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With changes to the Centers for Medicare & Medicaid Services reimbursement policy on the horizon, facilities and organizations have shown how better outcomes are the result of a better team environment in the operating room.

For some, the solution to better patient safety is among the clouds. The aviation industry, with its preflight checklists and standardized procedures, is a model for how the surgical environment might improve.

"We've really taken on the mantra of, 'See it, say it, fix it,'" said Nancye R. Feistritzer, RN, MSN, the associate hospital director at Vanderbilt University Medical Center. "Everyone has accountability."

Vanderbilt implemented Crew Resource Management tactics in its 54 ORs. Under Crew Resource principles, the facility sought team members who consistently were able to manage distractions, use sound judgment, make quality decisions and employ all available resources under stressful conditions in a time-constrained environment.

"We are challenged with the reality that our old model for safety had us believing that clinicians were infallible, that bad things happen only when people make mistakes, that people in organizations that fail are bad, that blame and punishment are really the ways in which we motivate people to be more careful, and that if we just work harder things will get better" Feistritzer said. "But as part of that change of culture, we're really trying to move to a new model, where risk of failure is inherent in complex systems - and clearly all of our organizations are complex - that risk is always emerging and that it's not always foreseeable, that people are fallible, that alert, well-trained clinicians are crucial, redundancies of processes to ensure patient safety is crucial, and that disclosure and open discussions are important to create a blame-free environment."

Using aviation's principals, Vanderbilt sought a reduction of errors through standardization of pre- and post-operative briefings, team time outs and checklists. The group also developed a shared mental model and increased the margin for error.

"When you're creating something like this checklist it requires people to change their rhythm, and that is a huge component of what makes it difficult to change the culture. If you're trying to do something out of step of the normal rhythm, you need to find what that is and find a way to incorporate it in a meaningful way."

Going beyond aviation principles, Vanderbilt also implemented performance metrics from organizations such as the Surgical Care Improvement Project (SCIP), the National Quality Forum (NQF), The Joint Commission on the Accreditation of Healtchcare Organizations (The Joint Commission) and The Leapfrog Group for Patient Safety.

SCIP is a national quality partnership of organizations that focuses on the improvement of surgical care by reducing complications. Its goal is to reduce preventable surgical morbidity and mortality by 25 percent by 2010.

"There are three different areas we focus on," said Dale Bratzler, DO, MPH, who currently serves as the medical director of the Hospital Interventions Quality Improvement Organizations Support Center and the Hospital Quality of Care Measures Special Study located at the Oklahoma Foundations for Medical Quality. "The first is prevention of surgical infections, the second area is prevention of cardiac complications and then the third area is prevention of venous and thrombal pulmonary disease."

SCIP encourages voluntary reporting along those quality measures. Currently 3,725 hospitals report SCIP measures nationally.

Where SCIP differs from the CMS "never events," is that it tracks point-of-care interactions, whereas CMS is ceasing payments on what a facility can bill patients for. Therefore, facilities reporting to SCIP should not see any changes to procedure as a result.

"I just think that these conditions will force hospitals to look even closer at team-based responsibility for ensuring the right care for the patient," Bratzler said.

At Vanderbilt, the overall team concept and standardized measures has resulted in average "OR Ready" to "In OR" times being reduced from 28-minutes to 13-minutes. Additionally, the facility has seen improved employee satisfaction - perioperative staff members feel the people they report to encourage teamwork, that their group works well together, and there is a sense of satisfaction and pride in the decisions and work that's done.

The facility has also seen significant reduction of wrong-site and wrong-side surgery.

"Since we implemented this in May of 2003, we've measured the days in between events," Feistritzer said. "And in that whole interval of time, in terms of a wrong actual operation occurring, we've had one in 185,000 cases, and that was on the wrong level of spine."

"We take very seriously any issues that are near misses, along with anything that is an event, and work very hard to understand how we can continue to prevent those," she said.

Read more on the upcoming CMS no-pay changes in the September issue of AORN Connections. Also in this issue of AORN Management Connections, see Bratzler's "Manager's Soapbox" column on how the new policy could bring about a shift in team interactions in the operating room.

Read more news in AORN Management Connections.