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SCORE School Systems-Based Practice
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SCORE School Systems-Based Practice
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Segment:0 .
AMIT JOSHI: Hello, everyone. It's Amit Joshi from SCORE. It's my great privilege to introduce Dr Doug Smink today who will be lecturing us on systems-based practice for SCORE School. Dr Smink is a great friend of SCORE having served as a longtime member of the score editorial board and frequent contributor. He's really a leader in surgical education. He currently serves as the chief of surgery at Brigham and Women's Faulkner Hospital.
AMIT JOSHI: He also serves as the associate chair of education at Brigham and Women's having just completed a long term as program director of the General Surgery Residency. Dr Smink received his medical degree from the University of Pennsylvania before completing his residency and general surgery at the Brigham where he also obtained an MPH from Harvard and finished a fellowship in minimally-invasive surgery at Dartmouth.
AMIT JOSHI: He currently is the editor in chief of the Journal of Surgical Education. He's a member of the American College of Surgeons Academy of Master Surgeon Educators and the APDSes president-elect. His clinical interests include abdominal wall hernias, fore-gut surgery, and biliary-track disease, and his research focuses on resident and faculty education, and how to teach communication, leadership, and decision making to surgeons and surgical teams.
AMIT JOSHI: For that work, he has a co-PI on an NIH RO1 provider awareness cultural dexterity toolkit for surgeons grant. With all those credentials, I can't think of anyone better to give our talk on systems-based practice. Thank you, Doug, for lending us your expertise.
DOUGLAS SMINK: Thanks, Ahmed. This is really an honor to get to be a part of SCORE School. I have loved being a part of the SCORE editorial board now for nine years, and it's really exciting to see this new addition. And I'm honored to be given the opportunity to speak, and I'm going to dive right in. As I looked at the TWIS modules, I would say this is a pretty busy, busy week. And there's a lot to unpack here among these TWIS modules.
DOUGLAS SMINK: I am going to focus on three of them. Advocating for quality patient care, identifying system errors root cause analysis, and then working in interprofessional teams. And as you just were nice enough to mention in that intro, a lot of my research interest is in interprofessional teams. And so that's really exciting for me to get to share some of my thoughts about that with you all.
DOUGLAS SMINK: So we'll start by advocating for quality patient care. I like surgical history so I thought I'd start with a little bit of history. You may be aware of Ernest Codman. He was a surgeon actually in Boston at Mass General Hospital, and he was really a pioneer in looking at patient safety and quality. He was one of, if not maybe the first person, to record his own patient's complications and outcomes, and he really encouraged other people to do the same.
DOUGLAS SMINK: He instituted the first morbidity and mortality conference. He founded the American College of Surgeons Hospital Standardization Program, which became the Joint Commission for TJC. And there's a quote there that I think is a good work from him. "The common sense notion that every hospital should follow every patient it treats to determine whether or not the treatment has been successful and then to inquire if not, why not, with a view to preventing similar failures in the future." I think that is what we do as surgeons, and that's really part of our surgical culture and our M&M culture.
DOUGLAS SMINK: Sadly, 100 years ago, he was roundly criticized for doing this, and his career really ended in disgrace, and he didn't, at the time, get the credit that was due to him. But we have all, I think, taken on this mantle to push for surgical quality and safety. This is the Institute of Medicine. You're probably all familiar with Crossing the Quality Chasm.
DOUGLAS SMINK: And I think it's just important to remember what the six dimensions of quality care are. That care should be safe, effective, patient centered, timely, efficient, and equitable. And although I think this book is over 20 years old, those six dimensions still hold true. When we talk about quality and health care, you often hear the term structured process and outcome. And I think it's important to just remember what we mean when we say those.
DOUGLAS SMINK: So the structure is usually pretty easy to measure, and it can be the structure of the building. How many beds you have, and how many operating rooms. But it's many other things that go into the structure of a hospital and a surgical delivery system that includes the individuals, the equipment, and how that group is sort of arranged. And then the process is how that system acts as a whole. And this is not surprisingly harder to measure.
DOUGLAS SMINK: Process measures can be challenging, but there are quality outcomes that we look at among processes or processes. And then when we talk about outcomes, we typically talk about patient outcomes and the downstream effect, or how the patient does ultimately after their surgical care. These, in some ways, can be easy to measure, but some ways can be hard.
DOUGLAS SMINK: I would say not so hard to measure, but hard to compare across institutions or even providers because of the challenge of risk adjustment. And now, we're very interested in value. We used to talk a lot about quality. As you all know, cost is a very important part of what we do, and we have an expensive health care system. And so it's really important to think of value, which is quality divided by cost.
DOUGLAS SMINK: Now, there's lots of reporting that occurs in quality measures, and so I just thought I'd run down a few of them. I talked about process measures. Those can include adherence to clinical guidelines, management of medications. I think outside of the surgical world, you might think of a process measure as whether a patient with a myocardial infarction got a beta blocker or got to the cath lab within 60 minutes for instance.
DOUGLAS SMINK: We're increasingly interested in patient experience, patient satisfaction. Now, patient reported outcome measures are very important, which are also listed under outcomes there. But we think, traditionally, we've thought a lot about mortality with surgery. But as we've become more and more effective at what we do, mortality is less and less of a differentiator among institutions.
DOUGLAS SMINK: And now, we look more at readmissions, hospital-acquired infections, and some certain complications. And then efficiency is really important. And this gets to the cost and the value that we're talking about. You're probably familiar with some of these groups that do provide data that we do look at. The National Surgical Quality Improvement Program from the HCS is one clinical metric that we use.
DOUGLAS SMINK: It's retrospective, but it uses chart review. It's very accurate but it's very slow and expensive and typically requires data abstractors to go into a sample of patient charts to determine clinical outcomes. And as a result, the samples are limited, and it's just a representative sample, typically, of the care delivered at any one hospital. But it does provide a way to compare across multiple institutions, and there is an ability to risk adjust so that you can compare not only quality, but you can compare the disease severity and co-morbidities of your patients.
DOUGLAS SMINK: And then there are some more administrative metrics that use billing data and some coding to determine complications, and that's similar-- or some databases that are available from AHRQ. The national inpatient sample is one of those. These are less accurate. They are very fast and efficient, and they have large populations of patients often across the entire nation or states, and so it gives a great amount of data, but it tends to be a 30,000 foot view, and sometimes isn't as granular as you may need for certain research questions.
DOUGLAS SMINK: People talk a lot about the quality-improvement cycle that you can use, and there are multiple ones. And I don't profess to say which one is the best to use. I thought I'd show a few of them here. There's the change-acceleration process. There's plan, do, study, act, and there's Six Sigma. These are just some common ones that are out there. And I think all are very good, and they're all very similar. There has to be some vision or plan.
DOUGLAS SMINK: You have to generate an intervention, and you have to implement it. And then to see if it's successful, you have to actually study it and then look at the outcomes. This simply, in a nutshell, and each one of these has its own nuances that some people would say are better than others. I think the key is though that you have to have this cycle.
DOUGLAS SMINK: And so you have to have a plan you have to study it and then, in many instances, have to modify it to continuously improve your quality. I think this is somewhat more important than any one of those specific rubrics that people use. But these are some of the fundamentals of what you need in quality improvement. And I think from the top, leadership support is incredibly important.
DOUGLAS SMINK: Only then will you have an engaged team, and that team, as you know, the care we deliver is multidisciplinary. So you need a multidisciplinary team. It should have front-line staff. It's great to have patients involved. And then you need to be very specific about your aims and your goals. And just like feedback, should be smart. These goals need to be smart.
DOUGLAS SMINK: So specific, measurable, attainable, relevant, and time balance so that they're not infinite time horizons. And then you need to have measures of your success. You have to test your plan. You need to implement your plan, and then you have to spread it. And then the real challenge for quality improvement is it's great to have a quality improvement project, but if it doesn't result in sustained change, then it's really not worth the time put into it.
DOUGLAS SMINK: So you have to have a plan to sustain your quality improvement. I thought I'd just share briefly a experience we had with quality improvement at my hospital, Brigham and Women's Hospital. And this was when I was residency director, and we had a number of residents interested in quality improvement. But I really want to give credit to Peter Najar who is now a faculty member, a colorectal surgeon at Johns Hopkins, but was one of our residents at the time and had done a quality and safety fellowship.
DOUGLAS SMINK: And we noticed that in our department, we kept seeing presentations at morbidity and mortality of patients who had gone home after a major abdominal surgery and suffered a pulmonary embolism or DVT and come back to the hospital. Some of them with catastrophic results. And so we said, is there anything we can do to fix that? First, we started by identifying the problem. We realized that it's the most common cause of death within 30 days of cancer surgery, venous thromboembolism, and we found it was certain patients.
DOUGLAS SMINK: It was patients with cancers and IBDs, so it was many of the patients on our colorectal service. And then we turned, and we realized that we were not doing anything really to prevent this. And we were probably a little bit behind the times. There were multiple guidelines that suggested that patients after discharge should have VTE prophylaxis, and we were not doing that. And so we thought of some of the obstacles.
DOUGLAS SMINK: Initially, obviously, we were not really aware of the evidence in the guidelines, or at least not everybody was. We had no local guideline. We knew it would be costly because we were talking about getting lovenox for people before it was a generic medication, and a lot of logistical barriers to patient compliance as well. But we set out to have a post-discharge prophylaxis program for patients going on to undergo abdominal or public surgery for cancer or IBD.
DOUGLAS SMINK: And I won't get into the specifics, but we ended up adopting a Caprini score, and this is what we used to determine the risk factors for the Caprini score and determine whether our patient qualified for going home on low-molecular weight heparin. And I think this is one of the really drastic and impressive improvements that we saw. So in April 2014, essentially, none of our patients were going home on lovenox.
DOUGLAS SMINK: And within just four months, we had over 90%. And we had some ups and downs after that, but we were able to keep it over 70% and mostly over 80% the rest of the way in. And at this point, it's really become part of the culture in our institution, and it's essentially one of the vital signs that residents talk about every morning on rounds. You can see before versus after.
DOUGLAS SMINK: Our VTE rate went down significantly, and after the intervention, we had no post-discharge events of thromboembolism which was really impressive. So I think this is a good example of quality improvement. I think it's also a great example because it was driven by residents who were seeing this problem and wanted to fix it. And I know this happens at many of our institutions.
DOUGLAS SMINK: Why did it succeed? I think there was leadership support both at the residency level, but also at the departmental level. We had quality officers within the institution that were on board as well. We educated our providers. We created a local guideline, and we gave people feedback about their performance. And as a result, we had a great clinical improvement.
DOUGLAS SMINK: So I will stop there and see if there are any questions for Dr Joshi before we move on to the next TWIS module.
AMIT JOSHI: Yeah, that's a great introduction to advocating for quality care, and a really nice example of how residents can even take the lead. I think what you presented was probably the ultimate version of what a resident can do. Could you give us some insight into what-- I'm thinking of one of my relatively new interns. They're not ready to spearhead a quality-improvement project. They certainly don't have the bandwidth to do it and to get it published and all that, give us some examples of what junior-level residents can do on a day-to-day basis or even on a weekly basis to try to advocate for quality care.
DOUGLAS SMINK: So I think there are some really simple things that we can all do on it, and I would say, I think one of the things as a resident, and I'm sure you felt this way and I did too, there are certain things that you see that occur over and over again for your patients, and you wish you could fix that problem. And I think that's the example that I showed, but it's really hard to change a whole system. But I think there are some really simple things that you can do in quality improvement that don't require that level of change.
DOUGLAS SMINK: And I guess I would start with some of the things that we know are so important, and we talk about all the time. But we don't always implement enough. I think of hand hygiene is one. It's really simple, and it takes some time to do it. I think people are better and better now in the era of COVID, but still they're not perfect. And I think even as a junior resident, you can set an example going in and out of every room in washing your hands.
DOUGLAS SMINK: You can encourage the medical students to do it, and sometimes your senior residents hopefully, to speak up and say, we should all wash our hands. The other thing that I see frequently is around Foley catheters. A lot of institutions have now systems in place for removing catheters, and if they're even placed, removing them on post-op day one, sometimes a nurse driven protocols.
DOUGLAS SMINK: And all those protocols show that it improves patient experience, but it also lowers urinary-tract infections. And so I think part of it is to be aware of some of those quality initiatives, and then be supportive of them and support removing the Foley when it really should be removed. Support the fact that everybody should be washing their hands. Those are just examples.
DOUGLAS SMINK: And then I think it's a good idea to build a little list of things you'd like to fix because as you get further along, you might have a chance and be put in a position to get to change some of them.
AMIT JOSHI: Yeah, I love that idea. Something I talk about in my program is trickle-up leadership or trickle-up professionalism. So even though you may think you're at the bottom of the totem pole, just leading by example, even if it's people who technically outrank you, can be really powerful. So Thanks for those great examples.
DOUGLAS SMINK: And I totally agree. I think for all those interns who are listening in on this at some point, you can be the leader of your team in many different ways. And so don't forget that. That trickle-up up leadership is really important.
AMIT JOSHI: Thanks.
DOUGLAS SMINK: All right, should we move on to the next one?
AMIT JOSHI: Yes.
DOUGLAS SMINK: OK, so the next module we were going to talk about is identifying system errors and root cause analysis. As Dr Joshi mentioned, I have a new role as chief of surgery at one of our affiliate hospitals, Brigham and Women's Faulkner hospital, which has really been a great experience. And I've been really fascinated to see how the cultures of that institution around root cause analysis and safety reporting.
DOUGLAS SMINK: And I've been really impressed about the fact that we have a very open safety reporting and a very nonjudgmental way of doing it. And I've really enjoyed being part of that as the chief of surgery. I do get involved in a lot of those that are surgery related. And I thought I'd just share some of the culture and the outlook that we have at our institution, which is not unique, and I think is true in a lot of institutions.
DOUGLAS SMINK: I think a lot of us think of our medical system and our hospitals as high-reliability organizations. That means we function under very trying conditions all the time. We're incredibly busy. Patients are sick, and yet most of us are able to manage to have very few negative outcomes or accidents.
DOUGLAS SMINK: That's not to say we have zero because that would not be realistic, but we have very few in many of our institutions. And how do we do that? Locally, we have adopted just culture, which you may be familiar with. And it's a guide of how we respond to an adverse event or even a near miss that didn't result in a patient harm, but we felt was worth investigating.
DOUGLAS SMINK: And usually, we have a safety-reporting system, and I'm always impressed how many different people will report sometimes the same incident from different angles and many different specialties and professions. And they report it really just because they think it's something that we can learn about as an institution. And then the just culture, the goal is to find and fix gaps in our system so that we can remain highly reliable.
DOUGLAS SMINK: I think the important thing about just culture is it is often the system that we're looking at, and there may be something broken. Any institution is responsible for the system, but it also does point out that individuals are responsible for their choices. And I think that's an important thing. It's not to be critical of individuals, but it's to realize that we do play a role in our organizations.
DOUGLAS SMINK: So we look at both the system and the choices that individuals make. We have found in our institution that more than 80% of medical error comes from systems. So in our framework, we do look at systems issues first. But we also look at personal performance factors and the choices of any staff member involved in the event. And we ask five questions when we go through these.
DOUGLAS SMINK: So what is the risk? What are the competing priorities for the individuals as they are making that decision? And what's the system they are currently functioning under? And then we really have to ask ourselves, is the system effective? Can it manage risk during normal operations? And if that's true, and it is effective, and it can manage risk, then we move on to the next question.
DOUGLAS SMINK: But if the system that we're looking at is not effective to manage risk under normal circumstances, then we need to think about how do we redesign the system. But if it's effective, the fifth question is, is it resilient? And does that mean, can it function even under abnormal situations? And if no, then again, we need to address the system and redesign it. We also know that the system influences performance.
DOUGLAS SMINK: So obviously, the training that we all undergo impacts our performance. But the environment we work in, the policies and processes, the equipment we have. You all may go to different institutions and realize that at one hospital you have certain equipment, in another hospital you have different equipment and may be more comfortable with it at one or another, and that's important.
DOUGLAS SMINK: And also the system puts stress on us, and we're fatigued. And those are all things that are imposed on individuals by the system. But there are also personal influences that impact our performance. So it may be our own health, mental or physical, experiences that we've had, understanding or perception of how risky a situation is. Sometimes we're just not aware of the risk that we're confronted with.
DOUGLAS SMINK: And then we may have our own personal distractions or stress or fatigue. They may be related to the system, but they may be external to the system. I'm not going to go through any of our specific safety reports, but I do want to just bring up this last slide as I talk about this just culture and safety reporting. I think culture is something that's very hard to change.
DOUGLAS SMINK: But I think we all positive culture when we see one. I've always been struck by this work by Amy Edmondson, who you may be familiar with. She's a business school professor at Harvard Business School, and she has spent a lot of time looking at high-reliability organizations and particularly health care. And she really focuses on psychological safety, and I think that's a system and a team and an environment where you feel comfortable speaking up when you see something that you think is unsafe.
DOUGLAS SMINK: You think you're not going to be reprimanded for it or criticized for it, but that it's safe for you that you feel psychologically safe to speak up and speak your mind. And she's actually done investigations of institutions and compared, for instance hospital units, and looked at their safety-reporting culture. And I think what's fascinating is she has found that units that submit the most safety reports actually have lower complication rates and lower morbidity and mortality, which I think is fascinating.
DOUGLAS SMINK: You would think that they would be-- if they're submitting more reports, that means that the care there is not as good. But actually, it turns out that in her studies, the more safety reports you have, the safer your units. And I think that's because it's a culture where it's safe to speak up, and you speak up for things that may even not be bad outcomes but are just near misses.
DOUGLAS SMINK: And then the group comes together and learns about that mistake so that they don't actually make it again. So I've always been struck by that, and I think it's a fascinating relationship that you might not think would be present but actually is. And I think we've all been in institutions and services and teams where you feel comfortable speaking up, and I think it's actually better for the providers.
DOUGLAS SMINK: But it's also better for the patients.
AMIT JOSHI: Yes, fascinating. I have a question, maybe this is on behalf of my administrator chief resident. The module you just discussed, my takeaway point from that is the more that each individual resident, and frankly, faculty, are exposed to the safety apparatus, so whether that's a root-cause analyses or a reporting mechanism, and certainly the example you gave of VTE prevention.
AMIT JOSHI: The more they're thinking about it, the better safety officers everyone becomes. And so my question for you is, how much time does this take? So maybe I'll just ask you anecdotally. At Brigham, as a program director, how many hours were you-- or how many root-cause analyses were each of your residents involved in? How much time did that take?
AMIT JOSHI: Nothing is time free, and there are many competing interests. So give us some sense of how much commitment it takes.
DOUGLAS SMINK: Yeah, I would say, I think this is a really hard perspective, at least it was hard for me as a resident and even as a program director. I understood the perspective, but I think it was very hard to help my residents, all of my residents, understand it. And so I would encourage residents to try to get involved and be aware. I would say that the large majority of my residents have not been involved in a root-cause analysis.
DOUGLAS SMINK: As useful as I think that would be, it's very time consuming, as you pointed out. I think as a resident, often as well, they might feel like root-cause analyses or safety reporting can be weaponized a little bit, and the finger is pointed at them. And I have felt as a program director the need to protect a resident sometimes from theses. That said, I think in the right culture, they can be really, really helpful.
DOUGLAS SMINK: But they do take time, and in my current job, we do an hour meeting once a week where we go through the root-cause analyses, but actually, our quality and safety division does them and only summarizes them or pulls in individuals to be involved in those RCAs. But then we do a summary that takes an hour or so. We're doing a good number of RCAs. More than a couple a week at a smaller institution than the Brigham.
DOUGLAS SMINK: And trainees are not always involved. I think it would be really helpful. But to your point, there are so many polls on a residents time so I don't have a great answer for that unfortunately.
AMIT JOSHI: Well, I do think that one of your first slides was the importance of leadership in advocating for equality, and so not just heightening the awareness of all the physicians to that-- and I'm specifically talking about physicians here-- but obviously, everyone who takes care of patients needs to be aware of that. But heightening people's awareness and then giving them some space and time and resources to actually try to implement change.
DOUGLAS SMINK: Correct. We'll keep moving, and we're going to talk about working in interprofessional teams. And as I mentioned at the beginning, this is a real area of interest and focus, and something I'm incredibly passionate about. Well, I'm going to talk about teamwork a fair amount, and I've had a great team who I've worked with at multiple setting stratuses.
DOUGLAS SMINK: Our simulation center at the Brigham. CRICO was our malpractice insurer that I work with. And then these are two research centers, the Center for Surgery in Public Health and Ariadne Labs, that I've had just great collaborators to work with. And so I always like to point out the team of physicians, nurses, PhDs that I've gotten to work with to really do this teamwork or to do this work on teamwork I should say.
DOUGLAS SMINK: I'm going to share a few opinions that I have for you. These come from my time both as a program director training surgeons, but also as a trainee myself, and then now, doing research in this area. And my opinions are that I think as surgeons, we focus too much on technical skill. And I think that's true of surgical educators as well. And I'm going to talk about non-technical skills, which I think are at least as important, if not more important, than technical skill in assuring that we deliver safe surgical care.
DOUGLAS SMINK: So I'll try to do all that in the next few minutes. Just so we're all on the same page, what is a team? These are some of the characteristics. Has to be two or more members. The goals and objectives need to be the same. Their tasks are typically interdependent. In many instances, there are multiple sources of information. And if the team is effective, there should be close coordination among team members.
DOUGLAS SMINK: Now, as you heard, I'm actually from Philadelphia, which is where Dr. Joshi is right now, but I've been in New England for over 20 years. And so when I ask people around here what they think of is a team, I would say up until this season they would talk to me about the New England Patriots. But this is the team that we work in on a regular basis. And this is the team that I'm most fascinated by. And so let's talk about that team a little bit more.
DOUGLAS SMINK: I have some questions that I want you to think about. And I'll ask you, do you have a practice with your team, with your surgical team in particular? And then how often do you talk to your team about the work that you do together? So these two things have really driven a lot of this work that I've been involved in because I would say, in many instances, surgeons don't practice with their team, and they almost never talk to their team about the work they do together, and I think both of those are problems.
DOUGLAS SMINK: And I think we're behind other industries as a result. So I'm going to talk a little bit about non-technical skills, and what I mean by that, some training methods, and then a little bit of assessment. So as you heard, I'm very interested in surgical education so I like to think of this with the lens of a surgical educator. And we have a lot of challenges in surgical education. There's so much more that trainees need to know.
DOUGLAS SMINK: We're more sub specialized. We're being pushed to do things faster, more higher quality, at a lower cost. And at the same time, our teams are these dynamic, interprofessional teams that I think are more complicated than they ever were. They're constantly changing, whether it's during an operation or over the course of a day in a pod or a unit.
DOUGLAS SMINK: And so we need to adapt to that. And I take quite offense at some of these studies that have been published in the past 10 years asking whether residents are well trained, and I'm just showing one, but there are a handful of them that question the training of our current residents and our recent graduates. And so to all of you residents listening, I'm going to give you my opinion.
DOUGLAS SMINK: I was asked this at an education meeting in our institution by a very senior surgeon who was retired at that point. And he looked at me, and he said, you don't really think today's residents are as good as they used to be? And I said, actually, sir, I think they're better. And he was so dumbfounded that I would say that to him that I thinks he spilled his coffee on his tie, and I had to help clean him up.
DOUGLAS SMINK: But I do. I really think you guys are better than we were in the past. Unfortunately, we don't stress that enough, but there's so much more that you know than what we used to know. And some of those things are clinical like types of surgery that didn't even exist 30 years ago, or critical care which wasn't even really a specialty when I started training.
DOUGLAS SMINK: There are all these new diseases and treatments. And at the same time, we talk about things like core competencies, professionalism, systems-based practice like our topic today, that were never discussed before. And we talk about quality improvement like we just talked about. And honestly, I find that the people who are most engaged and active and successful in quality improvement are trainees and our junior faculty, not the senior faculty.
DOUGLAS SMINK: The challenge that we have in surgical school education is as those changes that I mentioned earlier have occurred, we've cut back on our autonomy. We still are able to give some, and I think it's enough, but it would be better if it were more. And so as a result, we don't know how good you are, and sometimes you don't know how good you are. But I assure you, you really are fantastic. But I think one of the problems is that we focus too much on technical skills.
DOUGLAS SMINK: So there's a lot of requirements that are around technical skill, the number of operations, the curricula you have to do, even the assessments that are focused on technical skill. I'm not saying that technical skill is not important, but I remember as I was just learning-- just starting to be a surgeon and fascinated with surgical technique, I remember my program director saying that we can teach a monkey to operate.
DOUGLAS SMINK: The question is, can we teach them to think like a surgeon and act like a surgeon? So that's what I think. That's what non-technical skills are, and that's what I've always been driven by. We do know that technical skills matter. So here's a study you're probably familiar with from the New England Journal. They showed that as surgical skill rating or bariatric surgery procedures went up, complications rates went down.
DOUGLAS SMINK: We do know technique matters. But I'm going to argue that technique only takes you so far. So this is a picture of a beautifully performed, technical operation. Done very swiftly, bloodless, no blood loss, beautiful dissection of the portal vein. As you may well gather though, that wasn't the intended operation.
DOUGLAS SMINK: This is a common bile duct injury that occurred during a laprascopic cholecystectomy. And people have done research into these injuries. Larry Way is a surgeon who had a very high referral practice of biliary tract injuries, and you can see there at the bottom that he studied over 250 consecutive cases of laparoscopic bile duct injuries and found that the cause of the error was technical skill only 3% of the time.
DOUGLAS SMINK: And 97% of the time, it was either situation awareness or decision making. And I'll talk about those a little bit more in a second. I have had the privilege of working with a PhD psychologist who has spent part of his career studying surgeons. His name is Stephen Yule, and he developed what's called NOTSS or non-technical skills for surgeons, and he calls them the cognitive.
DOUGLAS SMINK: The way you think and process information. And the social skills, how you interact with your environment that underpins surgical performance of surgical excellence. And so what is NOTSS, and what are non-technical skills? So what is situational awareness? As a surgeon, how aware are you of what is going on around you, whether it's in the operative field, the anatomy, and the structures nearby, or in the operating room?
DOUGLAS SMINK: Who are the people in the room, and what are their abilities and skills? Decision making. So then how do you process your environment and make decisions about what to do next, whether it's a decision of where to dissect or-- Sorry, a decision about where to dissect, or maybe in a trauma case, it might be whether you proceed with a dissection in trying to control the bleeding, or whether you pause and give your anesthesiologist time to catch up.
DOUGLAS SMINK: Leadership is incredibly important as a surgeon and in the operating room. It's an important role for the surgeon. I would argue that actually the leader of the operation is not the surgeon 100% of the time. Sometimes it's the anesthesiologist. Sometimes it's a nurse, but the large majority of time, the surgeon is the leader. And then communication and teamwork are really essential.
DOUGLAS SMINK: And so how do you communicate your decision making, your leadership, to your team so that they function at the highest possible level? We know that non-technical skill failures lead to patient harm. So this is just a list of some studies that have looked at the information that's transmitted or not well received, if information is not fully shared, these can lead to complications and malpractice claims.
DOUGLAS SMINK: So it's important that we train. If we think these non-technical skills are important, it's important that we train them. And these are all areas that if we don't train in them and practice them, why would we expect ourselves to get better? Communication, leadership, decision making, coping with pressure. There are definitely studies that show that if you train teams in surgery, their performance improves.
DOUGLAS SMINK: So this is a VA study showed that the teams that got team training had a more significant drop in morbidity and mortality. And then you may be familiar with a program called TeamSTEPPS which is another team training program, which, again, has been shown to improve morbidity and mortality, as well as team behavior and some process measures after people went through that training.
DOUGLAS SMINK: I've had the real joy of getting to do considerable amounts of team training at my institution and across our city. We have a malpractice insurer that's very forward thinking. They are CRICO, and they have actually supported the training program in our simulation centers across some of the major teaching hospitals in the Boston area to encourage us to do interdisciplinary, multidisciplinary operating room team training where we have five hour sessions.
DOUGLAS SMINK: We have surgeons, anesthesiologists, and nurses doing multiple scenarios. And then actually the learning occurs not in-- this is in simulation-- the learning occurs not in the simulation scenario so much, but in the debriefings that we do afterwards. To Dr. Joshi's comment earlier about these things take time. I do agree, and thankfully, we've been able to generate some incentives to have their physicians participate.
DOUGLAS SMINK: I do want to highlight one concept that we actually teach to those teams and that I think is really important as a surgeon to think about, and it's really about that safety environment, psychological safety, that Amy Edmondson talks about. So I'm going to share this study. I was not involved in this study, but I think it as one of the more elegant ones that I have seen to drive home this point where in a simulation environment, the medical students were taught about a certain procedure.
DOUGLAS SMINK: And they were taught that there is this critical point where if you mistakenly cut the blood vessel, it could be a real problem. And so the students were taught about this procedure, and then they're put in a simulated operating room. And the surgeon intentionally gets up to that point of the procedure and almost cuts the blood vessel and is about to cut the blood vessel. But the randomization occurs in that at the beginning of the procedure, the surgeon either turns to the student and says, your opinion is important.
DOUGLAS SMINK: If you see something unsafe, please speak up. And he or she says that to half the students, and the other half, the surgeon says do what I say and save your questions for next time. And not surprisingly, when the surgeon said, if you see something important, please speak up, over 80% of the time the students speak up. Markedly different from when they're told, save your questions for next time.
DOUGLAS SMINK: In our simulation training program, we actually do practice the safe surgery checklist. And now at my institution, this is our checklist at Brigham and Women's Faulkner Hospital. And you can see in relatively small fonts at the bottom, we've added to this as part of each section of the safety pause. If anyone sees anything unsafe, please speak up in an attempt to try to create a psychologically safe environment.
DOUGLAS SMINK: I'll talk just briefly about assessment, and you might ask, why should we assess our behavior at work? Well, a lot of other high-reliability or high-risk industries and high-reliability organizations do assess their behavior, and it's part of the job of pilots and offshore oil rig experts to actually go and observe others doing their job and give them feedback about how well they do it, and how safely they do it.
DOUGLAS SMINK: This is the USS Midway, which now is a museum in San Diego, and I've had walked on it. It has cut outs of the different jobs of different people on the aircraft carrier, and this person there, he is the safety officer. And his job is to observe every takeoff and landing and then give safety-related feedback to the pilots afterwards. And I've always been fascinated by that and thought, wouldn't it be great if we had surgeons go and observe other surgeons and give them feedback about how they performed and the safety of their operating room, specifically around their non-technical skills.
DOUGLAS SMINK: So this is a little bit about the NOTSS taxonomy. I told you that the categories are situational awareness, decision making, communication and teamwork, and leadership. And I think the beauty of NOTSS is that it's one thing for me to tell a resident, well, you need to improve your situational awareness. But actually, NOTSS has elements within that. So there are different aspects of situational awareness. It might be their gathering of information, it might be about how they understand the information, or it might be how they project what's going to happen next.
DOUGLAS SMINK: And then even within that, there are specific good and bad behaviors. So within situation awareness, I mentioned gathering information. NOTSS has a list of good behaviors and poor behaviors for a surgeon to either emulate or try to avoid. There is an assessment scale built into NOTSS.
DOUGLAS SMINK: And actually, it's being used around the world, including in North America, increasingly so. But it did start in the United Kingdom, and Europe is the place that it's used the most, I would say. Trainees in the UK actually have to be assessed on their non-technical skills twice a year during their training, and I would love to see us get to the point where we do that here in the US.
DOUGLAS SMINK: So hopefully, I've helped you understand that these non-technical skills that are so important in our interdisciplinary teams, we can observe, we can coach, and then we can assess.
AMIT JOSHI: Thank you, Doctor. You and Dr Yule have really established yourselves as leaders in NOTSS certainly in America but even in Europe. So to hear you give a masterclass in NOTSS is fantastic. I have certainly encouraged myself and my residents to look over those checklists and even just the traits of good, high achievers in non-technical skills. It's a great thing to look at.
AMIT JOSHI: All of those are linked on the SCORE portal and within this specific module. Can I ask you, for residents who are interested in becoming even more proficient and delving more into the world of NOTSS, what's a good place to start, and what are some good resources to look at?
DOUGLAS SMINK: Sure, so I would say, there are a number of ways you can do that. I think that the most important thing to realize, and I think if a resident is to the point where they wanted to delve into it more, I think they've realized that these non-technical skills are not just innate. I used to feel like leadership might be something there was an innate skill and is not something you could teach. But I'm increasingly aware of the ability to teach those things and to improve them on your own.
DOUGLAS SMINK: There is a NOTSS handbook which is on the SCORE website. We've recently published an updated version. The NOTSS handbook was written with observations in Scotland. We've recently done some observations in the US and updated it with some slightly different skills. There's a lot of overlap, but there are some slightly different ones that I've had the chance to publish with Dr Yule and some folks at the American College of Surgeons.
DOUGLAS SMINK: So you could certainly look that up. I think the really key thing as a resident is to be aware of these skills and to observe them in others. It's easier to observe them in others than in yourself, and I would look out for or seek out the faculty that you think are the best leaders in the operating room or seem to have the best decision making. And I would do everything you can to observe them and particularly around decision making.
DOUGLAS SMINK: I would ask them, how do you make those decisions? Why are you doing it that way? And then the other thing I would challenge you to do, and I find this really helpful with my trainees, is to as you're doing a procedure, think out loud so that the attending hears what you're thinking, and particularly around your decision making. That's one of the best ways to improve your decision making and require, I think, an upfront discussion with the faculty to say, I'd like to work on how I make decisions during an operation.
DOUGLAS SMINK: So I'm going to try to talk out loud while I'm doing them, and I'd love your feedback on how you're doing, or how I'm doing because that's one of the challenges with some of these non-technical skills is they're not so easy to observe. But I think if you are purposeful about it, and you try to articulate some of your thoughts and your decisions and your awareness of what's going on around you, you'll be able to improve it over time.
AMIT JOSHI: Great advice. Dr Smink, thank you so much. This has been a great episode of SCORE School, and we'll see everyone next week. Thank you.
DOUGLAS SMINK: Thanks so much for having me.
Segment:0 .
AMIT JOSHI: Hello, everyone. It's Amit Joshi from SCORE. It's my great privilege to introduce Dr Doug Smink today who will be lecturing us on systems-based practice for SCORE School. Dr Smink is a great friend of SCORE having served as a longtime member of the score editorial board and frequent contributor. He's really a leader in surgical education. He currently serves as the chief of surgery at Brigham and Women's Faulkner Hospital.
AMIT JOSHI: He also serves as the associate chair of education at Brigham and Women's having just completed a long term as program director of the General Surgery Residency. Dr Smink received his medical degree from the University of Pennsylvania before completing his residency and general surgery at the Brigham where he also obtained an MPH from Harvard and finished a fellowship in minimally-invasive surgery at Dartmouth.
AMIT JOSHI: He currently is the editor in chief of the Journal of Surgical Education. He's a member of the American College of Surgeons Academy of Master Surgeon Educators and the APDSes president-elect. His clinical interests include abdominal wall hernias, fore-gut surgery, and biliary-track disease, and his research focuses on resident and faculty education, and how to teach communication, leadership, and decision making to surgeons and surgical teams.
AMIT JOSHI: For that work, he has a co-PI on an NIH RO1 provider awareness cultural dexterity toolkit for surgeons grant. With all those credentials, I can't think of anyone better to give our talk on systems-based practice. Thank you, Doug, for lending us your expertise.
DOUGLAS SMINK: Thanks, Ahmed. This is really an honor to get to be a part of SCORE School. I have loved being a part of the SCORE editorial board now for nine years, and it's really exciting to see this new addition. And I'm honored to be given the opportunity to speak, and I'm going to dive right in. As I looked at the TWIS modules, I would say this is a pretty busy, busy week. And there's a lot to unpack here among these TWIS modules.
DOUGLAS SMINK: I am going to focus on three of them. Advocating for quality patient care, identifying system errors root cause analysis, and then working in interprofessional teams. And as you just were nice enough to mention in that intro, a lot of my research interest is in interprofessional teams. And so that's really exciting for me to get to share some of my thoughts about that with you all.
DOUGLAS SMINK: So we'll start by advocating for quality patient care. I like surgical history so I thought I'd start with a little bit of history. You may be aware of Ernest Codman. He was a surgeon actually in Boston at Mass General Hospital, and he was really a pioneer in looking at patient safety and quality. He was one of, if not maybe the first person, to record his own patient's complications and outcomes, and he really encouraged other people to do the same.
DOUGLAS SMINK: He instituted the first morbidity and mortality conference. He founded the American College of Surgeons Hospital Standardization Program, which became the Joint Commission for TJC. And there's a quote there that I think is a good work from him. "The common sense notion that every hospital should follow every patient it treats to determine whether or not the treatment has been successful and then to inquire if not, why not, with a view to preventing similar failures in the future." I think that is what we do as surgeons, and that's really part of our surgical culture and our M&M culture.
DOUGLAS SMINK: Sadly, 100 years ago, he was roundly criticized for doing this, and his career really ended in disgrace, and he didn't, at the time, get the credit that was due to him. But we have all, I think, taken on this mantle to push for surgical quality and safety. This is the Institute of Medicine. You're probably all familiar with Crossing the Quality Chasm.
DOUGLAS SMINK: And I think it's just important to remember what the six dimensions of quality care are. That care should be safe, effective, patient centered, timely, efficient, and equitable. And although I think this book is over 20 years old, those six dimensions still hold true. When we talk about quality and health care, you often hear the term structured process and outcome. And I think it's important to just remember what we mean when we say those.
DOUGLAS SMINK: So the structure is usually pretty easy to measure, and it can be the structure of the building. How many beds you have, and how many operating rooms. But it's many other things that go into the structure of a hospital and a surgical delivery system that includes the individuals, the equipment, and how that group is sort of arranged. And then the process is how that system acts as a whole. And this is not surprisingly harder to measure.
DOUGLAS SMINK: Process measures can be challenging, but there are quality outcomes that we look at among processes or processes. And then when we talk about outcomes, we typically talk about patient outcomes and the downstream effect, or how the patient does ultimately after their surgical care. These, in some ways, can be easy to measure, but some ways can be hard.
DOUGLAS SMINK: I would say not so hard to measure, but hard to compare across institutions or even providers because of the challenge of risk adjustment. And now, we're very interested in value. We used to talk a lot about quality. As you all know, cost is a very important part of what we do, and we have an expensive health care system. And so it's really important to think of value, which is quality divided by cost.
DOUGLAS SMINK: Now, there's lots of reporting that occurs in quality measures, and so I just thought I'd run down a few of them. I talked about process measures. Those can include adherence to clinical guidelines, management of medications. I think outside of the surgical world, you might think of a process measure as whether a patient with a myocardial infarction got a beta blocker or got to the cath lab within 60 minutes for instance.
DOUGLAS SMINK: We're increasingly interested in patient experience, patient satisfaction. Now, patient reported outcome measures are very important, which are also listed under outcomes there. But we think, traditionally, we've thought a lot about mortality with surgery. But as we've become more and more effective at what we do, mortality is less and less of a differentiator among institutions.
DOUGLAS SMINK: And now, we look more at readmissions, hospital-acquired infections, and some certain complications. And then efficiency is really important. And this gets to the cost and the value that we're talking about. You're probably familiar with some of these groups that do provide data that we do look at. The National Surgical Quality Improvement Program from the HCS is one clinical metric that we use.
DOUGLAS SMINK: It's retrospective, but it uses chart review. It's very accurate but it's very slow and expensive and typically requires data abstractors to go into a sample of patient charts to determine clinical outcomes. And as a result, the samples are limited, and it's just a representative sample, typically, of the care delivered at any one hospital. But it does provide a way to compare across multiple institutions, and there is an ability to risk adjust so that you can compare not only quality, but you can compare the disease severity and co-morbidities of your patients.
DOUGLAS SMINK: And then there are some more administrative metrics that use billing data and some coding to determine complications, and that's similar-- or some databases that are available from AHRQ. The national inpatient sample is one of those. These are less accurate. They are very fast and efficient, and they have large populations of patients often across the entire nation or states, and so it gives a great amount of data, but it tends to be a 30,000 foot view, and sometimes isn't as granular as you may need for certain research questions.
DOUGLAS SMINK: People talk a lot about the quality-improvement cycle that you can use, and there are multiple ones. And I don't profess to say which one is the best to use. I thought I'd show a few of them here. There's the change-acceleration process. There's plan, do, study, act, and there's Six Sigma. These are just some common ones that are out there. And I think all are very good, and they're all very similar. There has to be some vision or plan.
DOUGLAS SMINK: You have to generate an intervention, and you have to implement it. And then to see if it's successful, you have to actually study it and then look at the outcomes. This simply, in a nutshell, and each one of these has its own nuances that some people would say are better than others. I think the key is though that you have to have this cycle.
DOUGLAS SMINK: And so you have to have a plan you have to study it and then, in many instances, have to modify it to continuously improve your quality. I think this is somewhat more important than any one of those specific rubrics that people use. But these are some of the fundamentals of what you need in quality improvement. And I think from the top, leadership support is incredibly important.
DOUGLAS SMINK: Only then will you have an engaged team, and that team, as you know, the care we deliver is multidisciplinary. So you need a multidisciplinary team. It should have front-line staff. It's great to have patients involved. And then you need to be very specific about your aims and your goals. And just like feedback, should be smart. These goals need to be smart.
DOUGLAS SMINK: So specific, measurable, attainable, relevant, and time balance so that they're not infinite time horizons. And then you need to have measures of your success. You have to test your plan. You need to implement your plan, and then you have to spread it. And then the real challenge for quality improvement is it's great to have a quality improvement project, but if it doesn't result in sustained change, then it's really not worth the time put into it.
DOUGLAS SMINK: So you have to have a plan to sustain your quality improvement. I thought I'd just share briefly a experience we had with quality improvement at my hospital, Brigham and Women's Hospital. And this was when I was residency director, and we had a number of residents interested in quality improvement. But I really want to give credit to Peter Najar who is now a faculty member, a colorectal surgeon at Johns Hopkins, but was one of our residents at the time and had done a quality and safety fellowship.
DOUGLAS SMINK: And we noticed that in our department, we kept seeing presentations at morbidity and mortality of patients who had gone home after a major abdominal surgery and suffered a pulmonary embolism or DVT and come back to the hospital. Some of them with catastrophic results. And so we said, is there anything we can do to fix that? First, we started by identifying the problem. We realized that it's the most common cause of death within 30 days of cancer surgery, venous thromboembolism, and we found it was certain patients.
DOUGLAS SMINK: It was patients with cancers and IBDs, so it was many of the patients on our colorectal service. And then we turned, and we realized that we were not doing anything really to prevent this. And we were probably a little bit behind the times. There were multiple guidelines that suggested that patients after discharge should have VTE prophylaxis, and we were not doing that. And so we thought of some of the obstacles.
DOUGLAS SMINK: Initially, obviously, we were not really aware of the evidence in the guidelines, or at least not everybody was. We had no local guideline. We knew it would be costly because we were talking about getting lovenox for people before it was a generic medication, and a lot of logistical barriers to patient compliance as well. But we set out to have a post-discharge prophylaxis program for patients going on to undergo abdominal or public surgery for cancer or IBD.
DOUGLAS SMINK: And I won't get into the specifics, but we ended up adopting a Caprini score, and this is what we used to determine the risk factors for the Caprini score and determine whether our patient qualified for going home on low-molecular weight heparin. And I think this is one of the really drastic and impressive improvements that we saw. So in April 2014, essentially, none of our patients were going home on lovenox.
DOUGLAS SMINK: And within just four months, we had over 90%. And we had some ups and downs after that, but we were able to keep it over 70% and mostly over 80% the rest of the way in. And at this point, it's really become part of the culture in our institution, and it's essentially one of the vital signs that residents talk about every morning on rounds. You can see before versus after.
DOUGLAS SMINK: Our VTE rate went down significantly, and after the intervention, we had no post-discharge events of thromboembolism which was really impressive. So I think this is a good example of quality improvement. I think it's also a great example because it was driven by residents who were seeing this problem and wanted to fix it. And I know this happens at many of our institutions.
DOUGLAS SMINK: Why did it succeed? I think there was leadership support both at the residency level, but also at the departmental level. We had quality officers within the institution that were on board as well. We educated our providers. We created a local guideline, and we gave people feedback about their performance. And as a result, we had a great clinical improvement.
DOUGLAS SMINK: So I will stop there and see if there are any questions for Dr Joshi before we move on to the next TWIS module.
AMIT JOSHI: Yeah, that's a great introduction to advocating for quality care, and a really nice example of how residents can even take the lead. I think what you presented was probably the ultimate version of what a resident can do. Could you give us some insight into what-- I'm thinking of one of my relatively new interns. They're not ready to spearhead a quality-improvement project. They certainly don't have the bandwidth to do it and to get it published and all that, give us some examples of what junior-level residents can do on a day-to-day basis or even on a weekly basis to try to advocate for quality care.
DOUGLAS SMINK: So I think there are some really simple things that we can all do on it, and I would say, I think one of the things as a resident, and I'm sure you felt this way and I did too, there are certain things that you see that occur over and over again for your patients, and you wish you could fix that problem. And I think that's the example that I showed, but it's really hard to change a whole system. But I think there are some really simple things that you can do in quality improvement that don't require that level of change.
DOUGLAS SMINK: And I guess I would start with some of the things that we know are so important, and we talk about all the time. But we don't always implement enough. I think of hand hygiene is one. It's really simple, and it takes some time to do it. I think people are better and better now in the era of COVID, but still they're not perfect. And I think even as a junior resident, you can set an example going in and out of every room in washing your hands.
DOUGLAS SMINK: You can encourage the medical students to do it, and sometimes your senior residents hopefully, to speak up and say, we should all wash our hands. The other thing that I see frequently is around Foley catheters. A lot of institutions have now systems in place for removing catheters, and if they're even placed, removing them on post-op day one, sometimes a nurse driven protocols.
DOUGLAS SMINK: And all those protocols show that it improves patient experience, but it also lowers urinary-tract infections. And so I think part of it is to be aware of some of those quality initiatives, and then be supportive of them and support removing the Foley when it really should be removed. Support the fact that everybody should be washing their hands. Those are just examples.
DOUGLAS SMINK: And then I think it's a good idea to build a little list of things you'd like to fix because as you get further along, you might have a chance and be put in a position to get to change some of them.
AMIT JOSHI: Yeah, I love that idea. Something I talk about in my program is trickle-up leadership or trickle-up professionalism. So even though you may think you're at the bottom of the totem pole, just leading by example, even if it's people who technically outrank you, can be really powerful. So Thanks for those great examples.
DOUGLAS SMINK: And I totally agree. I think for all those interns who are listening in on this at some point, you can be the leader of your team in many different ways. And so don't forget that. That trickle-up up leadership is really important.
AMIT JOSHI: Thanks.
DOUGLAS SMINK: All right, should we move on to the next one?
AMIT JOSHI: Yes.
DOUGLAS SMINK: OK, so the next module we were going to talk about is identifying system errors and root cause analysis. As Dr Joshi mentioned, I have a new role as chief of surgery at one of our affiliate hospitals, Brigham and Women's Faulkner hospital, which has really been a great experience. And I've been really fascinated to see how the cultures of that institution around root cause analysis and safety reporting.
DOUGLAS SMINK: And I've been really impressed about the fact that we have a very open safety reporting and a very nonjudgmental way of doing it. And I've really enjoyed being part of that as the chief of surgery. I do get involved in a lot of those that are surgery related. And I thought I'd just share some of the culture and the outlook that we have at our institution, which is not unique, and I think is true in a lot of institutions.
DOUGLAS SMINK: I think a lot of us think of our medical system and our hospitals as high-reliability organizations. That means we function under very trying conditions all the time. We're incredibly busy. Patients are sick, and yet most of us are able to manage to have very few negative outcomes or accidents.
DOUGLAS SMINK: That's not to say we have zero because that would not be realistic, but we have very few in many of our institutions. And how do we do that? Locally, we have adopted just culture, which you may be familiar with. And it's a guide of how we respond to an adverse event or even a near miss that didn't result in a patient harm, but we felt was worth investigating.
DOUGLAS SMINK: And usually, we have a safety-reporting system, and I'm always impressed how many different people will report sometimes the same incident from different angles and many different specialties and professions. And they report it really just because they think it's something that we can learn about as an institution. And then the just culture, the goal is to find and fix gaps in our system so that we can remain highly reliable.
DOUGLAS SMINK: I think the important thing about just culture is it is often the system that we're looking at, and there may be something broken. Any institution is responsible for the system, but it also does point out that individuals are responsible for their choices. And I think that's an important thing. It's not to be critical of individuals, but it's to realize that we do play a role in our organizations.
DOUGLAS SMINK: So we look at both the system and the choices that individuals make. We have found in our institution that more than 80% of medical error comes from systems. So in our framework, we do look at systems issues first. But we also look at personal performance factors and the choices of any staff member involved in the event. And we ask five questions when we go through these.
DOUGLAS SMINK: So what is the risk? What are the competing priorities for the individuals as they are making that decision? And what's the system they are currently functioning under? And then we really have to ask ourselves, is the system effective? Can it manage risk during normal operations? And if that's true, and it is effective, and it can manage risk, then we move on to the next question.
DOUGLAS SMINK: But if the system that we're looking at is not effective to manage risk under normal circumstances, then we need to think about how do we redesign the system. But if it's effective, the fifth question is, is it resilient? And does that mean, can it function even under abnormal situations? And if no, then again, we need to address the system and redesign it. We also know that the system influences performance.
DOUGLAS SMINK: So obviously, the training that we all undergo impacts our performance. But the environment we work in, the policies and processes, the equipment we have. You all may go to different institutions and realize that at one hospital you have certain equipment, in another hospital you have different equipment and may be more comfortable with it at one or another, and that's important.
DOUGLAS SMINK: And also the system puts stress on us, and we're fatigued. And those are all things that are imposed on individuals by the system. But there are also personal influences that impact our performance. So it may be our own health, mental or physical, experiences that we've had, understanding or perception of how risky a situation is. Sometimes we're just not aware of the risk that we're confronted with.
DOUGLAS SMINK: And then we may have our own personal distractions or stress or fatigue. They may be related to the system, but they may be external to the system. I'm not going to go through any of our specific safety reports, but I do want to just bring up this last slide as I talk about this just culture and safety reporting. I think culture is something that's very hard to change.
DOUGLAS SMINK: But I think we all positive culture when we see one. I've always been struck by this work by Amy Edmondson, who you may be familiar with. She's a business school professor at Harvard Business School, and she has spent a lot of time looking at high-reliability organizations and particularly health care. And she really focuses on psychological safety, and I think that's a system and a team and an environment where you feel comfortable speaking up when you see something that you think is unsafe.
DOUGLAS SMINK: You think you're not going to be reprimanded for it or criticized for it, but that it's safe for you that you feel psychologically safe to speak up and speak your mind. And she's actually done investigations of institutions and compared, for instance hospital units, and looked at their safety-reporting culture. And I think what's fascinating is she has found that units that submit the most safety reports actually have lower complication rates and lower morbidity and mortality, which I think is fascinating.
DOUGLAS SMINK: You would think that they would be-- if they're submitting more reports, that means that the care there is not as good. But actually, it turns out that in her studies, the more safety reports you have, the safer your units. And I think that's because it's a culture where it's safe to speak up, and you speak up for things that may even not be bad outcomes but are just near misses.
DOUGLAS SMINK: And then the group comes together and learns about that mistake so that they don't actually make it again. So I've always been struck by that, and I think it's a fascinating relationship that you might not think would be present but actually is. And I think we've all been in institutions and services and teams where you feel comfortable speaking up, and I think it's actually better for the providers.
DOUGLAS SMINK: But it's also better for the patients.
AMIT JOSHI: Yes, fascinating. I have a question, maybe this is on behalf of my administrator chief resident. The module you just discussed, my takeaway point from that is the more that each individual resident, and frankly, faculty, are exposed to the safety apparatus, so whether that's a root-cause analyses or a reporting mechanism, and certainly the example you gave of VTE prevention.
AMIT JOSHI: The more they're thinking about it, the better safety officers everyone becomes. And so my question for you is, how much time does this take? So maybe I'll just ask you anecdotally. At Brigham, as a program director, how many hours were you-- or how many root-cause analyses were each of your residents involved in? How much time did that take?
AMIT JOSHI: Nothing is time free, and there are many competing interests. So give us some sense of how much commitment it takes.
DOUGLAS SMINK: Yeah, I would say, I think this is a really hard perspective, at least it was hard for me as a resident and even as a program director. I understood the perspective, but I think it was very hard to help my residents, all of my residents, understand it. And so I would encourage residents to try to get involved and be aware. I would say that the large majority of my residents have not been involved in a root-cause analysis.
DOUGLAS SMINK: As useful as I think that would be, it's very time consuming, as you pointed out. I think as a resident, often as well, they might feel like root-cause analyses or safety reporting can be weaponized a little bit, and the finger is pointed at them. And I have felt as a program director the need to protect a resident sometimes from theses. That said, I think in the right culture, they can be really, really helpful.
DOUGLAS SMINK: But they do take time, and in my current job, we do an hour meeting once a week where we go through the root-cause analyses, but actually, our quality and safety division does them and only summarizes them or pulls in individuals to be involved in those RCAs. But then we do a summary that takes an hour or so. We're doing a good number of RCAs. More than a couple a week at a smaller institution than the Brigham.
DOUGLAS SMINK: And trainees are not always involved. I think it would be really helpful. But to your point, there are so many polls on a residents time so I don't have a great answer for that unfortunately.
AMIT JOSHI: Well, I do think that one of your first slides was the importance of leadership in advocating for equality, and so not just heightening the awareness of all the physicians to that-- and I'm specifically talking about physicians here-- but obviously, everyone who takes care of patients needs to be aware of that. But heightening people's awareness and then giving them some space and time and resources to actually try to implement change.
DOUGLAS SMINK: Correct. We'll keep moving, and we're going to talk about working in interprofessional teams. And as I mentioned at the beginning, this is a real area of interest and focus, and something I'm incredibly passionate about. Well, I'm going to talk about teamwork a fair amount, and I've had a great team who I've worked with at multiple setting stratuses.
DOUGLAS SMINK: Our simulation center at the Brigham. CRICO was our malpractice insurer that I work with. And then these are two research centers, the Center for Surgery in Public Health and Ariadne Labs, that I've had just great collaborators to work with. And so I always like to point out the team of physicians, nurses, PhDs that I've gotten to work with to really do this teamwork or to do this work on teamwork I should say.
DOUGLAS SMINK: I'm going to share a few opinions that I have for you. These come from my time both as a program director training surgeons, but also as a trainee myself, and then now, doing research in this area. And my opinions are that I think as surgeons, we focus too much on technical skill. And I think that's true of surgical educators as well. And I'm going to talk about non-technical skills, which I think are at least as important, if not more important, than technical skill in assuring that we deliver safe surgical care.
DOUGLAS SMINK: So I'll try to do all that in the next few minutes. Just so we're all on the same page, what is a team? These are some of the characteristics. Has to be two or more members. The goals and objectives need to be the same. Their tasks are typically interdependent. In many instances, there are multiple sources of information. And if the team is effective, there should be close coordination among team members.
DOUGLAS SMINK: Now, as you heard, I'm actually from Philadelphia, which is where Dr. Joshi is right now, but I've been in New England for over 20 years. And so when I ask people around here what they think of is a team, I would say up until this season they would talk to me about the New England Patriots. But this is the team that we work in on a regular basis. And this is the team that I'm most fascinated by. And so let's talk about that team a little bit more.
DOUGLAS SMINK: I have some questions that I want you to think about. And I'll ask you, do you have a practice with your team, with your surgical team in particular? And then how often do you talk to your team about the work that you do together? So these two things have really driven a lot of this work that I've been involved in because I would say, in many instances, surgeons don't practice with their team, and they almost never talk to their team about the work they do together, and I think both of those are problems.
DOUGLAS SMINK: And I think we're behind other industries as a result. So I'm going to talk a little bit about non-technical skills, and what I mean by that, some training methods, and then a little bit of assessment. So as you heard, I'm very interested in surgical education so I like to think of this with the lens of a surgical educator. And we have a lot of challenges in surgical education. There's so much more that trainees need to know.
DOUGLAS SMINK: We're more sub specialized. We're being pushed to do things faster, more higher quality, at a lower cost. And at the same time, our teams are these dynamic, interprofessional teams that I think are more complicated than they ever were. They're constantly changing, whether it's during an operation or over the course of a day in a pod or a unit.
DOUGLAS SMINK: And so we need to adapt to that. And I take quite offense at some of these studies that have been published in the past 10 years asking whether residents are well trained, and I'm just showing one, but there are a handful of them that question the training of our current residents and our recent graduates. And so to all of you residents listening, I'm going to give you my opinion.
DOUGLAS SMINK: I was asked this at an education meeting in our institution by a very senior surgeon who was retired at that point. And he looked at me, and he said, you don't really think today's residents are as good as they used to be? And I said, actually, sir, I think they're better. And he was so dumbfounded that I would say that to him that I thinks he spilled his coffee on his tie, and I had to help clean him up.
DOUGLAS SMINK: But I do. I really think you guys are better than we were in the past. Unfortunately, we don't stress that enough, but there's so much more that you know than what we used to know. And some of those things are clinical like types of surgery that didn't even exist 30 years ago, or critical care which wasn't even really a specialty when I started training.
DOUGLAS SMINK: There are all these new diseases and treatments. And at the same time, we talk about things like core competencies, professionalism, systems-based practice like our topic today, that were never discussed before. And we talk about quality improvement like we just talked about. And honestly, I find that the people who are most engaged and active and successful in quality improvement are trainees and our junior faculty, not the senior faculty.
DOUGLAS SMINK: The challenge that we have in surgical school education is as those changes that I mentioned earlier have occurred, we've cut back on our autonomy. We still are able to give some, and I think it's enough, but it would be better if it were more. And so as a result, we don't know how good you are, and sometimes you don't know how good you are. But I assure you, you really are fantastic. But I think one of the problems is that we focus too much on technical skills.
DOUGLAS SMINK: So there's a lot of requirements that are around technical skill, the number of operations, the curricula you have to do, even the assessments that are focused on technical skill. I'm not saying that technical skill is not important, but I remember as I was just learning-- just starting to be a surgeon and fascinated with surgical technique, I remember my program director saying that we can teach a monkey to operate.
DOUGLAS SMINK: The question is, can we teach them to think like a surgeon and act like a surgeon? So that's what I think. That's what non-technical skills are, and that's what I've always been driven by. We do know that technical skills matter. So here's a study you're probably familiar with from the New England Journal. They showed that as surgical skill rating or bariatric surgery procedures went up, complications rates went down.
DOUGLAS SMINK: We do know technique matters. But I'm going to argue that technique only takes you so far. So this is a picture of a beautifully performed, technical operation. Done very swiftly, bloodless, no blood loss, beautiful dissection of the portal vein. As you may well gather though, that wasn't the intended operation.
DOUGLAS SMINK: This is a common bile duct injury that occurred during a laprascopic cholecystectomy. And people have done research into these injuries. Larry Way is a surgeon who had a very high referral practice of biliary tract injuries, and you can see there at the bottom that he studied over 250 consecutive cases of laparoscopic bile duct injuries and found that the cause of the error was technical skill only 3% of the time.
DOUGLAS SMINK: And 97% of the time, it was either situation awareness or decision making. And I'll talk about those a little bit more in a second. I have had the privilege of working with a PhD psychologist who has spent part of his career studying surgeons. His name is Stephen Yule, and he developed what's called NOTSS or non-technical skills for surgeons, and he calls them the cognitive.
DOUGLAS SMINK: The way you think and process information. And the social skills, how you interact with your environment that underpins surgical performance of surgical excellence. And so what is NOTSS, and what are non-technical skills? So what is situational awareness? As a surgeon, how aware are you of what is going on around you, whether it's in the operative field, the anatomy, and the structures nearby, or in the operating room?
DOUGLAS SMINK: Who are the people in the room, and what are their abilities and skills? Decision making. So then how do you process your environment and make decisions about what to do next, whether it's a decision of where to dissect or-- Sorry, a decision about where to dissect, or maybe in a trauma case, it might be whether you proceed with a dissection in trying to control the bleeding, or whether you pause and give your anesthesiologist time to catch up.
DOUGLAS SMINK: Leadership is incredibly important as a surgeon and in the operating room. It's an important role for the surgeon. I would argue that actually the leader of the operation is not the surgeon 100% of the time. Sometimes it's the anesthesiologist. Sometimes it's a nurse, but the large majority of time, the surgeon is the leader. And then communication and teamwork are really essential.
DOUGLAS SMINK: And so how do you communicate your decision making, your leadership, to your team so that they function at the highest possible level? We know that non-technical skill failures lead to patient harm. So this is just a list of some studies that have looked at the information that's transmitted or not well received, if information is not fully shared, these can lead to complications and malpractice claims.
DOUGLAS SMINK: So it's important that we train. If we think these non-technical skills are important, it's important that we train them. And these are all areas that if we don't train in them and practice them, why would we expect ourselves to get better? Communication, leadership, decision making, coping with pressure. There are definitely studies that show that if you train teams in surgery, their performance improves.
DOUGLAS SMINK: So this is a VA study showed that the teams that got team training had a more significant drop in morbidity and mortality. And then you may be familiar with a program called TeamSTEPPS which is another team training program, which, again, has been shown to improve morbidity and mortality, as well as team behavior and some process measures after people went through that training.
DOUGLAS SMINK: I've had the real joy of getting to do considerable amounts of team training at my institution and across our city. We have a malpractice insurer that's very forward thinking. They are CRICO, and they have actually supported the training program in our simulation centers across some of the major teaching hospitals in the Boston area to encourage us to do interdisciplinary, multidisciplinary operating room team training where we have five hour sessions.
DOUGLAS SMINK: We have surgeons, anesthesiologists, and nurses doing multiple scenarios. And then actually the learning occurs not in-- this is in simulation-- the learning occurs not in the simulation scenario so much, but in the debriefings that we do afterwards. To Dr. Joshi's comment earlier about these things take time. I do agree, and thankfully, we've been able to generate some incentives to have their physicians participate.
DOUGLAS SMINK: I do want to highlight one concept that we actually teach to those teams and that I think is really important as a surgeon to think about, and it's really about that safety environment, psychological safety, that Amy Edmondson talks about. So I'm going to share this study. I was not involved in this study, but I think it as one of the more elegant ones that I have seen to drive home this point where in a simulation environment, the medical students were taught about a certain procedure.
DOUGLAS SMINK: And they were taught that there is this critical point where if you mistakenly cut the blood vessel, it could be a real problem. And so the students were taught about this procedure, and then they're put in a simulated operating room. And the surgeon intentionally gets up to that point of the procedure and almost cuts the blood vessel and is about to cut the blood vessel. But the randomization occurs in that at the beginning of the procedure, the surgeon either turns to the student and says, your opinion is important.
DOUGLAS SMINK: If you see something unsafe, please speak up. And he or she says that to half the students, and the other half, the surgeon says do what I say and save your questions for next time. And not surprisingly, when the surgeon said, if you see something important, please speak up, over 80% of the time the students speak up. Markedly different from when they're told, save your questions for next time.
DOUGLAS SMINK: In our simulation training program, we actually do practice the safe surgery checklist. And now at my institution, this is our checklist at Brigham and Women's Faulkner Hospital. And you can see in relatively small fonts at the bottom, we've added to this as part of each section of the safety pause. If anyone sees anything unsafe, please speak up in an attempt to try to create a psychologically safe environment.
DOUGLAS SMINK: I'll talk just briefly about assessment, and you might ask, why should we assess our behavior at work? Well, a lot of other high-reliability or high-risk industries and high-reliability organizations do assess their behavior, and it's part of the job of pilots and offshore oil rig experts to actually go and observe others doing their job and give them feedback about how well they do it, and how safely they do it.
DOUGLAS SMINK: This is the USS Midway, which now is a museum in San Diego, and I've had walked on it. It has cut outs of the different jobs of different people on the aircraft carrier, and this person there, he is the safety officer. And his job is to observe every takeoff and landing and then give safety-related feedback to the pilots afterwards. And I've always been fascinated by that and thought, wouldn't it be great if we had surgeons go and observe other surgeons and give them feedback about how they performed and the safety of their operating room, specifically around their non-technical skills.
DOUGLAS SMINK: So this is a little bit about the NOTSS taxonomy. I told you that the categories are situational awareness, decision making, communication and teamwork, and leadership. And I think the beauty of NOTSS is that it's one thing for me to tell a resident, well, you need to improve your situational awareness. But actually, NOTSS has elements within that. So there are different aspects of situational awareness. It might be their gathering of information, it might be about how they understand the information, or it might be how they project what's going to happen next.
DOUGLAS SMINK: And then even within that, there are specific good and bad behaviors. So within situation awareness, I mentioned gathering information. NOTSS has a list of good behaviors and poor behaviors for a surgeon to either emulate or try to avoid. There is an assessment scale built into NOTSS.
DOUGLAS SMINK: And actually, it's being used around the world, including in North America, increasingly so. But it did start in the United Kingdom, and Europe is the place that it's used the most, I would say. Trainees in the UK actually have to be assessed on their non-technical skills twice a year during their training, and I would love to see us get to the point where we do that here in the US.
DOUGLAS SMINK: So hopefully, I've helped you understand that these non-technical skills that are so important in our interdisciplinary teams, we can observe, we can coach, and then we can assess.
AMIT JOSHI: Thank you, Doctor. You and Dr Yule have really established yourselves as leaders in NOTSS certainly in America but even in Europe. So to hear you give a masterclass in NOTSS is fantastic. I have certainly encouraged myself and my residents to look over those checklists and even just the traits of good, high achievers in non-technical skills. It's a great thing to look at.
AMIT JOSHI: All of those are linked on the SCORE portal and within this specific module. Can I ask you, for residents who are interested in becoming even more proficient and delving more into the world of NOTSS, what's a good place to start, and what are some good resources to look at?
DOUGLAS SMINK: Sure, so I would say, there are a number of ways you can do that. I think that the most important thing to realize, and I think if a resident is to the point where they wanted to delve into it more, I think they've realized that these non-technical skills are not just innate. I used to feel like leadership might be something there was an innate skill and is not something you could teach. But I'm increasingly aware of the ability to teach those things and to improve them on your own.
DOUGLAS SMINK: There is a NOTSS handbook which is on the SCORE website. We've recently published an updated version. The NOTSS handbook was written with observations in Scotland. We've recently done some observations in the US and updated it with some slightly different skills. There's a lot of overlap, but there are some slightly different ones that I've had the chance to publish with Dr Yule and some folks at the American College of Surgeons.
DOUGLAS SMINK: So you could certainly look that up. I think the really key thing as a resident is to be aware of these skills and to observe them in others. It's easier to observe them in others than in yourself, and I would look out for or seek out the faculty that you think are the best leaders in the operating room or seem to have the best decision making. And I would do everything you can to observe them and particularly around decision making.
DOUGLAS SMINK: I would ask them, how do you make those decisions? Why are you doing it that way? And then the other thing I would challenge you to do, and I find this really helpful with my trainees, is to as you're doing a procedure, think out loud so that the attending hears what you're thinking, and particularly around your decision making. That's one of the best ways to improve your decision making and require, I think, an upfront discussion with the faculty to say, I'd like to work on how I make decisions during an operation.
DOUGLAS SMINK: So I'm going to try to talk out loud while I'm doing them, and I'd love your feedback on how you're doing, or how I'm doing because that's one of the challenges with some of these non-technical skills is they're not so easy to observe. But I think if you are purposeful about it, and you try to articulate some of your thoughts and your decisions and your awareness of what's going on around you, you'll be able to improve it over time.
AMIT JOSHI: Great advice. Dr Smink, thank you so much. This has been a great episode of SCORE School, and we'll see everyone next week. Thank you.
DOUGLAS SMINK: Thanks so much for having me.
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