Selected Serious Events: Success Stories

Building a culture of safety in the operating room

At the foundation of successful patient safety and quality improvement efforts is a culture of patient safety within the hospital or surgical center. A strong safety culture can help minimize medical errors and strong support from leadership is crucial to truly moving the needle on patient safety and quality.

Minnesota hospitals and ambulatory surgery centers performed 2 .6 million invasive procedures during the 2012-13 reporting year, including procedures in the operating room, radiology, diagnostic/labs, and other settings. Dr. Mark Migliori, chair of the perioperative safety committee at Abbott Northwestern Hospital in Minneapolis, part of Allina Health, believes a culture of safety is a prerequisite for delivering good care for every patient, every procedure, every time.

"Patients deserve for safety to be front and center," said Dr. Migliori. "It is the essential first step. They are entrusting us with their care and implicit in that trust is that we will be their guardian when they are under our care." He believes surgeon leadership is critical in building a culture of safety in the operating room. While Minnesota hospitals and surgical centers have done a great job of developing multidisciplinary teams where everyone has a voice, some traditional hierarchies still persist.

"On one hand, the surgeon should have the same role as other team members in building a culture of safety," said Dr. Migliori. "In reality though, the surgeon has the capability to level the hierarchy within the operating room. By acting as a servant leader yourself — sharing power, putting the needs of others first and helping people develop and perform as highly as possible — it sends the message to the rest of the team that their professionalism demands the emphasis on safety." By fostering a culture that enables staff to feel comfortable to speak up, Dr. Migliori feels listening goes a long way in giving people a voice.

"One of the most obvious steps we can take is to listen — to let staff talk," he says. "We create so many barriers to let someone give their opinion. We need to break down those barriers and then give them a place to carry their idea forward." As a leader, Dr. Migliori hears the suggestion or concern and then gives the staff member ownership to carry the idea forward. He also feels it is important to recognize people when they speak up, as it creates a positive outcome. That's why he feels it is important to talk about near misses and recognize the person who caught it. "It sends the message that people are watching and this is important," says Dr. Migliori.

Dr. Migliori gives the example of the early days of implementing one of components of the Universal Protocol — the team briefing process. As chief of staff, he embraced the concept, yet was initially resistant to the idea that everyone needed to introduce themselves, feeling that people on the team already knew one another. Others felt strongly about its importance and so the team kept that critical piece of the protocol in place. He soon realized its significance. "It helps people talk. When the tech introduces herself, it gives her a reason to talk. So next time there's a reason to speak up for safety, she's less intimidated to do so," he explained. "When you don't know someone well, you're less likely to speak up and question them."

Dr. Migliori says a strong leader is one who has balance. Balance between confidence and humility; competence and being unsure enough to look at a situation from a different angle; and someone who is passionate and yet can observe and allow others to impact. A strong leader is always looking to give a voice to those who don't have one, and advocating for those who are the most vulnerable, whether it is staff, a patient or someone else.

Building a culture of safety takes continuous improvement. Hospitals and staff must be willing to constantly re-evaluate what they're doing and say, what can we do to make it better? Dr. Migliori feels it's good to have the awareness that mistakes can happen at any time. It's realizing that while you're good, it's not good enough. "Any organization that does safety work has glimpses of a safety culture," he says. "It's maintaining it that is hard. And that takes energy and humility."

Collaboration and communication are key to driving forward a culture of safety. Dr. Migliori encourages surgeon leaders to discard old approaches where members of the team are separate and instead create opportunities for groups to come together and have a dialogue around safety. "We must create the constant message that we're in this together. It all falls to communication and doing everything you can to enable voices to be heard," he says. "I'm so appreciative of the effort to make safety culture bigger than hospital versus hospital, but rather something that if we want to provide care in Minnesota, this is the standard."

(Minnesota Department of Health, 2014)

Utilization of Safety Crosses as a Quality Management Tool in Sterile Processing Department

At Markham Stouffville Hospital the Sterile Processing Department is responsible for the decontamination, cleaning, reprocessing and sterilization of instruments and equipment for the entire hospital. The Sterile Processing Department follows stringent criteria, best practice guidelines and standards to ensure the delivery of quality safe services to stakeholders such as the Operating Room and the Emergency Department. The department's commitment to safety and quality aligns with the hospital's belief statement "we must deliver safe, high quality care".

Although the department strives to exceed standards of practice, frontline staff identified the following two gaps:

1. Audit results such as instrument set error rate, missing chemical indicators, sterilization record accuracy and the frequency of sharps being found on used/soiled trays were inconsistently tracked and shared with frontline staff.
2. The lack of a systematic process such as a weekly audit tool to capture all reprocessing volume/activities, including thermal and high level disinfection, sterilization, weekly testing, and maintenance, and descaling of reprocessing equipment such as instrument, ultrasonic and cart washers.

Simultaneously, while the Sterile Processing Department was exploring solutions to the above concerns, some of the acute inpatient units were implementing Releasing Time to Care. Releasing Time to Care is a process used to capture and report quality outcome indicators such as falls and pressure ulcer rates. The Sterile Processing Department, after visiting these acute inpatient units, adopted the Safety Crosses as a format to capture and disseminate the audits results as outlined above in Gap 1. The team also developed a weekly departmental audit tool to monitor and report their various departmental reprocessing volumes and activities as noted above in Gap 2.

After many months of hard work, the department now boasts a quality board that proudly displays their four Safety Crosses: instrument/set errors, missing chemical indicators (internal and external), sterilization completion and accuracy rates and sharps sent to the Sterile Processing Department by end-users. The quality board also serves as a mode to track and report the department's weekly reprocessing activities and volume. Staff now has immediate access to reports and audits results. They are also a part of the process because they actively complete the Safety Crosses on a daily basis. Through education, completion of iReports and direct follow-ups with sending departments, the team has noticed a decline in the frequency in which sharps are returned to Sterile Processing Department.

(Health Standards Organization, 2013)