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The spine surgery operating room is a complex environment where stakes are high. Hundreds of thousands of quality adjusted life years and thousands of lives have been saved or significantly improved with the advances made in modern spine surgery. Yet there is a great deal of room for improvement. Death by medical error continues to be one of the leading causes of mortality in the United States. Communication is the most likely root cause for most categories of medical error, yet we are woefully behind in efforts to develop structured communication and organizational infrastructure which supports coordination of processes in our complex spine surgery care system.
And surgeons are often not fully aware of the depth of the problem. In multiple studies, self-assessment of communication and teamwork skills by surgeons and anesthesiologists is discordant with the opinions of nursing staff. Team work is an important step forward towards ensuring reliable outcomes for patients.
Dedicated, experienced teams improve the flow and efficiency of complex tasks.
While intuitive, adoption of dedicated operative teams has been slow and sporadic in our hospital systems, especially compared with other areas of industry. The efficiency and safety benefits of team work on complicated tasks are easily visible in jobs outside of medicine.
During flight simulations, a NASA study compared fatigued crews who had experience flying together with well-rested crews who had never flown with one another, and found that the former made significantly fewer errors despite their depleted individual metal states. Similarly, an NTSB analysis revealed that 44% of airline accidents occur on a crew’s first flight together, with 73% of accidents occurring on the crew’s first day.
Examples from professional sports abound. In one investigation of all NBA basketball games played from 1980 to 1994 showed that as teams gained more experience, they won more games.
In healthcare, evidence within both the surgical and non-surgical fields indicates that the implementation of dedicated teams, inspired by those found in athletics, NASA, and aviation, reduces errors, improves performance, and increases value.
While there was limited literature on dedicated teams in spinal surgery, other surgical fields have demonstrated that consistent and well-trained teams have potential to reduce errors and improve performance. A study of cardiac surgery outcomes in Pennsylvania investigated cardiac surgeons who had transitioned between multiple hospitals. At a given hospital, each procedure the surgeon performed lowered the mortality risk for that surgeon at that hospital, but when the surgeon began operating at a different hospital, the mortality risk returned to baseline.5 The technologies and methods were the same at each hospital, suggesting that improved outcomes came from the process of practicing with a given team and learning to leverage the unique talents of each member. Rather than merely improving his or her surgical skills over time, the surgeon was adapting to a specific team and environment, where a more developed team relationship helped achieve peak performance.
A team is a group of people linked in a common purpose. It’s especially appropriate for high complexity tasks, like spine surgery. Teams include people with complementary skills who develop synergy through coordinated effort and mutual commitment. This relies on communication, psychological safety and belonging, and a clear understanding of goals and purpose.
The hospital in general, and the operating room, in particular, is a complex environment with multiple levels of hierarchy, matrixed across multiple disciplines. Miscommunication can occur when an individual inaccurately encodes a message, when the receiver decodes the sent information incorrectly, or when the information is given at the wrong time or received by the wrong individual (figure 1).
Miscommunication has been implicated as the root cause of error and adverse outcomes in surgery and can be worse when teams are unfamiliar with each other. The principles of effective communication include clarity, comprehensiveness, and confirming that messages have been received. Checklists are a common example of tools that enable teams to formalize communication.
Optimum, effective communication requires both supportive structure and strong culture. Communication is always better when there is “psychological safety”. Psychological safety exists when team members know and trust each other and are united in a common purpose and goals. Within teams, explicitly stating the team’s needs and goals can build coordination skills and allow team members to develop clear expectations and understanding. As experience and trust grow, teams develop a collective knowledge about their roles, responsibilities, and capabilities of each member. The ability to anticipate team members’ needs enhances coordination and communication in a self-fulfilling feedback loop. Teams lacking in shared understanding and experience have reduced coordination which leads to a greater chance of poor performance. Safety can also be lacking when members don’t trust their team mates to fulfill their roles and responsibilities.
In psychologically safe environments, people believe that if they make a mistake others will not penalize or think less of them for it. They also believe that others will not resent or humiliate them when they ask for help or information. This belief comes about when people both trust and respect each other, and it produces a sense of confidence that the group won’t embarrass, reject, or punish someone for speaking up. Psychological safety doesn’t mean that teams will be able to avoid conflict but does allow for the higher chance of resolving conflict.
Steep authority gradients and strong hierarchical culture can inhibit more junior team members from speaking up. Much has been written about the imperative to minimize hierarchy in our operating rooms and hospitals.
It is possible to have both high psychological safety and high accountability. To do so, leaders must communicate clear expectations about performance and accountability without communicating a resistance to hearing bad news. In attempting to establish an environment of psychological safety, the emphasis should be on the group’s tasks, how they’re changing, and what’s needed to do them well. To cultivate a psychologically safe environment, leaders should be accessible and approachable, acknowledge the limits of current knowledge, be willing to display fallibility, invite participation, refrain from penalizing failure, use direct language, set boundaries, and hold people accountable.
In order to facilitate better teamwork within their environment, surgeon-leaders should strive to
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