource management.6 The concept pro- motes a team approach in the operating room by opening channels of communication during formal preoperative and postoperative briefings among health care profes- sionals to improve patient safety.

In 2006, the collaborative efforts of the Agency for Healthcare Research and Quality and the Department of Defense produced an evidence-based resource for team training in health care.7,8 Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) adopts crew resource management strategies by imple- menting preoperative and postoperative briefings and encourages situational awareness and communication by all members of the health care team.9,10

As a quality improvement and patient safety project, urology residents at the study medical center participated in leading the preoperative and postoperative briefings during the past year when TeamSTEPPS was imple- mented in the operating rooms throughout the Department of Surgery, including all surgical subspecialties. The pur- pose of this project was to evaluate the operating room efficiency and patient safety level within the urology ser- vice related to improved channels of communication among operating room personnel during the first year of implementation of TeamSTEPPS.

Methods

The study organization’s institutional review board approved this study as a performance improvement proj- ect. All health care personnel in the operating room accomplished TeamSTEPPS training, which included didactic-based modules on the 4 core competencies: leadership, situation monitoring, mutual support, and

583671 AJMXXX10.1177/1062860615583671American Journal of Medical QualityWeld et al research-article2015

1San Antonio Military Medical Center, Fort Sam Houston, TX

Corresponding Author: Thomas E. Novak, MD, MCHE-SDU, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234. Email: [email protected]

TeamSTEPPS Improves Operating Room Efficiency and Patient Safety

Lancaster R. Weld1, Matthew T. Stringer, DO1, James S. Ebertowski, MD1, Timothy S. Baumgartner, MD1, Matthew C. Kasprenski, MD1, Jeremy C. Kelley, DO1, Doug S. Cho, MD1, Erwin A. Tieva, MD1,

and Thomas E. Novak, MD1

Abstract The objective was to evaluate the effect of TeamSTEPPS on operating room efficiency and patient safety. TeamSTEPPS consisted of briefings attended by all health care personnel assigned to the specific operating room to discuss issues unique to each case scheduled for that day. The operative times, on-time start rates, and turnover times of all cases performed by the urology service during the initial year with TeamSTEPPS were compared to the prior year. Patient safety issues identified during postoperative briefings were analyzed. The mean case time was 12.7 minutes less with TeamSTEPPS (P < .001). The on-time first-start rate improved by 21% with TeamSTEPPS (P < .001). The mean room turnover time did not change. Patient safety issues declined from an initial rate of 16% to 6% at midyear and remained stable (P < 0.001). TeamSTEPPS was associated with improved operating room efficiency and diminished patient safety issues in the operating room.

Keywords TeamSTEPPS, medical errors, communication, operative briefings

Weld et al 409

communication. TeamSTEPPS was implemented throughout the Department of Surgery in the operating rooms in November 2013. For each operating room, a preoperative briefing was conducted in the operating room 30 minutes prior to the planned start time for that room. The briefings typically lasted 5 to 10 minutes and covered pertinent aspects of all cases planned for the day (Table 1). The attending and resident urologists, anesthesiologist or nurse anesthetist, circulating nurse, surgical technician, and various other trainees attended the briefings. The team also attended a postoperative briefing (Table 1) following each case before leaving the operating room, usually during patient arousal; these briefings lasted less than 5 minutes. During the “con- cerns” section of the postoperative briefing, health care team members identified any potential or realized patient safety issues. Issues were annotated and reported to the department chief to identify root causes and trends, and to administer corrective actions. The briefings were led by the resident urologist assigned to the operating room under direct supervision of the attending urological surgeon.

Patient movement from the pre-anesthesia unit through the operating room and back to the postanesthesia unit was timed and documented in the anesthesia record. The “anesthesia start to in-room time” was the time that the anesthesia representative took from first seeing the patient in the pre-anesthesia unit until the patient entered the operating room. The “in-room to turn-over-to-surgeon time” was the time that the anesthesia representative needed to induce anesthesia and allow the surgical team to begin positioning and preparing the patient. The “turn- over-to-surgeon to surgical start time” encompassed the time from when the anesthesia team turned the case over to the surgeon until the surgeon actually started the case. The “surgical time” only included the time from proce- dure start to finish and did not include anesthesia induc- tion, patient positioning and preparation, or arousal from anesthesia. The “case time” is the sum of all previously described times starting when the anesthesia team first saw the patient in the pre-anesthesia unit until the case completed. An on-time start was defined as the patient entering the operating room with an anesthesiologist or nurse anesthetist prior to or at the planned start time, typi- cally 7:30 am. An operating room turnover time was defined as the time between the patient leaving the oper- ating room and the next patient entering the room.

A database was retrospectively constructed of all per- tinent times for all urology cases from November 2012 to October 2013, prior to TeamSTEPPS implementation, to serve as a baseline cohort. Operative times also were recorded for all urology cases after implementation of TeamSTEPPS from November 2013 to October 2014. Each postoperative debriefing that raised patient safety

issues was categorized as being personnel, instrument/ equipment, or support service (pharmacy/radiology/lab- oratory) related. Personnel-related incidents included issues such as unfamiliarity with the procedure or equip- ment that affected patient safety. Instrument and equip- ment issues typically involved incorrect instruments or instrument sets and equipment malfunctions. For exam- ple, some of these issues resulted in potential or realized patient safety issues related to visibility during endo- scopic procedures or control of hemorrhage. Support service issues generally involved slow responses to requests during surgery resulting in prolonged anesthesia

Table 1. Briefing Checklists.

Preoperative Briefing Team introductions Surgeon: • Procedures and plan for the day • Instruments/supplies not normally used • Expected specimens/implant verification • Critical moments of the case (eg, no counting, lunch

breaks) • Potential complications/blood loss • Special requests (eg, X-ray, equipment representatives) • Postoperative plan (eg, PACU, ICU) • Concerns Anesthesia: • Antibiotics • Allergies • Anesthesia plan • Blood availability • Concerns Nurse/technician: • Equipment/instrument/supplies/implants • Contact precautions • Correct bed • Positioning • Concerns

Postoperative Debrief Technician/nurse: • Counts correct • Wound classification • Medications • Concerns Anesthesia: • Verify postoperative plan • Concerns Surgeon: • Procedures performed • Verify specimens • Verify implants • What went right/wrong • Concerns

Abbreviations: ICU, intensive care unit; PACU, postanesthesia care unit.

410 American Journal of Medical Quality 31(5)

time, which exposed the patient to unnecessary risks. Additionally, each identified patient safety issue was fur- ther categorized as potential or realized. Potential issues were defined as events that occurred with no resultant adverse patient outcome but that could cause complica- tions under different clinical circumstances. Realized issues were defined as events directly related to adverse patient outcomes.

To evaluate operating room efficiency data, statistical comparisons with the appropriate t test or χ2 test were made between cases with TeamSTEPPS versus before TeamSTEPPS. For patient safety data, a χ2 test was per- formed comparing patient safety issues from the first 6 months of the year during TeamSTEPPS implementation to issues during the second 6 months. The result of a χ2 test performed to compare patient safety issues during the first month of TeamSTEPPS implementation (November 2013) to issues at midyear in May 2014 is reported in Figure 1.

Results

A total of 1481 cases with TeamSTEPPS and 1513 cases before TeamSTEPPS were compared. Table 2 shows the cases performed and categorized by procedure type and ACGME category with and before TeamSTEPPS. Also, cases were categorized by first-start cases, turnover cases, and add-on urgent cases. The distribution of cases in all

categories is similar between years with and before TeamSTEPPS.

Table 3 shows the operating room efficiency data with and before TeamSTEPPS. The mean in-room to turn- over-to-surgeon time, mean turn-over-to-surgeon to sur- gical start time, mean surgical time, and mean case time were significantly shorter with TeamSTEPPS. The mean case time including anesthesia and surgical time decreased by 10.1% with TeamSTEPPS. The on-time first-start rate was significantly higher with TeamSTEPPS. The mean late interval for first-start cases and mean turnover time was similar before and with TeamSTEPPS.

Table 4 shows the patient safety data categorized by potential versus realized issues and by source of issue (personnel, instrument/equipment, or support service related). The data are divided into issues that occurred during the first 6 months of TeamSTEPPS implementa- tion and issues during the second 6 months. The inci- dence of patient safety issues (combined potential and realized) and the incidence of realized issues decreased significantly. The incidence of potential issues was statis- tically similar.

Figure 1 illustrates the percentage of cases during which a potential or realized patient safety issue was identified by month. The numerator is the number of operative cases with one or more potential or realized issues reported during the respective month, and the denominator is the total number of operative cases for

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Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

% P

at ie

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Figure 1. Percentage of potential or realized patient safety issues by source category identified at TeamSTEPPS postoperative briefings by month. Abbreviation: TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

Weld et al 411

Table 2. Surgical Case Distribution.

Number of Cases Before TeamSTEPPS

Number of Cases With TeamSTEPPS

Total Number of Cases

Procedure type Endoscopic/ESWL 855 839 1694 Laparoscopic/robotic 114 103 217 Open 544 539 1083 ACGME category ESWL 24 20 44 Female 50 75 125 General 4 65 109 Male urethra 43 32 75 Pediatric major 26 25 51 Pediatric minor 171 167 338 Pelvic oncology 70 62 132 Penis 35 36 71 Percutaneous 30 15 45 Prostate biopsy 27 26 53 Retroperitoneal oncology 75 59 134 Scrotal/inguinal 164 153 317 Transurethral 447 396 843 Ureteroscopy 307 350 657 Totals 1513 1481 2994 First-start cases 479 457 936 Turnover cases 861 851 1712 Add-on urgent cases 173 173 346

Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; ESWL, extracorporeal shock wave lithotripsy; TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

Table 3. Operating Room Efficiency Data.

Before TeamSTEPPS With TeamSTEPPS P Value

Mean anesthesia start to in-room time (minutes) 10.97 11.30 .200 Mean in-room to turnover-to-surgeon time (minutes) 14.45 13.75 .017a

Mean turnover-to-surgeon to surgical start time (minutes) 16.29 15.19 .004a

Mean surgical time (minutes) 83.45 72.23 <.001a

Mean case time (minutes) 125.16 112.47 <.001a

On-time first-start rate 48.9% 69.8% <.001a

Mean late interval for first-start cases (minutes) 12.46 14.54 .212 Mean turnover time (minutes) 41.48 40.49 .193

Abbreviation: TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety. aStatistically significant.

that month. In the initial month of TeamSTEPPS, the overall rate of patient safety issues was 15.8%. The rate declined to 6.2% at midyear and remained near that rate for the remainder of the year (P < .001). The most sub- stantial improvement was realized in the instrument/ equipment category.

Discussion

Barriers to the implementation of TeamSTEPPS in the operating room include concerns about time requirements

for the briefings. The preoperative briefings took place in the operating room 30 minutes prior to the planned start time for that room and lasted 5 to 10 minutes. The post- operative briefings occurred after each case during patient arousal from anesthesia and lasted less than 5 minutes. Therefore, additional provider time was only required for the preoperative briefings.

Physicians, nurses, and technicians are trained in sepa- rate, diverse educational programs that teach attention to details regarding their specific roles. Given the interdisci- plinary nature of health care, communication is critical to

412 American Journal of Medical Quality 31(5)

ensure patient safety. Teams make fewer mistakes than individual members when each team member accepts his or her responsibilities, knows the responsibilities of other team members, and feels comfortable communicating to those other members.11,12 TeamSTEPPS provides a framework to foster communication about patient care issues regardless of role or position in the operating room. Nonetheless, as with pilots leading crew resource man- agement strategies among crew members, the surgeon remains the leader of the operating room and is respon- sible for establishing an open environment conducive to communication by all operating room health care mem- bers.13 This leadership skill involving communication is essential to patient safety and can be taught to surgical residents simultaneously with the technical skills required for surgery.

Operating room efficiency is increasingly used as a marker of quality of surgical care. Operating room time is estimated to cost $15 per minute and constitutes approxi- mately 40% of hospital revenue.14 As a result, efforts to improve quality in the hospital setting are often focused on reducing preventable delays and increasing effi- ciency.15 Nundy et al associated operating room briefings with a 31% reduction in operating room delays.16 The cur- rent study showed an average reduction of 10% in overall case time with TeamSTEPPS, and the on-time first-start rate increased from 49% to 70% with TeamSTEPPS. Turnover time did not improve with TeamSTEPPS possi- bly because of minimal impact of improved team com- munication on the processes involved in room turnover, such as housekeeping and instrument sterilization, which require a fixed interval of time. Improved efficiency and capacity allows more operations to be performed during the daytime, when personnel familiar with the scheduled cases are readily available. Fewer operations are per- formed at night, when teams unfamiliar with one another

are more likely to work together. Thus, TeamSTEPPS has the potential to improve both quality and safety while increasing efficiency and creating a more predictable work environment.

The implementation of TeamSTEPPS is the most likely factor resulting in the improvement in operating effi- ciency. The Department of Urology experienced minimal turnover in surgical staff, with all subspecialties of urol- ogy offered throughout the 2-year study period. Also, the beneficiaries of medical care at the military medical cen- ter study site consist of a relatively fixed patient popula- tion. Additionally, there were no other significant changes in facilities, administrative policies, or services offered to the patient population to account for a change in effi- ciency. To further analyze the impact of TeamSTEPPS on operating room efficiency, operating room data from another comparable service were evaluated. The most comparable service to urology in terms of numbers of sur- geons and operative case load at the study medical center is the Department of Orthopedics. The orthopedic mean surgery time the year prior to TeamSTEPPS was 115 min- utes compared to 96 minutes the year TeamSTEPPS was implemented (P < .01). This 19-minute improvement on average per orthopedic case was similar to the 11-minute improvement realized by the urology service. In terms of on-time first-start rates, the orthopedic rate improved from 63% to 75% of first cases starting on time with TeamSTEPPS implementation (P = .01). By comparison, the urology service experienced an improvement from 49% to 70% of first cases starting on time. These similar improvements in the Department of Orthopedics opera- tive data at the medical center further support the impact of TeamSTEPPS on operating room efficiency.

Literature supporting the patient safety benefits of operative briefings is plentiful. Preoperative briefings have been shown to reduce medical errors.17-19 Multiple

Table 4. Patient Safety Data.

First 6 Months With TeamSTEPPS Second 6 Months With TeamSTEPPS P Value

Total number of cases 699 782 Patient safety issues 73 (10.4%) 43 (5.4%) .022a

Potential issues 34 (4.9%) 27 (3.5%) .610 Personnel 12 11 Instrument/equipment 13 13 Support services 9 3 Realized issues 39 (5.6%) 16 (2.0%) .004a

Personnel 16 9 Instrument/equipment 19 7 Support services 4 0

Abbreviation: TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety. aStatistically significant.

Weld et al 413

studies show that briefings improve team communica- tion, cohesion, and interprofessional insight.20,21 Operating room staff report increased confidence to voice a concern about potential patient safety issues when brief- ings are held.16 Postoperative briefings offer benefit through reflective learning, deliberate practice, and immediate feedback.22 The current study demonstrated a reduction in overall patient safety issues and realized issues over the course of the first year since TeamSTEPPS implementation. The rate of potential patient safety issues was unchanged from the first half of the year to the sec- ond. Patient safety issues related to surgical instruments and equipment accounted for 51% of all reported patient safety issues, which is comparable to a recent article reporting 63% of issues related to instruments and equip- ment.22 The current study realized the most substantial improvement within the surgical instruments and equip- ment category. Surgeons utilized the postoperative brief- ing reports to elevate instrument or equipment problems to hospital leadership for prompt attention. Ironically, as surgery adopts more technically advanced tools such as fiber optics and robotics, the present study suggests that a basic proficiency of communication among operating room personnel about those instruments and equipment actually improves patient safety.

TeamSTEPPS promotes a culture of safety by encour- aging communication. A growing confidence to commu- nicate among health care personnel signals that patient safety is truly valued.18,21,23,24 Characteristics of a strong culture of safety include a commitment to discuss and learn from patient safety issues and incorporation of a nonpunitive system for reporting and analyzing issues.

This study was limited to cases performed at a large teaching medical center. As such, dedicated urology nurses and technicians are not available for every urology case. The findings of increased operating room efficiency with improved communication may not be applicable to institutions that always have dedicated personnel for spe- cific urology procedures. Despite minimal surgeon turn- over and similar case volumes and types during the 2 years of this study, individual case complexity variations may potentially introduce confounding factors when comparing between years. Also, surgeon experience is gained over the course of the study, potentially influenc- ing operative times. The patient safety issues in this study were reported by the individual operating room teams. Complacency in reporting or fear of reprisal may have affected reporting patterns.

Conclusion

TeamSTEPPS provided a framework for urology resi- dents to open channels of communication among inter- disciplinary health care team members in the operating

room. This process improved operating room efficiency by reducing mean case time by 10.1% and increasing on- time first-start rates by 20.9%. Also, patient safety improved, with the rate of reported patient safety issues declining by more than half within the first 6 months of TeamSTEPPS implementation.

Authors’ Note

The authors prepared this work within the scope of their employment with the United States Army Medical Corps and United States Air Force Medical Corps.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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