For Patient Rounds on Tuesday morning, I joined Dr. Mike Rose and the Leadership Team for a visit to the Operating Room. We had an opportunity to learn about the safety work that is ongoing in the OR with the Safety Checklist, particularly with a pilot project in Orthopaedics. This pilot project extends the Safety Checklist to a ‘Brief and DeBrief.’
During the walk-through by the team on Tuesday, we saw a great deal of transparency, some emotional, as the record of events and improvement ideas from the ‘Brief/DeBrief’ are posted on the OR walls. In talking with Dr. Rose, he remarked, “I think it demonstrates a couple of things. First, that as safe as we are and have been, there is more to do. Secondly, the difference between being just safe, and exceptionally safe is likely to be the many individuals engaged in a case holding each other accountable to insure that their specific tasks are completed, but more importantly, feeling accountable together for the patient’s result. Folks are accustomed to a task orientation–’I do what I am supposed to’–but less to ‘we all have done what is necessary.’ The latter is the key to the cultural change and it will be transformative.”
I had a moment this morning to compare notes on the ‘Brief/DeBrief’ with Dr. Pat Denton who is one of the physician leaders of this pilot work. He explained the benefit of the ‘DeBrief’ as the team identifies at the end of the case those areas of improvement that would have allowed the operation to go better. A simple question at the close of the case, ‘what could we/I have done differently to make things smoother, better?’
It is important work and there will be benefits as it spreads to all Operating and Procedure rooms. I want to thank Dr. Mike Rose, Carolyn York and Emily Harsh for giving us this opportunity to see how this work shows our ’spirit of improvement’ in the OR.