Anda di halaman 1dari 11

Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.

com
BMJ Quality & Safety Online First, published on 22 May 2015 as 10.1136/bmjqs-2014-003764
SYSTEMATIC REVIEW

Teamwork, communication and


safety climate: a systematic review
of interventions to improve surgical
culture
Greg D Sacks,1 Evan M Shannon,2 Aaron J Dawes,1 Johnathon C Rollo,1
David K Nguyen,1 Marcia M Russell,1,3 Clifford Y Ko,1,3
Melinda A Maggard-Gibbons1,3

Additional material is ABSTRACT Conclusions The literature provides promising


published online only. To view Objectives To define the target domains of evidence for various strategies to improve
please visit the journal online
(http://dx.doi.org/10.1136/bmjqs- culture-improvement interventions, to assess the surgical culture, although these approaches
2014-003764) impact of these interventions on surgical culture differ in terms of the interventions employed as
1 and to determine whether culture improvements well as the techniques used to measure culture.
Surgery, David Geffen School of
Medicine, University of California lead to better patient outcomes and improved Nevertheless, culture improvement appears to be
Los Angeles, Los Angeles, healthcare efficiency. associated with other positive effects, including
California, USA Background Healthcare systems are investing better patient outcomes and enhanced
2
UCSF School of Medicine,
considerable resources in improving workplace healthcare efficiency.
San Francisco, California, USA
3
General Surgery, VA Greater culture. It remains unclear whether these Trial registration number CRD42013005987.
Los Angeles Healthcare System, interventions, when aimed at surgical care, are
Los Angeles, California, USA successful and whether they are associated with INTRODUCTION
Correspondence to changes in patient outcomes. Healthcare organisations are employing
Dr Greg D Sacks, Surgery, Methods PubMed, Cochrane, Web of Science interventions that aim to improve local
David Geffen School of and Scopus databases were searched from culture as a way to create a more positive
Medicine, University of California
Los Angeles, Los Angeles,
January 1980 to January 2015. We included and patient-friendly clinical environment.
CA 90095, USA; studies on interventions that aimed to improve Many successful quality improvement
gsacks@mednet.ucla.edu surgical culture, defined as the interpersonal, projects, such as the statewide reduction
social and organisational factors that affect the in catheter-related bloodstream infections
Received 7 November 2014
Revised 1 May 2015 healthcare environment and patient care. The in Michigan1 and the reduced morbidity
Accepted 5 May 2015 quality of studies was assessed using an adapted and mortality associated with the WHO
tool to focus the review on higher-quality Surgical Safety Checklist,2 included
studies. Due to study heterogeneity, findings efforts to improve the culture surround-
were narratively reviewed. ing healthcare delivery. In fact, leaders of
Findings The 47 studies meeting inclusion these projects often attribute improve-
criteria (4 randomised trials and 10 moderate- ments in care as much to the changes
quality observational studies) reported on in local organisational culture as to
interventions that targeted three domains of components of the intervention itself.3 It
culture: teamwork (n=28), communication appears, therefore, that combining
(n=26) and safety climate (n=19); several quality improvement with efforts to
targeted more than one domain. All moderate- promote workplace culture has the
quality studies showed improvements in at least potential to improve both the quality and
one of these domains. Two studies also efficiency of healthcare delivery.
demonstrated improvements in patient In To Err Is Human, the Institute of
outcomes, such as reduced postoperative Medicine (IOM) highlights the import-
complications and even reduced postoperative ance of building a culture of safety as a
To cite: Sacks GD, mortality (absolute risk reduction 1.7%). Two prerequisite to improving healthcare
Shannon EM, Dawes AJ, et al.
BMJ Qual Saf Published Online studies reported improvements in healthcare quality and reducing patient harm.4 In
First: [ please include Day efficiency, including fewer operating room this context, culture refers to the beliefs,
Month Year] doi:10.1136/ delays. These findings were supported by similar values and behavioural norms shared
bmjqs-2014-003764
results from low-quality studies. between individuals in a team or unit.

Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764 1


Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
These issues are particularly salient in fields like Based on our initial title and abstract screening, we
surgery, where procedures are dynamic, complex, determined that studies employed culture-improvement
high-stakes and rely on contributions from team strategies that fit within discrete domains. In order to
members across multiple disciplines.5 better describe the improvement strategies, the authors
Since the IOM report, many organisations have identified these domains empirically and revised them
attempted to measure, understand and even improve in an iterative process as our search progressed.
their local culture. Within surgery, culture often varies Full-length studies were then screened and included in
by provider type and physician specialty, even within our review if they met the following inclusion criteria:
the same institution.6 7 While the threshold for positive the study reported on an intervention that aimed to
culture depends heavily on the method of assessment, improve surgical culture and culture change was mea-
better culture, as it pertains to patient safety, appears to sured directly. We excluded editorials, reviews and titles
correlate with fewer adverse intraoperative and post- with no available abstracts. Studies were screened
operative events.810 What remains unclear, however, is sequentially based on title, abstract and full studies as
whether culture change is truly feasible and whether generated by our search; two investigators independ-
improving culture leads to better patient outcomes. ently performed each stage of screening.
Further, the optimal strategies for improving surgical
culture remain uncertain. To better characterise these Data collection
issues, we performed a systematic review with the fol- Data were abstracted using a structured abstraction tool.
lowing aims: (1) to identify the most common domains We collected data on the year of publication, domain
of culture improvement interventions, (2) to assess the and type of culture-improvement intervention used,
effectiveness of these interventions at improving surgi- study design, characteristics of study participants,
cal culture and (3) to determine whether culture healthcare setting, surgical specialty, country, medical
improvement is associated with better patient outcomes centre type, culture assessment tool used, study time
and more efficient healthcare delivery. frame and any potential obstacles to culture change that
were highlighted. When applicable, we also abstracted
METHODS data on related outcomes, which we divided into two
Review registration categories: patient outcomes (eg, morbidity or mortal-
This systematic review was registered with PROSPERO ity) and healthcare efficiency (eg, operating room (OR)
(University of York, Centers for Reviews and turnover time, equipment availability issues, handoff
Dissemination), an international database of prospect- problems).
ively registered systematic reviews (registration number
CRD42013005987). The methodology and reporting Quality assessment
were performed in line with the Preferred Reporting The primary goal of our quality assessment was to
Items for Systematic review and Meta-Analyses.11 assess the reliability of the study design and the gen-
eralisability of the findings. We therefore adapted a
Search strategy quality assessment tool used in prior reviews that
Our search strategy, developed with the assistance of a evaluated interventions in which the results are sensi-
research librarian, began with a comprehensive defin- tive to the context and implementation of the pro-
ition of surgical culture: the interpersonal, social and gramme.12 13 Strong study designs included the use
organisational factors that affect the healthcare environ- of a control group and/or repeated outcome mea-
ment and influence patient care in the perioperative surements to assess the sustainability of culture
period. We searched PubMed, Cochrane, Web of change. Studies were determined to be generalisable
Science and Scopus databases from January 1980 to if they reported on an intervention that was either
January 2015 for interventions directed at improving implemented or measured in actual clinical settings
any aspect of surgical culture. Our final search protocol as opposed to simulation-based exercises. In addition
included the Medical Subject Headings (MeSH) terms to design and generalisability, better quality studies
Organizational Culture, Social Environment, met the following three criteria: intervention per-
Interprofessional Relations, Attitude of Health formed at multiple sites (separate hospitals, clinics or
Personnel, Surgery Department, Hospital, Operating health centres), use of an established theory as a basis
Rooms, Surgical Procedures and Operative/standards as for the intervention and mandatory participation for all
well as important keywords, such as teamwork, commu- staff members (which we assumed to be more represen-
nication and safety climate (see online supplementary tative of real-world interventions than those requiring
appendix 1). References of included studies were also voluntary participation). In order to focus our review
screened for additional studies relevant to our topic. on studies of higher quality, studies were categorised as
high quality if they met all criteria, moderate quality if
Review and study inclusion and exclusion they met four criteria and low quality if they met fewer
We screened for studies relevant to surgery, including than four criteria. Two investigators independently per-
labour and delivery and other surgical subspecialties. formed quality assessment. To supplement this quality

2 Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764


Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
assessment tool, we also assessed randomised trials risk of bias and 1 had unclear risk of bias (see online
using the Cochrane Collaborations Tool for Assessing supplementary appendix 2). However, all four of
Risk of Bias.14 these studies evaluated an intervention that took place
in a simulated environment, greatly limiting their rele-
RESULTS vance and generalisability to real-world clinical set-
Description of the studies tings. These studies were therefore categorised as low
Our search yielded 47 studies that met our inclusion quality by our quality assessment tool.23 24 31 43 Of
criteria ( figure 1). Twenty-five studies were performed the 43 observational studies, 10 (23.3%) were deter-
in the USA, while the remaining studies were per- mined to be moderate-quality and 33 (76.7%) to be
formed in the UK (n=13), Canada (n=4) or other low quality (see online supplementary appendix 3);
international settings (n=5). Most studies were per- none met criteria for high quality. Five studies used a
formed in academic medical centres; four took place controlled pre-post study design without randomisa-
at a Veterans Affairs Hospital.1518 Overall, the vast tion,21 27 29 44 45 two of which were deemed moder-
majority of studies involved interventions targeting ate quality. The remaining studies used pre-post study
the intraoperative or perioperative period (n=38). design without a control group. The moderate-quality
Fewer studies targeted postoperative (n=7)1824 or and low-quality studies are summarised in Table 1 and
preoperative care (n=6); however, several studies tar- online supplementary appendix 4, respectively.
geted more than one setting.22 2529
Studies mostly included interventions that targeted Cultural definition and measurement
surgeons and nurses (n=43). Twenty studies focused The most common tool for culture measurement,
specifically on surgery or anaesthesia residents and used by over half of the moderate-quality studies
three studies studied culture improvement among (n=6),1517 22 38 46 was the Safety Attitudes
medical students.17 2024 27 28 3042 Questionnaire (SAQ). The SAQ is a validated and
widely adopted tool used to measure work environ-
Quality assessment ment and patient safety culture.47 The second most
Of the 47 studies included in our review, 4 were ran- frequently used tool across all studies was the Oxford
domised control trials (RCTs), of which 3 had low Non-technical Skills scale.23 24 29 32 44 48

Figure 1 Identification of eligible studies.

Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764 3


Table 1 Summary of moderate-quality studies evaluating effects of cultural interventions
4

Systematic review
Results
Study design Authors/year Culture target Intervention Subjects* Primary outcomes Other outcomes
Controlled pre Haugen et al Improve safety climate WHO Surgical Safety Surgeons, anaesthesiologists, Positive changes in the checklist Positive but non-significant association
intervention 201321 perceptions Checklist nurses, CRNAs, staff intervention group for culture; frequency with improved patient safety,
/postintervention Preintervention: of events reported, adequate staffing teamwork within units, communication
Intervention group N=146 with regression coefficients of 0.25 on error, hospital management

Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com


Control group N=178 (95% CI 0.47 to 0.07) and 0.21 promoting safety
Postintervention: Intervention (95% CI 0.07 to 0.35)
group N=140
Control group N=152
Weaver et al Evaluate if team training Training curriculum based Surgeons, anaesthesiologists, Significantly more pre-case briefings Positive but non-significant association
201045 effectiveness can improve on TeamSTEPPS. nurses, CRNAs, surgical techs, ( p<0.001); significantly improved with improved leadership and situation
teamwork behaviour and Compared outcomes to physician assistants communication (use of handoffs, monitoring, feedback and
safety climate untrained control group Intervention group N=29 call-out, check-back) ( p<0.05) communication about error,
Control group N=26 communication openness, overall
patient safety scores
Uncontrolled Bleakley et al Improve teamwork climate Multipronged, including Surgeons, anaesthesiologists, Significant improvement in teamwork Positive but non-significant association
preintervention/ 201246 among OR staff educational programming, nurses, staff
climate ( p=0.034; effect size not with mean scores for other SAQ
Preintervention N=187 domains ( job satisfaction, perception
postintervention reporting system, a reported)
Postintervention N=164 of management, working conditions,
newsletter, open-access
website safety climate). Stress recognition
reduced significantly
Armour Forse et al Improve teamwork and TeamSTEPPS Surgeons, surgical residents, Culture: No change in team self-assessment;
201119 communication in the OR anaesthesiologists, anaesthesia Improvement in communication and negative but non-significant
residents, CRNAs, nurses, leadership based on survey at 9 months association with PACU communication
other staff; sample size not and teamwork
Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764

( p<0.05)
reported
Quality outcome:
Increase in rates of antibiotics, 78% to
97% ( p<0.005); VTE administration,
74% to 91% ( p<0.05); beta-blockers,
19.7% to 100% ( p<0.05); mortality,
2.7% to 1% ( p<0.05); morbidity,
20.2% to 11.0% ( p<0.05)
Efficiency:
Improvement in first case start (69% to
81%) and turnover (43 to 35.5 min,
p<0.05)
Arriaga et al Develop and evaluate an Multiple educational 211 critical events reviewed Decrease in critical events not None reported
201120 1360 patients communicated to attending (33% to
intervention to reduce sessions, awareness
2%, p<0.0001), rates of failure to notify
breakdowns in communication campaigns, and reminder attending surgeon of patient status on
during inpatient surgical care, tools for expected weekends (14.9% to 1.3%, p<0.0001),
particularly between resident communication standards proportion of patients not visited by
and attending surgeons attending surgeon on weekends fell
(61% to 33%, p=0.0002)

Continued
Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764

Table 1 Continued
Results
Study design Authors/year Culture target Intervention Subjects* Primary outcomes Other outcomes
Carney et al Reduce the difference between MTT 9616 attendees of learning Elimination of discrepancy in safety Postintervention, perceptions of
2011, Changing providers at high- and sessions climate ratings between individuals at medium-complexity
perceptions15 medium- complexity facilities medium-complexity and high-complexity facilities were more favourable than

Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com


at the Veteran Health facilities those at high-complexity facilities for
Administration for perceptions I would feel safe being treated here
of organisational commitment as a patient ( p=0.005) and Medical
to safety errors are handled appropriately in this
hospital ( p =0.023)
Carney et al Reduce disparities in MTT Physicians and nurses Significant improvement in all six Nurses do not perceive difference in
2011, Improving perception of teamwork Preintervention N=2074 teamwork climate items among nurse input well-received
perceptions16 between surgeons and nurses Postintervention N=790 physicians; nurses significant
improvement in 5/6 items
Pettker et al Improve patient safety and Outside expert review, Obstetricians, nurse midwives, Improvements in the proportion of staff Positive but non-significant association
201122 safety culture protocol standardisation, paediatricians, neonatologists, members with favourable perceptions of with percentage of providers
creation of a patient anaesthesiologists, residents, teamwork culture (39% in 2004 to perception of stress recognition
safety nurse position and nurses, surgical technicians, 63% in 2009, p<0.0001), safety culture
patient safety committee aides, and social workers. (33% to 63%, p<0.0001), job
Median N=191 responding to satisfaction (39% to 53%, p=0.009),
each survey (range 183198) and management (10% to 37%,
p<0.0001)
Wolf et al 201017 Improve teamwork and patient MTT 4863 MTT debriefings Culture: Positive but non-significant association
safety in OR Improvement in perceptions of with teamwork climate, safety climate,
management ( p=0.003) and working job satisfaction, stress recognition
conditions ( p=0.004)
Efficiency:
Decrease in operating room delays (23%
to 10%, p<0.0001), equipment
availability problems (14% to 4%,
p<0.001), equipment malfunction
problems (7% to 2.7%, p=0.019),
reported handoff issues (5.4% to 0.3%,
p<0.0001)
Pettker et al Improve patient safety and Outside expert review, Obstetricians, midwives, Ob/ Culture: Positive but non-significant association
200938 safety culture protocol standardisation, Gyn residents, Duplication of results from Pettker with certain individual complications,

Systematic review
creation of a patient anaesthesiologists, nurses, et al22 including third-degree and
safety nurse position and staff fourth-degree lacerations and shoulder
patient safety committee Quality outcome: dystocia
Reduction in the Adverse Outcome Index
(linear regression, r2=0.50; p<0.01)
*N provided when available.
Effect size and p values provided when available.
CRNA, Certified Registered Nurse Anaesthetist; MTT, Medical Team Training; PACU, postanaesthesia care unit; PICUOR, operating room; SAQ, Safety Attitudes Questionnaire; TeamSTEPPS, Team Strategies to Enhance
Performance and Patient Safety; VTE, venous thromboembolism.
5
Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
Interventions employed SAQ after implementation of MTT and found a signifi-
Culture-improvement strategies varied between studies cant improvement in perceptions of management
but fit discretely into three separate domains: team- ( p=0.003) and working conditions ( p=0.004). There
work (n=28), communication (n=26) and safety was also a significant drop in nurse turnover during the
climate (n=19); several studies fit into more than one study period, a marker for nurse job satisfaction.17
domain. Studies were included in a given domain if While improvement in one domain of culture was
the authors directly expressed the goals of improving nearly ubiquitous, 30 of the 47 studies also reported
that domain of culture. Moderate-quality studies were no improvement in one or more of the other mea-
represented equally in all three domains (safety sured domains. For example, Bleakley et al46 noted a
climate,15 19 21 22 38 teamwork16 19 21 22 45 46 and significant improvement in teamwork after an educa-
communication17 1921). tional intervention ( p=0.034) but failed to observe
Interventions were grouped into several categories, significant changes in other domains, including job
including briefings/debriefings (n=23), team-building satisfaction, perception of management, working con-
exercises (n=22), educational campaigns (n=21) and ditions and safety climate. In some cases, an interven-
checklists (n=15). Often, more than one type of inter- tion led to improvements among one group of
vention was employed. On occasion a single interven- providers but not others. For example, in a study by
tion was directed at multiple domains of culture. For Carney et al that implemented MTT, surgeons
example, checklists were used to improve communica- reported a significant improvement ( p<0.05) in all
tion but were also used to improve teamwork and six teamwork items of the SAQ. However, there was
safety climate.34 49 no change in nurses response to nurse input is well
Briefings and debriefings typically refer to a brief, 5 received after the intervention.16 Similar, partial
min assembly of the surgical team before and after the improvement in culture was reported in 13 other
operation to discuss specific details of the case. studies.1517 22 27 30 32 34 37 41 46 49 50 Of note, two
Educational campaigns varied from voluntary review of the four RCTs also reported no improvement in at
of guidelines followed by a knowledge test38 to a least one domain of culture.31 43
human factors seminar lasting two full days.50
Checklist interventions aimed to improve culture by
Evidence of sustained improvements in culture
standardising processes, streamlining care pathways
Several studies continued to track the effects of the
and empowering team members to speak up when
intervention long after the intervention was imple-
care deviated from expected. Checklists were either
mented. In a few cases, the positive findings were sus-
implemented as an isolated intervention or as a com-
ponent of a more comprehensive intervention bundle tained for >1 year (n=4). 22 38 46 52 The median
(eg, medical team training (MTT), central line inser- follow-up time for all studies was 9 months.
tion bundles). In some cases, checklists used the
WHO Surgical Safety Checklist without any content Patient outcome measures
modification.21 34 41 49 51 Two moderate-quality studies made an attempt to
Educational campaigns and team-building exercises connect improved culture to better patient out-
were either developed by investigators or they were comes.19 38 Both reported a decrease in postoperative
adapted from previously validated programmes, most complications. Pettker et al38 reported a significant
notably Team Strategies to Enhance Performance and reduction in the Adverse Outcomes Index (a score
Patient Safety (TeamSTEPPS)19 25 28 40 45 and reporting on the number of neonatal deliveries with at
MTT.1518 30 least 1 of 10 adverse outcomes per total deliveries)
over 3 years after implementing a multifactorial patient
Improvements in culture safety intervention (R2=0.50; p=0.01). Armour Forse
All moderate-quality studies (n=10) reported an et al19 demonstrated a reduction in mortality from
improvement in at least one domain of culture (all low- 2.7% to 1% ( p<0.05) after implementing the
quality studies, with the exception of Morgan et al,44 TeamSTEPPS programme, and also reported a reduc-
also reported culture improvements). For example, tion in overall surgical morbidity (20.2% to 11.0%,
Weaver et al demonstrated a significant improvement p<0.05) as well as an increase in appropriate antibiotic
in communication in the OR as measured by an administration, deep vein thrombosis prophylaxis and
increased number of check-backs, call-outs and hand- beta-blocker administration. This study, however, did
offs after implementation of the TeamSTEPPS pro- not perform risk adjustment or include a control
gramme in comparison to a control arm ( p<0.05). group. Additionally, many of the findings in this study,
This study also demonstrated a significant improve- including reduced morbidity and mortality, were not
ment in communication as measured by the Hospital sustained at 1-year follow-up. Evidence regarding
Survey on Patient Safety Culture and Operating Room better patient outcomes following interventions to
Management Attitudes Questionnaire ( p<0.05).45 improve surgical culture was also provided by several
A study by Wolf et al measured job satisfaction using low-quality studies.2426 30 34 42 48 49 53 54

6 Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764


Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
Efficiency measures finding that measureable changes in culture can result
Two moderate-quality studies also measured improve- from multiple, seemingly unrelated interventions sug-
ments in efficiency after an intervention to improve gests that the formula for success is likely to be more
surgical culture.17 19 Armour Forse et al19 reported site-specific than intervention-specific. Multiple exam-
improved OR punctuality following implementation ples that similar interventions do not necessarily lead
of TeamSTEPPS (81% cases starting on time postinter- to similar outcomes exist in the quality improvement
vention vs 69% preintervention) while Wolf et al17 literature, including a recent study evaluating the man-
noted a reduction in OR delays (23% to 10%, dated implementation of the WHO Safe Surgery
p<0.0001), a decrease in equipment availability pro- Checklist in Ontario, Canada. Despite previous work
blems (24% to 7%, p<0.0001) and fewer patient suggesting that checklists lead to better patient out-
handoff issues (5.4% to 0.3%, p<0.0001) after MTT. comes,58 Urbach and colleagues failed to demonstrate
These findings were supported by three low-quality any improvement in the first three months after the
studies.28 55 56 policy was implemented.59 As any given intervention
even an effective and validated oneis unlikely to
Obstacles to culture improvements be successful in every clinical setting, healthcare
The two major obstacles to culture improvements institutions intent on improving their surgical culture
identified were participant reluctance to engage in may benefit more from developing individualised
activities and the regression of improvements over programmes based on proven domains (teamwork,
time.19 35 56 57 One study by Bethune et al56 noted communication and safety culture) than from imple-
it was rarely possible to get all members of the staff menting a standardised, off-the-shelf intervention in
together for a formal debrief . Additionally, Khoshbin their local environment.
et al35 reported that surgeons were concerned that Similar evidence from other specialties, particularly
mandating intervention compliance may result in critical care medicine, appears to support the idea that
completion of the required task without consideration improving institutional culture can result in better
of the underlying importance of the intervention, patient outcomes.1 60 The most successful of these
thereby reducing the interventions observed effects. strategies has been the Comprehensive Unit-based
Two studies reported regression towards baseline in Safety Program (CUSP), which harnesses the energy
some of the improvement initially noted in early and expertise of frontline providers and aligns them
follow-up measurements. Armour Forse et al19 with the resources of hospital leadership. According
noticed an increase in surgical mortality and morbid- to the CUSP model, efforts to engage and motivate
ity towards, but not reaching preintervention mea- frontline providers are made front and centre in order
sures, 1 year after implementation of TeamSTEPPS, to promote workplace culture that prioritises patient
and Bhmer et al57 reported that improvement in safety and celebrates high-quality care delivery. As a
communication was not maintained at 18 or result, a synergistic relationship emerges: delivering
24 months after implementation of the WHO Surgical high-quality care reinforces positive culture, which in
Safety Checklist. turn reinforces high-quality care. While the imple-
mentation of CUSP in the field of surgery has been
DISCUSSION limited,61 many successful strategies highlighted in
Our systematic review identified 10 moderate-quality this review, including TeamSTEPPS and MTT, include
studies, all of which demonstrated an improvement in basic CUSP principles.62 63 Rather than top-down,
at least one domain of culture. Several of these studies institution-wide quality programmes, future interven-
also showed marked improvements in patient out- tions in surgery may benefit from embracing a more
comes and healthcare efficiency, findings that were bottom-up approach.
further supported by a number of low-quality studies. While interventions to improve culture in non-
Our findings offer promising evidence that not only is surgical settings may inform similar efforts in surgical
it possible to improve surgical culture but that inter- settings, the OR itself presents unique challenges to
ventions aimed at improving culture may be viable measuring and improving institutional culture.
targets for the future of quality improvement. Multiple groups of providers (surgeons, anaesthesiolo-
Unlike clinical trials, which tend to use standardised gists, nurses)each with its own training and group
protocols and targeted outcomes, we identified a wide philosophymay limit effective team building.
range of successful culture interventions. While brief- Hierarchy (attending surgeons and trainees, surgeons
ings/debriefings and team-building exercises were and non-surgeons) may restrain communication, and
common components of successful interventions, indi- tradition may preclude efforts to promote a
vidual programmes varied widely across studies and safety-oriented climate. Given these challenges, efforts
many combined multiple components into a single to improve surgical culture must adopt a multimodal
intervention plan. Because of this, we were unable to approachone that takes into account all relevant
determine which specific types of interventions were team members and stakeholders, and capitalises on
most successful at improving culture. However, our the authority of institutional leadership. One

Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764 7


Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
promising development in this direction is the and safety climate. Improvements in culture also facili-
American College of Surgeons National Surgical tate progress in other domains of healthcare, includ-
Quality Improvement Program Quality In-Training ing patient outcomes and care efficiency. Future work
Initiative, a programme designed to facilitate account- should aim to standardise methods of culture meas-
ability for patient outcomes and foster an interest in urement and reporting.
quality improvement among surgical residents.64 As
Twitter Follow Greg Sacks at @gregDsacks
many of these trainees will go on to establish the stan-
Acknowledgements We acknowledge Paul Shekelle, MD, MPH,
dards for their future practice settings, training resi- PhD, West Los Angeles Veterans Affairs Medical Center, Los
dents to recognise the importance of culture is Angeles, California, for providing helpful guidance on study
essential to producing lasting changes in surgical methodology and manuscript writing, and Bethany Myers for
assisting with our search strategy.
practice.
Despite a general belief that culture change is Contributors All authors have contributed sufficiently to the
study to warrant authorship.
exceedingly difficult,65 almost all included studies
Competing interests None declared.
found improvements in at least one measured domain
Provenance and peer review Not commissioned; externally
of culture. Alternative explanations for these observed peer reviewed.
improvements may highlight potential limitations to Data sharing statement We are willing to share any additional
our review. One possibility is the Hawthorne effect: a details of our search strategy and results not already included in
phenomenon in which improvements occur as a result the manuscript.
of observation and measurement rather than actual
changes in practice.66 Culture may be particularly sus-
ceptible to these effects due to its loose definition and REFERENCES
imprecise measurement tools. Similarly, improvements 1 Pronovost P, Needham D, Berenholtz S, et al. An intervention
in culture, outcomes and efficiency may simply be an to decrease catheter-related bloodstream infections in the ICU.
artefact of other structural changes to patient care N Engl J Med 2006;355:272532.
rather than a result of studied interventions. Another 2 van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the
possible explanation is publication bias, namely that introduction of the WHO Surgical Safety Checklist on
unsuccessful attempts to improve culture are either in-hospital mortality: a cohort study. Ann Surg 2012;255:449.
not written up or not accepted for publication in 3 Gibbons W, Shanks HT, Kleinhelter P, et al. Eliminating
peer-reviewed journals.67 Our findings are also facility-acquired pressure ulcers at Ascension Health. Jt Comm
J Qual Patient Saf 2006;32:48896.
limited by the precision of our search strategy. Due to
4 Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human:
its complex definition, culture may have been imper-
Building a Safer Health System. Washington DC: National
fectly captured by our search terms, resulting in the Academies Press, 2000.
inadvertent exclusion of relevant studies. 5 Halverson AL, Neumayer L, Dagi TF. Leadership skills in the
Finally, although all studies demonstrated improve- OR: part II: recognizing disruptive behavior. Bull Am Coll Surg
ment in at least one culture domain, many also found 2012;97:1723.
areas where culture or outcomes did not improve. 6 Lyu H, Wick EC, Housman M, et al. Patient satisfaction as a
Those domains that were targeted specifically possible indicator of quality surgical care. JAMA Surg
appeared to improve universally (ie, interventions to 2013;148:3627.
improve communication do in fact improve communi- 7 Makary MA, Sexton JB, Freischlag JA, et al. Operating room
cation); however, there was inconsistent improvement teamwork among physicians and nurses: teamwork in the eye
for non-targeted domains and non-targeted clinical of the beholder. J Am Coll Surg 2006;202:74652.
sites. In fact, one study actually found lower commu- 8 Mardon RE, Khanna K, Sorra J, et al. Exploring relationships
between hospital patient safety culture and adverse events.
nication and teamwork ratings for the postacute care
J Patient Saf 2010;6:22632.
unit after performing an intervention on OR person-
9 Singer S, Lin S, Falwell A, et al. Relationship of safety climate
nel.19 These findings reiterate the importance of and safety performance in hospitals. Health Serv Res 2009;44
establishing multiple measurable targets, electing (2 Pt 1):399421.
hospital-based and unit-based programme leaders, and 10 Singer SJ, Falwell A, Gaba DM, et al. Identifying
applying sustained pressure through simultaneous and organizational cultures that promote patient safety. Health Care
complementary interventions.68 Considering the lack Manage Rev 2009;34:30011.
of longitudinal data, further research is also needed to 11 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items
determine the fidelity of interventions across health- for systematic reviews and meta-analyses: the PRISMA
care settings and the impact that intermittent, statement. BMJ 2009;339:b2535.
repeated interventions may have on the sustainability 12 Shekelle PG, Pronovost PJ, Wachter RM, et al. Agency for
Health Research and Quality. (Prepared by RAND Health
of culture change.
under contract No. HHSA-290-2009-10001C). AHRQ
Publication No. 11-0006-EF. Washington DC: US Department
CONCLUSION of Health and Human Services, Dec., 2010: 76p.
Surgical culture appears amenable to a wide range of 13 Goldzweig CL, Orshansky G, Paige NM, et al. Electronic
interventions to improve teamwork, communication patient portals: evidence on health outcomes, satisfaction,

8 Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764


Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
efficiency, and attitudes: a systematic review. Ann Intern Med 31 Boet S, Bould MD, Sharma B, et al. Within-team debriefing
2013;159:67787. versus instructor-led debriefing for simulation-based education:
14 Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane a randomized controlled trial. Ann Surg 2013;258:538.
Collaborations tool for assessing risk of bias in randomised 32 Catchpole KR, Dale TJ, Hirst DG, et al. A multicenter trial of
trials. BMJ 2011;343:d5928. aviation-style training for surgical teams. J Patient Saf
15 Carney BT, West P, Neily J, et al. Changing perceptions of 2010;6:1806.
safety climate in the operating room with the Veterans Health 33 Gore DC, Powell JM, Baer JG, et al. Crew resource
Administration medical team training program. Am J Med Qual management improved perception of patient safety in the
2011;26:1814. operating room. Am J Med Qual 2010;25:603.
16 Carney BT, West P, Neily JB, et al. Improving perceptions of 34 Haynes AB, Weiser TG, Berry WR, et al. Changes in safety
teamwork climate with the Veterans Health Administration attitude and relationship to decreased postoperative morbidity
medical team training program. Am J Med Qual and mortality following implementation of a checklist-based
2011;26:4804. surgical safety intervention. BMJ Qual Saf 2011;20:1027.
17 Wolf FA, Way LW, Stewart L. The efficacy of medical team 35 Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative
training: improved team performance and decreased operating and perioperative operating room briefings at the Hospital for
room delays: a detailed analysis of 4863 cases. Ann Surg Sick Children. Can J Surg 2009;52:30915.
2010;252:47783; discussion 835. 36 Lingard L, Regehr G, Orser B, et al. Evaluation of a
18 Paull DE, Deleeuw LD, Wolk S, et al. The effect of preoperative checklist and team briefing among surgeons,
simulation-based crew resource management training on nurses, and anesthesiologists to reduce failures in
measurable teamwork and communication among communication. Arch Surg 2008;143:1217; discussion 18.
interprofessional teams caring for postoperative patients. 37 Makary MA, Mukherjee A, Sexton JB, et al. Operating room
J Contin Educ Nurs 2013;44:51624. briefings and wrong-site surgery. J Am Coll Surg 2007;204:
19 Armour Forse R, Bramble JD, McQuillan R. Team training 23643.
can improve operating room performance. Surgery 38 Pettker CM, Thung SF, Norwitz ER, et al. Impact of a
2011;150:7718. comprehensive patient safety strategy on obstetric adverse
20 Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy- events. Am J Obstet Gynecol 2009;200:492.e18.
based intervention for the reduction of communication 39 Pian-Smith MC, Simon R, Minehart RD, et al. Teaching
breakdowns in inpatient surgical care: results from a residents the two-challenge rule: a simulation-based approach
Harvard surgical safety collaborative. Ann Surg to improve education and patient safety. Simul Healthc
2011;253:84954. 2009;4:8491.
21 Haugen AS, Softeland E, Eide GE, et al. Impact of the World 40 Paige JT, Kozmenko V, Yang T, et al. High-fidelity,
Health Organizations Surgical Safety Checklist on safety simulation-based, interdisciplinary operating room team
culture in the operating theatre: a controlled intervention training at the point of care. Surgery 2009;145:13846.
study. Br J Anaesth 2013;110:80715. 41 Putnam LR, Levy SM, Sajid M, et al. Multifaceted
22 Pettker CM, Thung SF, Raab CA, et al. A comprehensive interventions improve adherence to the surgical checklist.
obstetrics patient safety program improves safety climate and Surgery 2014;156:33644.
culture. Am J Obstet Gynecol 2011;204:216.e16. 42 Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with
23 Pucher PH, Aggarwal R, Qurashi M, et al. Randomized clinical operating room teams that stayed fixed during the day:
trial of the impact of surgical ward-care checklists on a multicenter study analyzing the effects on patient outcomes,
postoperative care in a simulated environment. Br J Surg teamwork and safety climate, and procedure duration. Anesth
2014;101:166673. Analg 2012;115:138492.
24 Pucher PH, Aggarwal R, Singh P, et al. Ward simulation to 43 Sydor DT, Bould MD, Naik VN, et al. Challenging authority
improve surgical ward round performance: a randomized during a life-threatening crisis: the effect of operating theatre
controlled trial of a simulation-based curriculum. Ann Surg hierarchy. Br J Anaesth 2013;110:46371.
2014;260:23643. 44 Morgan L, New S, Robertson E, et al. Effectiveness of
25 Johnson HL, Kimsey D. Patient safety: break the silence. facilitated introduction of a standard operating procedure into
AORN J 2012;95:591601. routine processes in the operating theatre: a controlled
26 Uhlig PN, Brown J, Nason AK, et al. Eisenberg Patient Safety interrupted time series. BMJ Qual Saf 2015;24:1207.
Awards. System innovation: Concord Hospital. Jt Comm J 45 Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork
Qual Improv 2002;28:66672. improve performance in the operating room? A multilevel
27 Cahan MA, Larkin AC, Starr S, et al. A human factors evaluation. Jt Comm J Qual Patient Saf 2010;36:13342.
curriculum for surgical clerkship students. Arch Surg 46 Bleakley A, Allard J, Hobbs A. Towards culture change in the
2010;145:11517. operating theatre: embedding a complex educational intervention
28 Capella J, Smith S, Philp A, et al. Teamwork training improves to improve teamwork climate. Med Teach 2012;34:e63540.
the clinical care of trauma patients. J Surg Educ 47 Sexton JB, Helmreich RL, Neilands TB, et al. The Safety
2010;67:43943. Attitudes Questionnaire: psychometric properties, benchmarking
29 Morgan L, Pickering SP, Hadi M, et al. A combined teamwork data, and emerging research. BMC Health Serv Res 2006;6:44.
training and work standardisation intervention in operating 48 McCulloch P, Mishra A, Handa A, et al. The effects of
theatres: controlled interrupted time series study. BMJ Qual Saf aviation-style non-technical skills training on technical
2015;24:11119. performance and outcome in the operating theatre. Qual Saf
30 Awad SS, Fagan SP, Bellows C, et al. Bridging the Health Care 2009;18:10915.
communication gap in the operating room with medical team 49 Lepanluoma M, Takala R, Kotkansalo A, et al. Surgical safety
training. Am J Surg 2005;190:7704. checklist is associated with improved operating room safety

Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764 9


Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Systematic review
culture, reduced wound complications, and unplanned 58 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety
readmissions in a pilot study in neurosurgery. Scand J Surg checklist to reduce morbidity and mortality in a global
2014;103:6672. population. N Engl J Med 2009;360:4919.
50 Allard J, Bleakley A, Hobbs A, et al. Pre-surgery briefings and 59 Urbach DR, Govindarajan A, Saskin R, et al. Introduction of
safety climate in the operating theatre. BMJ Qual Saf surgical safety checklists in Ontario, Canada. N Engl J Med
2011;20:71117. 2014;370:102938.
51 Mohammed A, Wu J, Biggs T, et al. Does use of a World 60 Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and
Health Organization obstetric safe surgery checklist improve improving safety climate in a large cohort of intensive care
communication between obstetricians and anaesthetists? units. Crit Care Med 2011;39:9349.
A retrospective study of 389 caesarean sections. BJOG 61 Wick EC, Hobson DB, Bennett JL, et al. Implementation of a
2013;120:6448. surgical comprehensive unit-based safety program to reduce
52 Costello J, Clarke C, Gravely G, et al. Working together to surgical site infections. J Am Coll Surg 2012;215:193200.
build a respectful workplace: transforming OR culture. 62 Clancy CM. TeamSTEPPS: optimizing teamwork in the
AORN J 2011;93:11526. perioperative setting. AORN J 2007;86:1822.
53 Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the 63 Dunn EJ, Mills PD, Neily J, et al. Medical team training:
operating room: shared cognition, teamwork, and patient applying crew resource management in the Veterans Health
safety. Chest 2010;137:4439. Administration. Jt Comm J Qual Patient Saf 2007;33:31725.
54 Paige JT, Aaron DL, Yang T, et al. Improved operating room 64 Kelz RR, Sellers MM, Reinke CE, et al. Quality in-training
teamwork via SAFETY prep: a rural community hospitals initiative--a solution to the need for education in quality
experience. World J Surg 2009;33:11817. improvement: results from a survey of program directors.
55 Ali M, Osborne A, Bethune R, et al. Preoperative surgical J Am Coll Surg 2013;217:112632.e15.
briefings do not delay operating room start times and are 65 Chassin MR. Improving the quality of health care: whats
popular with surgical team members. J Patient Saf taking so long? Health Aff (Millwood) 2013;32:17615.
2011;7:13943. 66 Wickstrom G, Bendix T. The Hawthorne effectwhat did the
56 Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and original Hawthorne studies actually show? Scand J Work
debriefings as a tool in improving team work, efficiency, and Environ Health 2000;26:3637.
communication in the operating theatre. Postgrad Med J 67 Matosin N, Frank E, Engel M, et al. Negativity towards negative
2011;87:3314. results: a discussion of the disconnect between scientific worth
57 Bohmer AB, Kindermann P, Schwanke U, et al. Long-term and scientific culture. Dis Model Mech 2014;7:1713.
effects of a perioperative safety checklist from the viewpoint of 68 Leape LL. The checklist conundrum. N Engl J Med
personnel. Acta Anaesthesiol Scand 2013;57:1507. 2014;370:10634.

10 Sacks GD, et al. BMJ Qual Saf 2015;0:110. doi:10.1136/bmjqs-2014-003764


Downloaded from http://qualitysafety.bmj.com/ on June 8, 2015 - Published by group.bmj.com

Teamwork, communication and safety


climate: a systematic review of interventions
to improve surgical culture
Greg D Sacks, Evan M Shannon, Aaron J Dawes, Johnathon C Rollo,
David K Nguyen, Marcia M Russell, Clifford Y Ko and Melinda A
Maggard-Gibbons
BMJ Qual Saf published online May 22, 2015

Updated information and services can be found at:


http://qualitysafety.bmj.com/content/early/2015/05/22/bmjqs-2014-00
3764

These include:
Supplementary Supplementary material can be found at:
Material http://qualitysafety.bmj.com/content/suppl/2015/05/22/bmjqs-2014-00
3764.DC1.html
References This article cites 66 articles, 16 of which you can access for free at:
http://qualitysafety.bmj.com/content/early/2015/05/22/bmjqs-2014-00
3764#BIBL

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Notes

To request permissions go to:


http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:


http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:


http://group.bmj.com/subscribe/

Anda mungkin juga menyukai