Improved communication techniques

RAS-ACS: Evolving demands of resident training

Improved communication techniques enable residents to provide better care now and in the future by Raphael C. Sun, MD; Afif Kulaylat, MD; Scott B. Grant, MD; and Juliet Emamaullee, MD Highlights • Spotlights the important role effective communication plays in delivering high-quality, well-coordinated, patient-centered care • Describes how certain tools, such as checklists and the development of multidisciplinary teams, can be used to improve communication and quality of care 26 |

• Explains how resident work-hour restrictions have added to the necessity of effective communication in training institutions to avoid potential problems resulting from more frequent hand-offs

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ffective communication is a key component and common denominator in successful organizations and businesses, and medical practices are no exceptions to this rule. Studies have consistently demonstrated that effective communication is essential to delivering safe and high-quality patient care.1,2 Until recently, residents have not been required to complete standardized courses in communication, and the subject has never been a formal component of graduate medical education. However, the emphasis placed on communication has increased since the Accreditation Council on Graduate Medical Education (ACGME) has identified it as one of the six core competencies for physicians.3 Consequently, many surgical training programs are teaching residents to become more effective communicators and developing processes to improve care coordination and provide more patient-centric care. As surgical training continues to evolve, renewed focus and innovative approaches in communication across disciplines ultimately will enhance the quality of patient care. Health care documentation has advanced from paper charts to electronic health records (EHR). This new method of communication between health care providers eliminates many potential errors. Illegible handwriting, misplaced orders, and delays in the processing of orders are all less likely to pose problems because of the new system.

RAS-ACS: Evolving demands of resident training

As medicine has evolved over the last few decades, so has surgery. Historically, patients who required surgery were brought into the operating room (OR), and the procedure began when the surgeon made the incision. Times have changed. Currently, a number of systematic protocols are implemented prior to patients undergoing surgery. With the advent of surgical checklists to confirm variables, such as patient’s consent, site of surgery, and procedure performed, morbidity and mortality have declined. Furthermore, as health care has become increasingly specialized, it has concordantly become more fragmented. Patients with complex diseases may often encounter multiple specialized health care teams during their hospital stay, each with its own management priorities and treatment plans. Communication failure among different health care providers is one of the most frequently cited causes of preventable harm to patients, and The Joint Commission has reaffirmed the relevance of improving the effectiveness of communication among care providers as a national patient safety goal.4 In addition to the communication challenges addressed here, it is important to note that the 80-hour workweek has completely changed surgical training. In order to abide by this rule, residents are engaged in the practice of sign-outs. These sign-outs place responsibility on the resident on call. Although the continuity of care by the same resident is compromised, the overall care of the patient should not be. Thorough and accurate sign-outs between residents ensure that everyone is reading off the same page and that the safety and quality of patient care remains intact.

Checklists—a tool for enhanced communication and teamwork

The aviation sector developed the first checklist after pilot Maj. P. Hill piloted a Boeing Model 299 that took off in Dayton, OH, on October 30, 1935, but then stalled and crashed. An investigation concluded that Maj. Hill forgot to release the elevator lock before taking off. The crash was classified as “pilot error,” and newspapers reported it was “too much airplane

for one man to fly.” A group of test pilots evaluated the incident and instead of abandoning the plane or requiring longer training, they created a checklist. This checklist resulted in the Model 299 flying nearly 2 million miles without an accident.5 Health care practitioners have been using checklists to improve patient safety and quality of care for at least 20 years. The Northern New England Cardiovascular Disease Study Group developed a checklist for all cardiac surgery patients in the early 1990s, which decreased the number of patient deaths by almost 300.6 In 1998, the American Academy of Orthopedic Surgeons made it standard practice for surgeons to initial, with a marker, the operative site before bringing a patient to the OR.6 In 2003, The Joint Commission approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. In the medical literature, checklists have shown successful reduction of morbidity and mortality. One memorable demonstration was by Peter Pronovost, MD, PhD, FCCM, senior vice-president for patient safety and quality and director, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, who created a five-item checklist for preventing infection during insertion of a central venous line.5 Although the five steps are simple and obvious—wash hands; clean the patient’s skin with chlorhexidine; put sterile drapes over the entire patient; wear a mask, hat, sterile gown, and gloves; and put a sterile dressing over the insertion site—Dr. Pronovost found that even experienced clinicians skipped at least one step in more than onethird of patients. After several years of implementing the checklist during central venous line insertion, his hospital and other hospitals in the U.S. successfully reduced infections and deaths, and there was a demonstrated reduction in costs. At Johns Hopkins, the checklist decreased the 10-day line-infection rate from 11 percent to only two line infections in more than two years, resulting in $2 million in savings. When the checklist was implemented in Michigan intensive care units (ICUs), hospitals saved more than 1,500 lives and approximately $175 million in the first 18 months.5

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AUG 2013 Bulletin American College of Surgeons

RAS-ACS: Evolving demands of resident training

In surgery, communication in the OR is complicated by having multiple team members who often have never worked together, including the circulating nurse, scrub nurse, anesthesia assistant, anesthesiologist, surgeon, and surgical assistant.

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Despite the obvious benefits of using checklists, they were met with some resistance. Some physicians believe their jobs were far too complicated to be reduced to a checklist or that clinical judgment was superior to protocol. Some physicians were offended by the suggestion that they needed checklists, and viewed checklists as beneath them and an embarrassment.5 Tom Piskorowski, MD, an ICU physician, said, “Forget the paperwork. Take care of the patient.”5 Others were concerned that the checklist had been developed by nonphysicians without their input. Some surgeons saw it as an irritation or an interference with their turf. They feared that the checklist broke with the surgical tradition of the virtuoso surgeon who could do it all himself. In surgery, communication in the OR is complicated by having multiple team members who often have never worked together, including the circulating nurse, scrub nurse, anesthesia assistant, anesthesiologist, surgeon, and surgical assistant.5 Studies have shown that nearly half the time the operating staff did not know each other’s names, but the silver lining was that when they did, communication ratings improved substantially.5 Recognizing the dangers in surgical care, health care professionals met at the World Health Organization (WHO) headquarters in 2007 to initiate the WHO Safe Surgery Saves Lives Campaign.5 At this meeting, leading experts identified problems, such as unsafe anesthesia, infections, and the surgeon’s lack of communication and respect for anesthetists and nurses.5 Several surgeons had experience with OR checklists, and with their input, the WHO group came to a consensus on several checkpoints important in surgery. A WHO working group took these checklists and condensed them into one document with three pause points where the team must stop to run through the checks before proceeding5: 1. Before induction of anesthesia 2. Before skin incision 3. Before the patient leaves the OR

Much of the recent attention on surgical checklists evolved from the work of Atul Gawande, MD, MPH, V98 No 8 Bulletin American College of Surgeons

FACS, who led the WHO Safe Surgery Saves Lives program and authored The Checklist Manifesto. The WHO group agreed on a 19-item checklist in spring 2007.5 This checklist decreased the rate of death from 1.5 percent to 0.8 percent, the rate of complications from 11 percent to 7 percent, the rate of surgical site infection from 6.2 percent to 3.4 percent, and the rate of unplanned reoperation from 2.4 percent to 1.8 percent (all p