By Don Sadler
Any successful sports team knows the importance of everybody on the team working together. Tom Brady received most of the accolades for the Tampa Bay Buccaneers’ recent Super Bowl victory and won the MVP Award. Yet, he would be the first to say that the Bucs’ suffocating defense and superior offensive line play helped make the team victorious.
It’s the same in the operating room environment. Surgeons are sometimes viewed as the “quarterback,” so to speak. But the best surgeons know that it takes teamwork on the part of everyone to help ensure a successful patient outcome. This includes surgeons, perioperative nurses, the sterile processing department, the environmental services department and more.
Poor teamwork among these and other departments can lead to a host of problems including surgery delays, cancellations, excessive callouts, tension and a lack of optimism and energy among staff, surgeon and staff dissatisfaction, and poor patient outcomes.
Working Together for Patient Health
Kay Ball, Ph.D., RN, CNOR, CMLSO, FAAN, a perioperative consultant and adjunct professor at Otterbein University in Westerville, Ohio, compares the teamwork required for a successful surgery to all the different parts of the body needing to work together for a healthy person.
“If the central service department doesn’t work closely with surgery, then the surgical department won’t run well or be as productive,” Ball says. “And if sterilized instruments aren’t available, then surgeries can be delayed and even cancelled.”
“These two departments must communicate regularly with each other so their actions will complement each other,” Ball adds.
William Duffy, RN, MJ, CNOR, FAAN, is the director for the nursing and healthcare administration masters of science in nursing program at Loyola University of Chicago’s Marcella Niehoff School of Nursing. He uses a different analogy to explain.
“When you look at the chessboard of a hospital’s operation, you have multiple teams/departments all trying to achieve their individual goals,” says Duffy. “Everybody is making moves to achieve their checkmate, if you will, and win the day.”
Duffy says he used to talk with his team frequently about the idea of “coopetition.”
“As departments, we are in competition with each other, but at the same time we are cooperating with each other to provide better patient care,” he says.
“If you follow the coopetition mindset, you know that if you want someone from another department to help you, then you need to also help them,” Duffy adds.
Carolyn Hooks, CSPM, sterile processing program manager at Children’s Hospital of The King’s Daughters in Norfolk, Virginia, takes things a step further.
“I think the first question is why are we even considered different departments?” she asks. “I say this because both areas (sterile processing and the OR) are so interconnected.”
Hooks believes the OR culture is moving away from segregation by departments toward a single group of people with mutual respect and a mutual goal of patient safety.
“It is imperative that those of us in SPD appreciate the urgency and stress that may be happening in the OR suite,” says Hooks. “The bottom line is that if you are engaged in the entire process and have a healthy respect for those who support you and those you support, you’ll be more useful as a perioperative staff member.”
Duffy includes in-patient units among the list of departments where teamwork is essential.
“As a perioperative director, I really worked to keep up my relationship with my inpatient counterparts,” he says.
“I tried not to point fingers but instead to respect the challenges they faced in meeting their goals when it comes to preparing patients for surgery,” Duffy adds. “Kindness and support go a long way.”
Communication is Critical
Perhaps the most common cause of friction between departments is poor communication.
“Good communication is a necessary component for good teamwork between surgeons and nurses,” says Melanie Perry, RN, BSN, CNOR, the host of First Case, a perioperative services podcast, and creator of The Circulating Life, a blog for OR nurses.
She gives the example of surgeons clearly stating what will be needed for the surgery when posting a case. “This ensures that the perioperative staff is prepared and reduces delays and frustration,” she says.
Perry tells the story of a recent rotator cuff procedure to illustrate the importance of good communication.
“Nothing in the posting mentioned that it would be an arthroscopic case, and this particular surgeon routinely does open rotator cuff repairs, so we set up for an open case,” says Perry. “When the resident informed us that the case was supposed to be a scope, we had to pull all new instruments, reposition the patient and gather new equipment, which of course delayed the case.”
Hooks stresses the importance of simple planning when it comes to improving teamwork between the SPD and OR. “For example, when a procedure card is regularly updated, the SPD staff can properly prepare the surgical trays and case carts.”
“Or when an SPD technician uses critical thinking and good communication skills while pulling cases to identify any needs or shortages prior to case time, this helps the surgery proceed more efficiently,” Hooks adds.
Hooks says she has witnessed scenarios where proper planning didn’t take place, resulting in a pulled case or surgical tray being insufficient.
“Inevitably, SPD staff are called into the OR as the sacrificial lamb,” she says. “This clearly is not the time for excuses or defensive behavior. We must take one for the team and then move forward to fix the situation.”
About 70 percent of adverse events in the perioperative setting are caused by communication breakdowns among team members, according to Lisa Spruce, DNP, RN, ACNP, CNOR, CNS-CP, ACNS, FAAN, the director of evidence-based perioperative practice for the Association of periOperative Registered Nurses (AORN).
“This is why it’s so important for all departments and teams to work well together and improve communication,” says Spruce. “Valuable information is shared between team members across many departments and this information is handed over to multiple personnel during the patient’s surgical encounter.”
Spruce says she has seen the harm that can result when communication breaks down and a team member fails to speak up.
“Most often, this is due to intimidating behaviors,” she says. “Team members are sometimes afraid to speak up when they experience intimidation or disrespectful and abusive behavior.”
Health care facilities should promote respect among all personnel “by encouraging honesty, learning and collaboration and speaking up,” Spruce adds. “They should also hold personnel accountable for their behavior.”
Create a Blame-Free Environment
A big part of improving communication is avoiding the “blame game.”
“A blame-free environment must be created so that infractions can be quickly identified and handled,” says Ball. “If staff members feel that they would get into trouble by reporting problems, then problems will always be present.”
Another part is assuming responsibility and accountability and not giving in to the temptation to point fingers.
“I find it interesting how things work when everyone in the OR takes the blame as a whole,” says Hooks. “It’s pretty amazing – we just move on.”
Hooks believes that one phrase in particular – “That’s not my job” – is especially counterproductive. “To me, this is profanity in the workplace,” she says. “And let’s not forget the dreaded information hoarders.”
While surgeons sometimes have a reputation for treating other team members poorly, Perry says she has also witnessed nurses treating surgeons disrespectfully.
“They dislike a particular surgeon for whatever reason so they’re rude, or they go slower during turnover, or they aren’t as quick to grab needed supplies as they would be for other surgeons.
In the end, this keeps the case from going as smoothly as it could,” says Perry. “The lack of teamwork affects not just the surgeon, but the patient as well.”
Another obstacle to teamwork that Duffy sees is the pressure that many health care leaders feel to meet productivity targets.
“Productivity consumes many managers, and it drives their decision making,” says Duffy. “Their individual performance becomes more important than the organization’s overall performance.”
What happens next, says Duffy, is that units start unilaterally deciding operational issues without thinking about the downstream or upstream impact. “When everybody is looking out to preserve their own jobs, the cooperation part of coopetition is lost,” he says.
“I realize that meeting productivity targets and controlling labor expense and supply utilization are all important factors, especially for organizations with thin margins,” Duffy adds. “But no one is an island – especially in health care. Leaders who do not see the need to have relationships where you support others at times and then they support you only exacerbate team problems.”
Taking Concrete Steps
Charlotte L. Guglielmi, MA, BSN, RN, CNOR, FAORN, the clinical manager for perioperative education at Beth Israel Deaconess Medical Center in Boston, says her facility took concrete steps to improve teamwork when they experienced a highly publicized wrong-site surgery back in 2008.
“One of the first things we did was create a weekly safety huddle where chiefs of divisions and chairs meet to review all the debriefs,” she says. “We also started what we call Faculty Hour, a dedicated time during the workweek when multi-disciplinary teams come together to find solutions to common problems.”
“This presents an opportunity to address unusual things that come up that nobody seems to know how to tackle,” Guglielmi adds.
Hooks says she has had many opportunities to see good teamwork in action.
“One in particular was a project we worked on to right-size our surgical trays,” she says. “The ENT specialty staff and surgeons took the time to really dig in and make major changes, including downsizing trays and redeploying instruments. This has reduced re-work and saved money for the organization.”
Spruce stresses the importance of establishing a team of stakeholders from all departments.
“They should have the authority and responsibility to provide oversight for system design, implement team training, develop communication tools, review safety measures, identify patient safety issues and report data to the leadership team.”
Personnel also need to collaborate and support each other “by crosschecking and monitoring so mistakes are captured,” Spruce adds. “And they should ask questions and request what is needed of each other, give timely and specific feedback to each other, and make sure they are verifying critical patient information by reading back what they have heard from their colleagues.”
Guglielmi believes that the most important factor in improving teamwork is getting engagement from leadership at the C-suite level.
“Teamwork has to be fostered at the top,” she says. “You need somebody who can go beyond clinical leadership to the senior management team. Otherwise, you’re never going to make it happen.”
In the end, improving teamwork and working well together “ensures that we’re providing the best possible care to our patients,” says Perry. “It also lowers frustration levels, increases efficiency, reduces delays and improves the working environment for all of us.”