Building Capabilities for a High-Performing Perioperative System

What would it be like to be inside a high-performing perioperative system? We may hold different opinions; I certainly have mine.

Recently that opinion was reinforced during a visit to a hospital that has been participating in NSQIP for several years, and which has steadily improved its performance on a number of categories.

How did this perioperative system get to where it is today?  I believe that, several years ago, the chief of surgery began to worry that surgical quality was not what it needed to be, but could not prove it. When NSQIP came along, he recognized that it would provide the credible yardstick for comparing his hospital’s complication rates to other hospitals’.  The results confirmed his fears.  Let’s just say they weren’t pretty…

The good news was that the results fired up the surgeons, who, like surgeons everywhere, crave reliable data.  But simply getting the surgeons to commit to an improvement program wasn’t going to be enough: He also needed to win the hearts, the minds and the enthusiastic participation of the nurses.  To accomplish that, he decided to improve the quality of dialogue between the physicians and the nurses through a dose of Team Resource Management delivered by a former airline pilot.

These steps alone would not have been sufficient.  After all, many hospitals – though not enough, in my opinion –are following a similar path.  What’s really different about this perioperative system is its internally generated commitment to grow its capabilities and, in doing so, to further transform its culture and thus to further improve outcomes.  It’s a virtuous cycle.

So, what’s it like inside the perioperative system at this hospital? Here’s what I learned from several people with whom I spoke:

• According to one nurse, surgeons had always been a sociable group, but rarely talked about their job.  Now they study the outcomes data and talk about reducing complications.
• A surgeon whom I met uses the pre-surgery Time Out to put the nurses and techs at ease by asking newbies, “Have you done this before?” Can you imagine how this must take the weight off the new person?
• The training in Team Resource Management has paid off.  Here’s what one person volunteered: “It’s all about a culture where people are not afraid to express their views and concerns.”
• The nurse who serves as the point of contact with NSQIP, the so-called Surgical Clinical Reviewer, has been taking courses in statistics to make her more effective in identifying opportunities for improvement.  It has paid off for the hospital because she has discovered some surprising correlations, and launched new programs that would not have been started without her new skill.  And it has gained her recognition within NSQIP.  As a result, everyone has come out a winner.
• The Nurse Manager of the Surgical Unit is helping her nurses to become local experts in some topics, wound care for example, by introducing them to relevant literature; challenging them to find more on their own; encouraging them to develop the expertise; and then passing on the knowledge to colleagues.  “It’s very empowering for them to be teaching!” she told me.
• Surgical Unit nurses are sent upstream to the OR, for example, to help them understand the work and the challenges in those areas, and to establish relationships that will contribute to better care throughout the patient’s journey.
• Not surprisingly, the changes are being welcomed, and the nurse retention rate is very high.
• The chief of surgery sums it up as follows:  “We’ve made a lot of people feel great about coming to work!”
• And the patients have noticed:  “I see a lot of people laughing,” observed one.

How is this investment in building capabilities – and, yes, culture is also a capability – paying off?  Although they have not reached the “Exemplary” end of the NSQIP O/E spectrum, they have made significant and consistent strides in improving outcomes.

Because the purpose of my visit was primarily to learn about their methods for improving outcomes, I don’t know how well they would score on the other dimensions of a high-performing perioperative system.  I am confident, however, that their outcomes will continue to improve.  Why? They’ve made a lot of progress, but are not satisfied.  In the words of one manager: “We’re not where we want to be but we know where we want to get to.”

What does it look like inside your perioperative system?