NO FEAR Do your nurses and techs have the courage to speak up in the OR?

Even the tiniest course correction in the OR could mean the difference between getting an a.m. patient home safe by lunchtime and having him endure an extended stay in the ICU. In some cases, it could also mean the difference between life and death.

Alex B. Haynes, MD, MPH, FACS, sees these kinds of course corrections daily in his OR: slight adjustments he agrees to after members of his surgical team speak up to make him aware of situations — most of them minor — that could cause an infection or otherwise affect a patient's surgical outcome.

"A lot of things can change between the time we do the booking sheet to the moment we head into the OR," says Dr. Haynes, a surgical oncologist with Massachusetts General Hospital in Boston. "Once we conclude the time out, I always say, 'At any point during the surgery, if anyone sees anything they think is not right or if they're unclear about what we're doing, please speak up.'"

And they do — every day. Usually it's the little things: "You might want an extra drape here or there because it's not quite as covered as we'd like" or "Someone's glove touched an unsterile part of the field."

In all too many ORs, though, potential red flags are noted but not spoken aloud. Dr. Haynes ascribes this silence to entrenched behaviors rooted in the traditional surgeon-first hierarchy, or simply the fear of being wrong and then chastised for interrupting the workflow. He's been heartened by a shift away from this archaic OR culture, even though it's happening more slowly than he would like.

"We should have an environment in the OR where it's not considered a courageous thing to say, 'I think you contaminated yourself,'" he says. "As a surgeon, I would be mortified if someone felt they were in any way not brave enough to say something like that. It's about members of a team working together, not the surgeon who believes others should speak only when spoken to. That's an absurd concept."

When, how to say it
A lack of courage has likely been a contributing factor in the crush of wrong-site surgeries, infections and other medical errors that happen in U.S. ORs every year. The result of not speaking up can bear a heavy weight, according to researchers from the Johns Hopkins University School of Medicine (osmag.net/D5ePMp). Their data shows that medical errors now account for as many as 251,000 deaths per year — nearly 700 per day — or about 9.5% of all deaths annually in the United States.

Dr. Haynes likens surgery to another high-risk profession — aviation — where an instance of someone lacking the courage to speak up could lead to unimaginable disaster. "A co-pilot may be aware that the pilot is ready to fly the plane into the ground, but he's not willing to issue a challenge," he says. "That's rooted in issues pertaining to culture and hierarchy, and it has nothing to do with common sense."

Spence Byrum appreciates the aviation analogy. He's the president and CEO of HRS Consulting, a Weston, Fla.-based firm founded to help the airline industry improve communication and safety. The firm has since branched out to health care, helping surgical facilities bring similar disciplines to the OR.

COURAGE UNDER FIRE
What Safety Lessons Can ORs Learn from the Airlines?

RAISE YOUR VOICE You don't have to be the one holding the scalpel to recognize a situation that could result in tragedy. Just ask the airline ramp worker in the story below.

The healthcare and airline industries have a lot in common, so there are a lot of lessons one can learn from the other, especially in matters of safety.

I like to tell a story about a time when I was on an airplane, because it's an almost perfect analogy for what might happen in an OR where courage wins. I saw a ramp worker looking up quizzically at the plane's wing. A few minutes later the same gentleman entered the cabin and went toward the cockpit to speak with the captain. The 2 men had a quick conversation and then left the plane to go out onto the tarmac for a closer look.

Soon enough, the airline announced that we had to offload. All of the passengers were grousing about the inconvenience of having to change planes, but it turns out we had a good reason to do so: It was a hydraulic leak, which is a serious situation you don't want to be dealing with when you're at 10,000 feet.

The person responsible for averting that potential disaster was a ramp worker, not a mechanic or someone who knows about the specifics of aviation. He saw something that didn't look quite right so he did the uncomfortable thing by going to the person who was in command.

It took the aviation industry 30 to 40 years to get to this point. Surgery can get there, too, but I think we need to compress the timeframe. It shouldn't take decades for an industry to have its people feel comfortable enough and empowered enough to raise their voice in what could be a life-or-death situation.

The point is this: You don't have to be the one holding a scalpel to recognize a situation that could result in tragedy.

— Spence Byrum

"In aviation and in surgery, all the risks are the same, and all the challenges are the same," he says. "You have a limited number of individuals tasked with performing tasks where lives are on the line, working in environments with constantly changing information. So many things could go wrong."

COMMON VALOR Imbuing every member of the surgical team with the courage to speak up may help to avoid situations that can hurt patient outcomes.

That's why adequate pre-procedures are so essential. In aviation, pilots have a team of individuals around them to alert them to potential problems (see "What Safety Lessons Can ORs Learn from the Airlines?" above). Why should surgery be any different?

"An organization has to clearly and explicitly tell its employees that they are expected to speak up if they see something wrong," says Mr. Byrum. "Part of it is teaching employees when to say it, how to say it. You also can't take away the responsibility of the decision maker, because he has to be able to receive the information and assimilate it to determine how to proceed, and all that happens in just a few seconds."

Mr. Byrum suggests surgical facility leaders teach staff to take a straightforward, multi-step approach to speaking up when they see something that could become a problem: Get the decision maker's attention in a clear, concise manner; state the problem; propose a solution; and wait for the decision maker to process the information and then make a decision. In order for this approach to truly do the job, staff must "close the loop" by performing each step fully and effectively. But first, employees need to have the courage to speak up.

"Leadership can be taught, enhanced and improved," he says. "Communication can be taught, enhanced and improved. Courage comes from within. However, the first 2 are absolutely critical to have the third one actually work. You can have courage to be the lone voice in the woods, but it doesn't mean you'll be listened to. You can't teach courage, but you can enhance the possibility that courage will be replicated by not slapping it down."

Whether staff members are right or wrong about their particular concerns, they need to feel that not only do they have a responsibility to speak up but also that they can do so safely, without fear of reprisal.

"All it takes is one time of someone getting slapped down for speaking up," says Mr. Byrum. "If that happens, anyone who witnessed it or even heard about it is going to think: I'm not going to risk getting verbally cuffed."

Checklists and balances
Dr. Haynes believes tools such as the surgical safety checklist can remove the issue of courage from the equation, so to speak.

"A checklist makes it clear that all members of the team need to know the details of the surgery and have valuable contributions and should give those contributions a voice," he says. "By doing that at the beginning of an operation, it creates a culture where the amount of courage to speak up about areas of concern or question is almost irrelevant."

In his role as associate director of the Safe Surgery Program at Ariadne Labs, Dr. Haynes — a longtime proponent of surgical safety checklists — was the lead author of a recent study that measured the effects of a voluntary surgical safety checklist on the perioperative outcomes of patients at 14 South Carolina hospitals (osmag.net/S6MssE). The 19-point checklist prompted members of a hospital's surgical team to discuss the surgical plan, as well as any risks or concerns they had, during each of the 3 phases of surgery: before induction of anesthesia ("sign in"); before the incision ("time out"); and before the patient leaves the operating room ("sign out"). In each phase, a checklist coordinator confirmed that the surgical team completed the listed tasks before proceeding.

The results: The participating hospitals decreased their 30-day post-operative mortality rate from 3.38% in 2010 — before the program's implementation — to 2.84% in 2013. In comparison, the 44 non-participating hospitals in South Carolina saw their 30-day post-operative mortality rate rise from 3.5% in 2010 to 3.71% in 2013.

"A checklist is not a piece of paper," says Dr. Haynes. "What is does is help to structure a verbal exercise so everyone in the OR is engaged and participating in constructive information sharing. Implicit communication turns explicit, so there's no assuming."

Dr. Haynes is quick to note that the checklist is only a tool, however an important one — "the centerpiece," as he calls it. The kinds of improvements seen in the South Carolina study reflect a broader, team-based commitment to patient safety.

"It takes a lot of work on the part of the different teams to integrate these kinds of processes into the routine," he says. "You need engagement at all levels, with champions at every level, from the C-suite down to the front-line workers. This is not something that happens overnight."

Even having OR personnel introduce themselves makes them feel more engaged, empowered and encouraged. In other words, the simple act of raising their voice to say their name will make them more likely to speak up when it matters most. OSM