Michael R. Moyer
Rosenthal Director, Shelter Animal Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA; and Bridgewater Veterinary Hospital, Inc., Bensalem, PA, USA
There is often a criticism that high volume surgery is "assembly line surgery" and axiomatically less good than low-volume (read: inefficient) surgery. We are trained (I know this, because I teach at one of these institutions) to take one patient at a time through a series of pre, peri-, and post-operative phases in a highly "individualized" (non-standardized) processes, and then repeat for another patient.
In contrast, high volume clinics typically have organized teams, standardized processes, a defined team leader/surgical coordinator with clear responsibilities (patient flow, standardized hand-offs, structured and simple communications) and are characterized by high efficiency and comparable or lower rates of anesthetic and surgical misadventure.
Surgical processes/procedures: SOPs and checklists, are vital to patient care and safety. They are the only tools to reliably address system errors/failures.
Emerging concept in healthcare quality and safety assurance programs is to borrow from avionics and Formula One racing(!) industries where highly trained teams perform complex and high-stakes tasks to a phenomenally high degree of precision.
1. Surgical Standard Operating Procedures - SOPs
ii. Patient care; process-based quality assurance
iii. Improved efficiency
iv. Facilitates training/cross-training
v. Facilitates leadership development***
vi. Facilitates continuous improvement
vii. Adherence or deviation from SOPs as basis for promotion/reward/discharge
viii. Protects against "migration to the boundaries"
b. How to create Surgical SOPs . (FYI - theses should be written with the anticipation that they will be read by lay persons potentially hostile to your interests. Write them well.)
i. Goal of task - global, e.g., high-volume TNR surgical laboratory
a) Include subsidiary goals such as patient safety, staff safety, teaching opportunities, leadership opportunities
b) It is appropriate to state over-arching concerns/issues to be avoided here
ii. Describe overall work flow, location, equipment encountered/used, roles and responsibilities; Example: Soft Tissue Surgery at ACCT. 9 a.m. 111 West Hunting Park Avenue
iii. Create individual task descriptions using checklists for crucial steps, e.g., Cat Spay Prep Station. Make certain that front line staff/volunteers work with draft versions of the SOPs while in development (that is, before you move onto step iv!)
a) Group tasks in logical work stations
b) Clearly identify all staff/volunteer roles and accountabilities. Team Leader (poll audience for other names for their surgical coordinator) must possess high level Situational Awareness skills
iv. Create appropriate documentation and make it available for orientation, for on-site reference, and posters for work stations
c. Use SOPs during orientation, on-site pre-clinic meeting, during the surgical shift, and during the post-event de-brief
i. Regularly revise/update/critically review the SOPs for content accuracy, clarity, simplicity, and necessity
ii. For improving efficiency, observe "choke points" (e.g., retrovirus testing in high volume cat clinics, recovery cage space for dogs)
2. Standards of Care
i. Best practices by consensus of practitioners
ii. Continuous quality improvement
iii. Third party quality assurance
iv. Process of standards compliance is a valuable team building exercise (if framed correctly)
v. Accreditation process is also a leadership development tool
vi. Organizational alignment
b. Who develops standards?
i. Who is allowed to vote and have input on new or revised standards? Joint Commission utilizes physicians, nurses, administrators to develop standards for human hospitals
ii. What is the formal step-by-step process?
iii. How are bias and commercial interests handled?
iv. How are negative votes or ballots handled
v. What type of consensus is required
c. Surgical standards in vet medicine
ii. Guidelines from ASV
iii. State Boards of Veterinary Medicine
iv. Case Law
3. Errors, adverse events, and bad outcomes: How good process and situational awareness improve quality
a. Situational awareness
b. Medical misadventures happen due to:
i. Systems factors
ii. Breakdown in delivery/function
iii. Productivity pressures
iv. Discontinuous care/handoffs
v. Weakly standardized processes/policies
vi. Poor communication systems
vii. Lack of patient data
viii. Failure to acquire SA1, 2, or 3
ix. Failed heuristics - "rules of thumb"
xi. Mental states-affect
xii. Technical factors - surgery
c. Common error points/paths in surgery
i. Incomplete information at check-in
ii. Paperwork errors
iii. Loss of information/errors in hand-offs
iv. Adverse event/crisis distraction from following SOPs (lack of adverse event/crisis checklist!)
v. Non-productive/non-work chatter displacing needed information transfer
vi. Bad equipment/facility/space creating workflow obstructions and pressure to push beyond SOP's to increase productivity
d. Lessons from the racetrack: Hallmarks of a formula 1 pit crew:
i. Structure - team
iii. Organization - orientation, pre-event meet, team leader (lollipop man), de-brief immediately post-event
v. Aggressive skepticism - team members must possess and use this mental posture in assessing incoming data and status
SOPs and Standards of Care in surgical practice - any kind of surgical practice - will improve outcomes and will provide a framework by which continuous improvement can occur. It will fundamentally improve the surgical team's ability to organize, train, function, and lead. It will lead to consideration of the importance of Situational Awareness and processes (including checklists) that reinforce key points in the work flow to address failure points.
SOPs and Standards of Care will clarify and reinforce goals = training
SOPs will improve your throughput/productivity = efficiency
SOPs are designed for process-based quality assurance and continuous improvement = reduced adverse events
SOPs give team members the ability to critically assess and reassess steps in the process and provide feedback on a continuous basis for revision of protocols and evaluation of adverse events.
SOPs are the specific steps towards best practices
1. European Union: Directive 98/34/EC of the European Parliament and of the Council of 22 June 1998 laying down a procedure for the provision of information in the field of technical standards and regulations Official Journal L é04, 21.7.1998, p. 37–48. (This page also provides references to amendments.) See also European Commission: Enterprise Directorate-General: Vademecum on European Standardisation. (This document contains a consolidated version of Directive 98/34/EC, dated 15 November 2003.) Accessed 2009-05-05.
2. Quoted from ISO/IEC 24751-1:2008: Information technology - Individualized adaptability and accessibility in e-learning, education and training - Part 1: Framework and reference model, p. v.
4. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Departments of Anesthesiology/CCM and Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Eliminating catheter-related bloodstream infections in the intensive care unit. Comment in: Crit Care Med. 2005 Jun;33(6):1466; author reply 1466 and Crit Care Med. 2004 Oct;32(10):2150–2152.