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What the introduction of the Card did was codify to both sides that communication is both welcome and expected.

Original Members: Surgical Chiefs Collaborative

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triggercards

Better Surgical Safety is in the Cards

By Missy Padoll, CRICO

Related to: Clinical Guidelines, Surgery

Several years ago, our data revealed that surgery-related claims were the second most common category of cases asserted against CRICO-insured institutions. These data are consistent with trends reflected in our Comparative Benchmarking System. Drilling down further, our data analysts identified two main problem areas:

  1. intra-operative technical errors in 68% of cases
  2. communication breakdowns in 46% of cases.

Based on these data, CRICO leaders initiated a multidimensional risk reduction program.

Unprecedented Collaboration

In an effort to address these areas of risk, the CRICO/Harvard Surgical Chiefs’ Safety Collaborative was formed. In 2005, we invited the surgical chiefs representing several Harvard teaching hospitals: Children’s Hospital Boston, Brigham and Women’s Hospital, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center. As the facilitator for this gathering, Atul Gawande, MD, (surgeon, author, and surgical error researcher), presented the leaders with malpractice claims data on surgery-related cases.

According to Gawande, ever since that first meeting, the chiefs have spoken openly about their data, their current interventions, and the vulnerabilities in their programs. They chose not to simply defend current practices or to work individually to address the problem areas that the data revealed. Instead, they joined together to find practical solutions. “It is truly a remarkable thing to have achieved collaboration between the Harvard chiefs,” says Gawande reflectively. “We brought together people from four competitive institutions, each with a national reputation, and asked them to share information about some of their most difficult problems. From the very beginning they shared information, shared ideas, and were extremely insightful.”

A Straightforward Solution

The CRICO data highlighted an overarching issue with communication between residents and attending physicians. In response, the chiefs decided to create a tool to improve resident/attending communication. Ultimately, the group created the “trigger card,” as a tool for communication between residents and attendings. Implementation of the trigger card has led to safer care for patients by bringing the attendings’ expertise to the bedside when they cannot be physically present. Across the Harvard academic hospitals, the trigger card has provided a chance to send a clear message to the house staff: attending physicians want to know what is going on with their patients and they want you to call them. In addition, the trigger card has provided the chiefs with an opportunity to highlight the importance of efforts to improve patient care. Although it looks simple, the trigger card is the result of several years of hard work.

“The collaborative was guided by problems the surgical chiefs had identified clinically. These impressions were reinforced by data from the malpractice experience where studies of claims have found communication failures in 46 percent of cases. Informal discussions between these chiefs—who already knew each other but seldom worked directly together—led to a focus on developing ways to prevent those failures,” says William Berry, MD, CRICO. “From the attendings’ point of view, virtually all of them thought they were being notified of any change in status of the patient. From the residents’ point of view, they thought they were calling when it was appropriate, but didn’t want to bother or disturb attendings. What the introduction of the trigger card did was codify to both sides that communication is both welcome and expected,” says Michael Zinner, MD, Chief of Surgery at Brigham and Women’s Hospital.

A post-implementation survey under the direction of Atul Gawande, MD, shows that those messages of support are paying off: over three rounds of data collection, residents are indicating they are much more likely to contact their attendings for significant patient problems.

Further Incentives

The trigger card is a clear demonstration of the power of ongoing collaboration among the surgical chiefs. In parallel with this work, CRICO is initiating several other projects to address malpractice risk in surgery. These include an effort to ensure technical proficiency and knowledge in basic laparoscopic skills, an initiative to improve teamwork in the operating room, and a program to help surgeons better communicate with their patients.

CRICO sponsors the fundamentals of laparoscopic surgery (FLS) program, underwriting the course and providing an incentive to each surgeon who completes the training. More than 120 surgeons have completed the course, and CRICO will be expanding the training to include gynecologic surgeons, urologists, thoracic surgeons, and vascular surgeons. Two Harvard institutions have made the course a requirement for credentialing in general surgery.

To support improvement in teamwork in the or, we are also sponsoring the development of an operating room team training program which includes simulation. Participation provides incentives both for individual surgeons and for their institutions. CRICO also will offer educational grants to the institutions to encourage nursing participation.

Finally, in collaboration with Robert Truog, MD of Children’s Hospital Boston, we are designing a program to help surgeons better communicate realistic expectations to their patients and patients’ family members. In a workshop on managing expectations, Dr. Truog will present malpractice case studies and facilitate attendees’ participation in simulations. Our data tell us that, even with these significant improvement efforts, surgery remains an area of significant risk for our affiliated institutions. We will remain actively committed to supporting innovative efforts to help surgeons, hospital leadership, and surgical team members avert adverse events and reduce malpractice claims.


February 16, 2012
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