Presurgery routine fosters 'see something, say something' safety culture

March 15, 2015

When an airliner is being prepared for takeoff, pilot and co-pilot go through a written cockpit checklist. They speak to one another with each step — one of them states a procedure, the other confirms.

The requirement that all voices be heard is a key element of TeamSTEPPS, an increasingly popular discipline in the nation's hospitals. It requires medical teams that gather before procedures to make sure that everyone, from lead surgeon to scrub technician, says out loud what he or she is there to do.


Dr. Michael Perez, left, a surgeon at Holy Cross Hospital in Ft. Lauderdale, Fla., confers with Dr. Edward Ferrer, an anesthesiologist, and surgery tech Laquita Walker before a procedure. The exchange is standard operating procedure in TeamSTEPPS, a formalized procedure to enhance patient safety.

Holy Cross Hospital in Ft. Lauderdale, Fla., began using TeamSTEPPS in its general surgery area in January 2014 and expanded it to other departments in September. Before any procedure, all team members introduce themselves, state their purposes and describe any concerns they have about possible complications.

That simple act of introduction can embolden a person to speak up during a procedure if he or she sees a problem, said Christine Marrero, the hospital's executive director of surgical services.

"If you use your voice, you are more likely to use it again if you see something of concern," Marrero said. "It makes everyone on the team feel more accountable and emboldened. It fosters an increased communication that can only be better for patient outcomes."

By the book
Dr. Kenneth Homer, chief medical officer at Holy Cross, said the program's military origins require a disciplined formality that some participants in the civilian world may find overdone.

"The Army approach may seem silly at first. But it's there to save that life in the field," Homer said. "So if we do something like introduce ourselves before a procedure, and we prevent one complication, then it's not so silly."

Homer also raised the comparison of TeamSTEPPS to the cockpit checklist. "And, just as in aviation, a formalized procedure makes for a much safer environment," he said. TeamSTEPPS is an acronym that stands for Team Strategies and Tools to Enhance Performance and Patient Safety.

Military and aviation procedures served as templates for big parts of TeamSTEPPS, which was developed by the Department of Defense and the Agency for Healthcare Research and Quality (part of the Department of Health and Human Services). In 2001, Congress mandated that the military develop a formal patient-safety program, in part because of the often-cited Institute of Medicine study, "To Err is Human: Building a Safer Health System," which two years before had concluded that preventable medical errors caused as many as 98,000 deaths annually in the U.S.

James Battles, a social science analyst for the Agency for Healthcare Research, said TeamSTEPPS is in use throughout the nation's military medical services and, in some substantial form, in about one-third of the nation's civilian hospitals.

Boot camp
Eight large hospitals or medical schools scattered through the country provide formal training in TeamSTEPPS.

Homer said Holy Cross sent eight representatives to Duke University in North Carolina for several days of introductory training. That led to more thorough training for about 30 staff members, including doctors, nurses and technicians, for the hospital's first TeamSTEPPS teams in the general surgery unit.

The hospital expanded the program to other surgical specialties, cardiac care, the intensive care unit and anesthesia in September with a ceremony and speech by Army Lt. Col. Jason Seery, M.D., director of the Army Trauma Training Center in Miami. Seery had used TeamSTEPPS during deployments in Iraq and Afghanistan.

Making it stick
Pat Schuldenfrei, patient safety officer and director of clinical performance improvement at Holy Cross, conducts regular training programs and refresher courses.

Making it stick is a big part of TeamSTEPPS, which is designed not only as a better way but also to avoid the natural tendency of well-intended people to drift back into old habits.

Other elements of the program are evaluating a hospital's procedures, with an emphasis upon finding shortcomings; forming a "change team" team that will study and practice the program and introduce it to the hospital staff; and monitoring both execution and continuing education. The eight civilian training centers, including Duke, provide expertise, training and follow-up throughout the TeamSTEPPS program.

Holy Cross does not use the term "change team," but it has medical teams in the surgical and anesthesia departments that understand the TeamSTEPPS system, train new staff members and provide ongoing education, Homer said.

He said the hospital has no data on program benefits in large part, because it is difficult to measure "a soft subject" like teamwork. But he said he believes the TeamSTEPPS discipline has helped hospital staff members avoid mistakes.

"I highly recommend that hospitals use a program such as this," he said. "We are always looking for ways to improve."

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