Using the AORN surgical checklist to effect OR culture change
Publish Date: 3/28/2012
During “Operating Room Training to Implement the AORN Surgical Checklist “ David Shapiro, MD, FACS, presented a look back at OR photos from the early 1900s to show how some things have not changed much (eg, Mayo stands, back tables) and how others have changed radically (eg, technology). One constant is the need for cohesive OR teamwork to provide positive patient outcomes. “When everything goes right, no one hears about it, but when things go wrong everyone hears,” he noted, attributing this to the culture of blame that often characterizes the OR. The culture of blame rarely solves problems. Shapiro noted that the Joint Commission’s root cause analysis of what causes retained surgical items, the number one sentinel event, was poor communication and poor leadership. To counteract this and ensure that patients had the best possible outcomes at his hospital they chose to improve OR communication by using the AORN surgical checklist.
To implement a culture of safety attendees need to identify their culture’s overall communication styles, team behaviors, everyday rituals, and tolerance for rituals and poor behavior by using an OR attitude questionnaire developed by the University of Texas Health Sciences Center. Shapiro identified difficulty discussing errors, inability of the culture to allow learning from mistakes and manager indifference or lack of awareness about these issues as problems. Barriers to communication that were identified included language, assumptions, efficiency, interruptions, side conversations, fatigue, stress, multi-tasking, the presence of a high-risk environment that was not treated as such and staff frustration.
Shapiro’s hospital undertook team training to attempt to correct these problems and implement the use of AORN’s checklist. They began by discussing crucial conversations and how to have them with all surgical team members. During this first phase, they asked the participants to identify what was wrong with an acted scenario and then discuss how to correct it and achieve positive outcomes. In the OR, topics may vary, but the stakes are always high and questions and solutions need to be addressed in an open environment. Participants need to reflect on themselves and their style of communication, figure out how to deal with conflict and find a safe environment to have the conversations. “Silence is the opposite of violence but often they have the same outcomes and neither should be an option,” he said. Stories often cause problems because they are a common way that information gets passed on. Stories about what has happened are often riddled with assumptions that then become the “truth.”
Shapiro asked participants to look at the patterns in their environment to determine what was the content of the stories told, what recurrent behavior they represented, and how they affect team members. To implement a practice change like the checklist, which requires the participation of all team members, commitment to team success is needed. Additional needs are building a common understanding of the issues, using best efforts to confront problems, contributing ideas and suggestions, and maintaining openness to the ideas of others. Participants must understand that they should work on themselves first before making an effort to change others.
Implementation of the AORN checklist occurred with support from unit champions and most staff members. There was some resistance initially, but staff members felt as if it brought them together and enabled them to improve patient outcomes and it provided them a framework in which to ask questions and insist on compliance. Implementing the checklist improved their communication and reduced equipment problems, disruptive behavior and impeded procedure flow. Shapiro gave the example of the average number of times a circulator must leave the OR during a case. The average at his hospital was nine exits per hour per four hour case. National ranges are estimated to be from zero to 25 exits and the higher the number of exits, the higher the number of surgical site infections. By implementing the surgical checklist they were able to drop this number to three exits per hour because the circulating nurse, surgeon and anesthesia care provider were required to check in before the case, thus preventing miscommunication, equipment malfunctions and forgotten supplies.
Shapiro encouraged the audience to recognize the need for change in the OR, measure baseline attitudes, implement team training curricula, introduce the tools needed to change, observe and audit checklist use, recognize barriers to change, and identify the metrics that demonstrate the changes affected to provide better care for patients and make the OR a better place to work.