SURGICAL TEAMWORK

AND COMMUNICATION

Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS

Director, Division of Research and Optimal Patient Care, ACS

Professor of Surgery, UCLA

Dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and

ethical practice environment

1913 1922 1950

1951

1998

2004

2005

2011

Trauma

2015

TQIP

ACS Quality Programs

Cancer Improvement program;

1500+ hospitals

Trauma; 500+

hospitals

Multispecialty (surgery)

600+ hospitals

Bariatric; 800+

hospitals

Peds Surg

Standards/

Verification Breast Centers; 500+

Four Guiding Principles of Continuous Quality Improvement:

1. Infrastructure • Staffing

level/Specialists/Culture

• Committees (care,

quality, peer review)

• Equipment

2. Standardization • Standards

• Protocols, pathways

• Quality Processes

• Innovation

3. Data • From EHR, Patients

• Financial, Registries

• Post-discharge tracking

• Continuously updated

4. Verification • External peer-review

• Creates public

assurance

THE NATIONAL STUDY ON

COSTS AND OUTCOMES

OF TRAUMA CENTER CARE

25% Mortality Reduction in age<55

Results- Change in O/E

Change 2006 to 2007

Complication Mortality

Mean Change in O/E -0.1137 -0.1740

P-value (mean not zero) <0.000001 <0.0001

Volume weighted mean -0.1126 -0.1631

% Institutions Improved 82% 66%

UTI

Pneumonia

SSI

Continuous improvement occurs when data are

fed back, and acted upon…

Mortality

Some hospitals took more time to get better. Why?

Good Improved Improved Bad Improved Improved Good Improved Improved Bad Improved Improved

Outliers in in Outliers in in Outliers in in Outliers in in

2005 2006 2007 2005 2006 2007 2005 2006 2007 2005 2006 2007 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

Complication Mortality

Standardize how

we do things

Observation 1: Some took longer to incorporate standardized evidence-based practice.

17.9%

10.6%

0%2%4%6%8%10%12%14%16%18%20%

0

10

20

30

40

50

60

70

80

90

Quarter 3 (2012) Quarter 4 (2012)

Re

adm

issi

on

Rat

e (

%)

Nu

mb

er

of

Pat

ien

ts

Discharges Readmissions Readmission Rate

Readmission Rate Decreased 41%

Standardization was essential, but something more was needed

“…we tried something new...”

“…we changed…”

“…innovated…”

Co

nti

nu

ou

s Q

ua

lity

Imp

rove

me

nt

Obs 2.

When do we innovate? When do we change?

Data

0

0.5

1

1.5

2

2.5

3

3.5

4

109

114

143

29

13

132

118

113

123

50

54

34

102

69

64

148

45

44

53

76

25

19

62

127

135

39

85

98

88

20

117

65

51

136

12

84 8

43

41

70

31

37

52

81

138

147

104

126

38

57

67

55

36

40

94

108

110 5

134

14

90

15

107

78

56

140

99

101

97

68

128

105

83

58

66

33

96

116

115

74

47

61

26

46

100 2

89

71

120

112

129

91

119

11

60

93

131

48

77

92

144

142

95

73

86

87

122

16

80

30 9

10

35 4

124

130

72

82

21

111

103

49

28

32

146

106

139

27

79

75

152

141

137

23

63

22

145 3

42

59

24

121

“I skate to where the puck is going to be, not where it has been.“

“You miss 100% of the shots you don’t take.“

When data told them something, “achieving” providers took more shots…

• Employed new ways to learn what they didn’t know how to do…

• Often required accelerating the failure cycle…not avoiding failure.

• Failed strategically.

• Lived like the “Hurt, didn’t it” parent

• Smart people haven't had as many opportunities to consider alternatives that failure affords

• So when they do fail, instead of critically examining inward, they tend to cast elsewhere…

• Accepted the notion that they didn’t always know…

Learn from failures. Fail cheap.

Observation 3 : Consider (and embrace) equifinality: There can be more than one solution to a problem (we often need to discover the answer)

“All roads lead to Rome…”

Many

Solution A

Solution B

Solution C

#4: Communication and teamwork (culture) is

routinely associated with sustained quality and

safety improvement

• Culture: a set of shared mental assumptions that guide interpretation and action in organizations by defining appropriate behavior for various situations.

• The way things get done around here

• It is THE most difficult organizational attribute to change, it can outlast organizational products, services, founders and leadership and all other physical attributes of the organization.

The type of strategy and success of implementation locally will depend on levels of evidence and culture

Less Rare; fix

culture

Ideal

Situation;

(easiest strategy)

Too common;

(most

challenging

strategy)

Rare; work on

evidence

Ev

ide

nce

Weak

Str

on

g

Culture

Weak Strong

Un

it P

RE

Un

it P

OS

T

--U

nit

Tim

e 3

0

10

20

30

40

50

60

70

80

90

100

WICU PRE CUSP

WICU POST CUSP

--SICU POST CUSP

Com

mun

icat

ion/

Team

wor

k

Communication/Teamwork Across Hospital’s Clinical Areas

Communication and teamwork will likely improve as quality and

safety is also improved (culture).

88%

68%

48%

99%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Surgeon Nursing Anesthesia AnesResident

Do you think: “Surgeons and Anesthesiologists

work together as a well-coordinated team”

“We have great culture/teamwork/leadership”

1:1

3:1

6:1

The Positivity Ratio for Achieving Communication and Teamwork

Being Positive…

“Yes, but…”

“Yes and…”

• What you get …

• Start with unexpected/unknown

• Co-creating something out of nothing

• Listening (follow a follower)

• Enhances positivity

Try This:

Team Brainstorming…Figuring out how to fix the problem (new ideas)

• Look for lots of ideas

• Accept all ideas; even if you think (to yourself) it’s stupid

• Make yourself “stretch”

• Take time to “simmer”

• Seek combinations of ideas, connect the dots - be a “hitchhiker”

• Defer judgment, no dominant logic

The Team Member “Portfolio” for CQI

Need to Harmonize The Team

Cycle of Implementing New Ideas

The Beatles

• British rock band 1960-1970

• Most #1 hits (20)

• Academy award; Grammy award (10)

• Best selling band in history

• 12 albums; 207 songs

The Beatles: Authorship and Collaboration

The Beatles: Authorship and Collaboration

Collaborative Writing:

Love Me Do

She Loves You

Can’t Buy Me Love

~68%

The Beatles: Authorship and Collaboration

Magical Mystery Tour

With a Little Help from my Friends

Yellow Submarine

The Beatles: Authorship and Collaboration

Let it Be: Paul

Octopus Garden: Ringo

Here Comes the Sun: George

Come Together: John

8% I’ve Got a Feeling

Dig it

Piggies

Birthday

Hey Bulldog

Seeds of our undoing are sewn at the

pinnacle of our success

-Joseph Schumpeter

Observations from the team that achieved better outcomes while also developing the best

culture…

1. Team-based approach with each having a key role

(not necessarily top-down leadership)

2. Empowering the front line people to provide and test

solutions

3. Biggest difference vs. the past: Everyone

participated in the process, was valued, and

believed they were helping the patient. Dedication.

Engagement. Teamwork/Collaboration.

Even if you increase your communication 4-fold,

you’re probably still not communicating enough

Thank you!