Overview

Kaiser Permanente instituted a program to improve patient safety by promoting more effective teamwork and communication among care teams. The results of an operating room pilot project indicate this approach can reduce adverse events and enhance team performance and attitudes toward safety.

Growing evidence points to poor team communication as a major cause of medical mistakes that jeopardize patient safety [1]. Communication failure has been implicated in nearly two-thirds of the sentinel events (mishaps resulting in serious patient harm or death) reported to the Joint Commission on Accreditation of Health Care Organizations (JCAHO) since 1995.

In its 1999 report, To Err Is Human, the Institute of Medicine (IOM) recommended that health care organizations establish team-training programs to improve patient safety in critical areas such as the operating room. The IOM pointed to the aviation industry's Crew Resource Management (CRM) training as a model to emulate, while also noting that CRM principles must be adapted to the health care setting. CRM training has been shown to enhance error reduction attitudes and behaviors among flight crews as part of a comprehensive error management strategy [2].

Objective and Intervention: To instill a culture of safety, Kaiser Permanente instituted a program of organizational learning to promote effective teamwork and communication among care teams working in high-risk areas such as surgery and obstetrics. This case study describes the results of an operating room pilot project, along with its replication and expansion.

Organization: Kaiser Permanente is a group model HMO serving 8.2 million people in nine states and the District of Columbia through an integrated care system. The Kaiser Permanente Anaheim Medical Center (pilot site) is a 200-bed facility that serves 345,000 health plan members in Orange County, Calif.

Date of Implementation: The Kaiser Permanente Anaheim Medical Center launched a preoperative safety briefing pilot project in February 2002.

Key Measures:

• wrong-site surgery events as a measure of outcome;
• reports of near misses, those incidents that could have resulted in patient harm;
• perceived safety climate as measured by the Safety Attitudes Questionnaire;
• and nursing staff turnover as a proxy for staff morale.

Process of Change: Kaiser Permanente collaborated with the University of Texas Human Factors Research Project, which is directed by CRM expert Robert Helmreich, to adapt and distill aviation safety principles and learning to the health care setting. A three-day, multidisciplinary educational session emphasized skills rehearsal and immediate application to everyday practice.

In response, a multidisciplinary team including surgeons, anesthetists, operating room nurses, technicians, and managers designed a preoperative safety briefing to enhance basic patient safety practices required by JCAHO, such as the "time out" before surgery as part of surgical site verification procedures.

A one-page checklist was developed to guide team member preparation for cases based on their respective roles, including practices to assess and mitigate safety risks. Analogous to the preflight checklist used in the airline industry, this form is adapted to the needs of each case and is posted throughout the operating theater as a mental prompt.

The operating room administrator and the assistant chief of surgery, who is designated as the patient safety director, conduct periodic in-service training for operating room personnel on human factors principles that highlight the value of team briefings. This training is followed by a short self-assessment for reinforcement.

Operating room personnel were surveyed throughout implementation to refine the briefing process. Based on one suggestion, wipe boards were installed in each operating room to write each team member's name and role for every surgery. Name recognition is important to effective teamwork, but physicians might be embarrassed to admit they can't remember a team member's name. The wipe board eases this process.

Results: After a six-month trial of preoperative safety briefings, wrong-site surgeries, which occurred three times in the year prior to the intervention, were eliminated. Reports of near misses increased, suggesting greater situational awareness and willingness to admit and learn from errors.

In addition, the perceived safety climate in the operating room improved, with 63 percent of team members rating the operating room safety climate as good, compared with 51 percent before the trial. Positive perceptions of teamwork doubled from 20 percent to 39 percent among operating room personnel. Other self-reported error management behaviors also increased, such as a willingness to speak up about safety concerns and discuss mistakes.

The nursing turnover rate decreased from 23 percent prior to the intervention to 7 percent and has been sustained at a lower level than comparison contract hospitals. The cost of the intervention was estimated to be $49,500 in one-time labor and training costs plus $15,500 to sustain the gains.

Next Steps: Similar improvement efforts have been implemented as part of a national best practice transfer program at 30 Kaiser Permanente sites in the areas of perinatal care, radiology, procedural sedation, and patient transfers. For example, the Orange County team collaborated with the post-anesthesia care unit to design "scripted handoffs" of patients to ensure that recovery room nurses have all the information they need to safely care for patients following surgery. Plans are underway to embed these techniques in the outpatient surgery setting.

Airlines have improved their CRM training by integrating lessons learned from safety incidents and observations of flight crews at work (Line Operations Safety Audits). Based on this model, Kaiser Permanente is planning a program to directly observe expected team behaviors that lead to high-reliability surgery. Confidential feedback will be provided to the team and data will be aggregated across teams to identify common patterns for learning and improvement.

Lessons Learned: Briefings are a powerful way to change the way that people think about and practice teamwork, according to James DeFontes, M.D., physician director of surgical services for Kaiser Permanente Orange County. A team briefing provides an opportunity for dialogue that builds situational awareness and places team members on the same "mental page." Explicit communication helps team members focus on the common task at hand, bridges gaps in training and experience, and avoids having members make unjustified assumptions about each others' knowledge.

Taking time out for team formation increases the efficient use of time overall. Use of a role-based checklist leads to a better organized team with increased productivity and reduced waiting times. Having an enhanced understanding of the surgeon's plan helps nurses prepare the necessary equipment and make adjustments when the situation changes. By reducing unexpected events, this intervention has given nurses the perception that their workload has decreased.

The critical factor for successful culture change is a "bottom-up approach" that involves front-line personnel in designing the process change, with support from management and clinical leaders. Physicians set the tone for teamwork and have a profound influence on whether staff members feel comfortable discussing concerns about safety, according to Michael Leonard, M.D., physician leader of patient safety at Kaiser Permanente. Creating a culture of excellence requires respect among all team members, he says.

Implications: Kaiser Permanente's experience illustrates that safety principles and techniques from other industries must be distilled to achieve the right cultural fit for medicine, says Dr. Leonard. Those implementing and studying team training should assess whether such programs can be tailored to the context in which health care teams work.

To reap the full benefit of patient safety practices, such as surgery site verification and team briefings, they must be embedded in broader culture change efforts that involve teamwork and process improvements. This might improve nursing staff morale and reduce staff turnover, giving these organizations a competitive advantage in the labor market.

For Further Information: See J. DeFontes and S. Surbida. (2004) Preoperative Safety Briefing Project. Permanente Journal 8, 21–27. For more on Kaiser Permanente's experience, see M. Leonard et al. (2004) The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health Care 13, i85–i90. Contact Michael Leonard, M.D., physician leader of patient safety at Kaiser Permanente, Colorado, at michael.w.leonard@kp.org. or James DeFontes, M.D., physician director of surgical services for Kaiser Permanente Orange County, at james.defontes@kp.org.

References:
1.L. Lingard et al. (2004) Communication failures in the operating room. Quality and Safety in Health Care 13, 330–334; A.A. Gawande et al. (2003) Analysis of Errors Reported by Surgeons at Three Teaching Hospitals. Surgery 133, 614–21. 2.R.L. Helmreich et al. (1999) The Evolution of Crew Resource Management Training in Commercial Aviation. International Journal of Aviation Psychology 9, 19–32; R. L. Helmreich (2000) On Error Management: Lessons from Aviation. British Medical Journal 320, 781–785.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.