Introduction
Patient safety has become a global priority to support reducing harm associated with
healthcare delivery.1 In Canada, patient safety incidents (PSI) are the third leading
cause of death behind heart disease and stroke and are associated with an additional
cost to the healthcare system of $2.75 billion each year.2 PSIs occur across the healthcare
continuum, but over half are associated with surgical care, which consists of preoperative,
intraoperative and postoperative care.3 4 Globally, four main threats to surgical
safety have been identified: (1) insufficient recognition of safety as a public health
concern, (2) lack of available data related to surgical outcomes, (3) the inconsistent
implementation of existing safety practices, and (4) the complexity of the surgical
setting.5 The WHO Guidelines for Safe Surgery, published in 2009, have increased and
highlighted the importance of surgical safety worldwide. However, key gaps related
to complexity of surgical processes still remain to be addressed. A leading cause
of these events is communication failure between care providers during surgical care,
and between transition points during ‘hand-offs’ or ‘handovers’.6 Information shared
at these transition points is required to facilitate continuity of information and
patient care, and to prevent medical errors.7 This has resulted in national organisations,
such as the Canadian Patient Safety Institute (CPSI), identifying surgical safety
as a key priority.
In a joint review by the Canadian Medical Protective Association (CMPA) and the Healthcare
Insurance Reciprocal of Canada (HIROC), data from 2004 to 2013, which consisted of
2974 legal cases, were reviewed and nearly half of the incidents occurred due to system-level
factors, rather than physician or healthcare provider (HCP)-level factors.8 A frequent
system-level issue was lack of adherence to protocols, such as use of the surgical
safety checklist (SSC), which is intended to improve team communication.8 9 In addition
to incidents that cause patient harm, PSIs also include events that do not lead to
patient harm as well as near-miss events.10 Hamilton and colleagues report that near
misses and adverse events are under-reported, particularly within the operating room
(OR) setting suggesting that exploration of how teams communicate in all phases of
surgical care is necessary.11
The purpose of this narrative review is to identify and summarise leading practices,
tools and resources for effective communication and teamwork during surgical care
including the immediate preoperative, intraoperative and postoperative phases.12 This
review addressed the following questions:
What practices, processes and tools are currently being used to improve communication
and teamwork during surgical care?
How are these practices, processes and tools being implemented into surgical practice?
Methods
We conducted a narrative review to explore existing practices, processes, tools and
resources available to improve communication and teamwork during all phases of surgical
care.13 14 We searched the databases PubMed, MEDLINE and CINAHL using a variety of
search terms associated with preoperative, intraoperative and postoperative care (table
1). Online supplementary file 1 provides detailed information related to the search
strategy.
10.1136/bmjoq-2020-000937.supp1
Supplementary data
Table 1
Summary of search terms
Phases of surgical care
Search terms
Preoperative
handover, handoff, preoperative, interdisciplinary communication, interprofessional
relations, communication, checklist, practice guideline, organizational innovation,
transition of care, patient discharge, continuity of patient care, interdisciplinary
collaboration, checklist, operating room, preadmit department, and preoperative admission
checklist
Intraoperative
handover, handoff, intraoperative, interdisciplinary communication, interprofessional
relations, communication, checklist, practice guideline, organizational innovation,
transition of care, patient discharge, continuity of patient care, interdisciplinary
collaboration, checklist, operating room, and surgical safety checklist
Postoperative
handover, handoff, postoperative, interdisciplinary communication, interprofessional
relations, communication, checklist, practice guideline, organizational innovation,
transition of care, patient discharge, continuity of patient care, interdisciplinary
collaboration, checklist, operating room, postanaesthetic care unit, and anaesthesia
recovery room
Included articles were peer-reviewed journal publications and contained a sample or
direct link to a process or tool intended to improve communication or teamwork during
surgical care. We excluded articles not published in English. Two authors screened
the articles based on title, topic and publication type. The content from the articles
was organised into a table to allow for comparisons of article type, year, country
and process or tool. In keeping with narrative review methodology,13 the articles
were not critiqued or assessed for quality. This type of review process therefore
allows for the summary of literature in common themes, but does not necessarily facilitate
the provision of practice recommendations.13
Results
Thirty-four articles, published from 2007 to 2017, were included. Figure 1 Four articles
were related to all phases of surgical care, 3 focused on preoperative care, 8 on
intraoperative care and 19 on postoperative care. Half of the papers were from the
USA, with additional perspectives from the UK, Canada, the Netherlands, Germany, India,
Singapore, France and China. Detailed information related to the bibliographic information,
descriptions of processes or tools, countries and clinical settings is located in
table 2. The results have been organised into three categories: (1) modifications
of processes or tools, (2) facilitators and barriers of process or tool use, and (3)
description of theory underpinning processes or tools.
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
Table 2
Table 2Description of included studies
Article
Country
Setting
Process or tool
1
Agarwal H, Saville B, Slayton J, et al. Standardized postoperative handover process
improves outcomes in the intensive care unit. Crit Care Med 2012;40:2109–2115. doi:10.1097/ccm.0b013e3182514bab
USA
Postoperative (OR-PICU)
Paediatric cardiac patient handover pathway
2
Agarwala A, Firth P, Albrecht M, et al. An electronic checklist improves transfer
and retention of critical information at intraoperative handoff of care. Anesth Analg
2015;120:96–104. doi:10.1213/ane.0000000000000506
USA
Intraoperative
Electronic anaesthesia handoff checklist
3
Ahmed K, Khan N, Khan M, et al. Development and content validation of a surgical safety
checklist for operating theatres that use robotic technology. BJU Int 2013;111:1161–1174.
doi:10.1111/bju.12010
UK
Intraoperative
SSC (for robotic procedures)
4
Burbos N, Morris E. Applying the World Health Organization surgical safety checklist
to obstetrics and gynaecology. Obstet Gynaecol Reprod Med 2011;21:24–26. doi:10.1016/j.ogrm.2010.09.009
UK
Intraoperative
SSC
5
Caruso T, Marquez J, Wu D, et al. Implementation of a standardized postanesthesia
care handoff increases information transfer without increasing handoff duration. Jt
Comm J Qual Patient Saf 2015;41:35–42. doi:10.1016/s1553-7250(15)41005-0
USA
Postoperative (OR-PACU)
I-PASS handoff process
6
Chaudhary N, Varma V, Kapoor S, et al. Implementation of a surgical safety checklist
and postoperative outcomes: a prospective randomized controlled study. J Gastrointest
Surg 2015;19:935–942. doi:10.1007/s11605-015-2772-9
India
Intraoperative
SSC
7
Craig R, Moxey L, Young D, et al. Strengthening handover communication in pediatric
cardiac intensive care. Paediatr Anaesth 2011;22:393–399. doi:10.1111/j.1460–9592.2011.03758.x
UK
Postoperative (OR-PICU)
Handover intervention structure
8
DeJohn P. ASCs take steps to improve handoffs. OR Manager 2009;25:26–29.
USA
Preoperative (ambulatory surgery centre)
MAPS for handoff communication
9
de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the
Surgical Patient Safety System (SURPASS) checklist. BMJ Qual Saf 2009;18:121–126.
doi:10.1136/qshc.2008.027524
Netherlands
All perioperative settings
SURPASS checklist
10
de Vries EN, Prins HA, Crolla RMPH, et al. Effect of a comprehensive surgical safety
system on patient outcomes. N Engl J Med 2010;363:1928–1937. doi: 10.1056/NEJMsa0911535
Netherlands
All perioperative settings
SURPASS checklist
11
de Vries EN, Prins HA, Bennink MC, et al. Nature and timing of incidents intercepted
by the SURPASS checklist in surgical patients. BMJ Qual Saf 2012;21:503–508. doi:
10.1136/bmjqs-2011–0 00 347
Netherlands
All perioperative settings
SURPASS checklist
12
Fabila TS, Hee HI, Sultana R, et al. Improving postoperative handover from anaesthetists
to non-anaesthetists in a children's intensive care unit: the receiver's perception.
Singapore Med J 2016;57:242–253. doi:10.11622/smedj.2016090
Singapore
Postoperative (OR-CICU)
PETS protocol with SBAR form
13
Funk E, Taicher B, Thompson J, et al. Structured handover in the pediatric postanesthesia
care unit. J Perianesth Nurs 2016;31:63–72. doi:10.1016/j.jopan.2014.07.015
USA
Postoperative (OR-PPACU)
ISBARQ checklist
14
Garson L, Schwarzkopf R, Vakharia S, et al. Implementation of a total joint replacement-focused
perioperative surgical home: A management case report. Anesth Analg 2014;118:1081–1089.
doi: 10.1213/ANE.0000000000000191
USA
Preoperative/intraoperative/postoperative
Clinical care pathways to manage total joint replacement surgery recovery
15
Gaucher S, Boutron I, Marchand-Maillet F, et al. Assessment of a standardized pre-operative
telephone checklist designed to avoid late cancellation of ambulatory surgery: the
AMBUPROG multicenter randomized controlled trial. PLoS One, 2016;11:1–14. doi:10.1371/journal.pone.0147194
France
Preoperative (ambulatory surgery centre)
AMBUPROG checklist
16
Gleicher Y, Mosko J, McGhee I. Improving cardiac operating room to intensive care
unit handover using a standardised handover process. BMJ Open Qual 2017;6:e000076.
doi:10.1136/bmjoq-2017–0 00 076
Canada
Postoperative (OR-ICU)
Cardiac OR to CVICU checklist and transfer note
17
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity
and mortality in a global population. N Engl J Med 2009;360:491–499. doi: 10.1056/NEJMsa0810119
USA
Intraoperative
SSC
18
Johnson F, Logsdon P, Fournier K, et al. SWITCH for safety: perioperative hand-off
tools. AORN J 2013;98:494–507. doi:10.1016/j.aorn.2013.08.016
USA
Intraoperative
SWITCH handoff tool
19
Kim SW, Maturo S, Dwyer D, et al. Interdisciplinary development and implementation
of communication checklist for postoperative management of pediatric airway patients.
Otolaryngol Head Neck Surg 2012;146:129–134. doi: 10.1177/0194599811421745
USA
Postoperative (OR-PICU)
Electronic Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary airway
checklist
20
Kitney P, Tam R, Bennett P, et al. Handover between anaesthetists and post-anaesthetic
care unit nursing staff using ISBAR principles: a quality improvement study. J Perioper
Nurs 2016;29:30–35.
USA
Postoperative (OR-PACU)
ISBAR cue card
21
McCarroll ML, Zullo MD, Roulette GD, et al. Development and implementation results
of an interactive computerized surgical checklist for robotic-assisted gynecologic
surgery. J Robot Surg 2015;9:11–18. doi 10.1007/s11701-014-0482-z
USA
Intraoperative
RORCC
22
Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation
in an ambulatory surgical facility. Can Journal Anaesth 2013;60:528–538. doi: 10.1007/s12630-013-9916-8
Canada
Intraoperative (ambulatory surgical facility)
SSC (modified)
23
Nagpal K, Arora S, Abboudi, M, et al. Postoperative handover: problems, pitfalls,
and prevention of error. Ann Surg 2010;252:171–176. doi: 10.1097/SLA.0b013e3181dc3656
UK
Postoperative
Postoperative handover proforma
24
Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of perioperative
protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac
Vasc Anesth 2012;26:11–16. doi:10.1053/j.jvca.2011.07.009
USA
Postoperative (OR-ICU/CSICU)
The perioperative handoff protocol
25
Potestio C, Mottla J, Kelley E, et al. Improving post anesthesia care unit (PACU)
handoff by implementing a succinct checklist. APSF Newsletter 2015;30:13–15.
USA
Postoperative (OR-PACU)
PACU handoff checklist
26
Riley CM, Merritt AD, Mize JM, et al. Assuring sustainable gains in interdisciplinary
performance improvement: creating a shared mental model during operating room to cardiac
ICU handoff. Pediatr Crit Care Med 2017;18:863–868.
USA
Postoperative (OR-ICU)
I-5 mnemonic
27
Robins HM, Dai F. Handoffs in the postoperative anesthesia care unit: use of a checklist
for transfer of care. AANA J 2015;83:264–268.
USA
Postoperative (OR-PACU)
Postoperative handoff checklist
28
Salzwedel C, Hansürgen B, Kühnelt I, et al. The effect of a checklist on the quality
of post-anaesthesia patient handover: a randomized controlled trial. Int J Qual Health
Care 2013;25:176–181. http://dx.doi.org/10.1093/intqhc/mzt009
Germany
Postoperative (OR-PACU)
Postanaesthesia handover checklist
29
Salzwedel C, Mai V, Punke MA, et al. The effect of a checklist on the quality of patient
handover from the operating room to the intensive care unit: a randomized controlled
trial. J Crit Care 2016;32;170–174. http://dx.doi.org/10.1016/j.jcrc.2015.12.016
Germany
Postoperative (OR-ICU)
Handover checklist for OR to ICU
30
Siragusa L, Thiessen L, Grabowski D, et al. Building a better preoperative assessment
clinic. J Perianesth Nurs 2011;26:252–261. doi:10.1016/j.jopan.2011.05.008
Canada
Preoperative (preoperative assessment clinic (PAC))
PAC pathway
31
Vergales J, Addison N, Vendittelli A, et al. Face-to-face handoff: improving transfer
to the pediatric intensive care unit after cardiac surgery. Am J Med Qual 2015;30:119–125.
doi:10.1177/1062860613518419
USA
Postoperative (OR-PICU)
Electronic Children’s Heart Center postsurgical summary
32
Weinger MB, Slagle JM, Kuntz AH, et al. A multimodal intervention improves postanesthesia
care unit handovers. Anesth Analg 2015;121:957–971. doi:10.1213/ane.0000000000000670
USA
Postoperative (OR-PACU)
The Vanderbilt Perioperative eHandover Report form (SBAR)
33
Yang JG, Zhang J. Improving the postoperative handover process in the intensive care
unit of a tertiary teaching hospital. J Clin Nurs 2016;25:887–1172. doi:10.1111/jocn.13115.
China
Postoperative (OR-ICU)
Postoperative handover protocol
34
Zavalkoff SR, Razack SI, Lavoie JM, et al. Handover after pediatric heart surgery:
a simple tool improves information exchange. Pediatr Crit Care Med 2010;12:309–313.
doi: 10.1097/PCC.0b013e3181fe27b6
Canada
Postoperative (OR-ICU)
Postcardiac surgery handover tool
AMBUPROG, pre-operative telephone checklist on the rate of late cancellations of ambulatory
surgery; CICU, children's intensive care unit; CSICU, cardiac surgical intensive care
unit; CVICU, cardiovascular intensive care unit; ICU, intensive care unit; ISBAR,
introduction/identification, situation, background, assessment, request/recommendations;
MAPS, medications, allergies, procedures/pertinent information, special needs; OR,
operating room; PETS, pre-handover, equipment handover, timeout, signout; PICU, paediatric
intensive care unit; PPACU, pediatric postanesthesia care unit; RORCC, robot-specific
checklist; SBAR, situation, background, assessment, recommendations; SSC, surgical
safety checklist.
Modifications of processes or tools
The reviewed work included processes or tools that were modified to accommodate the
needs of particular contexts prior to implementation. The most commonly described
tool to facilitate communication and safety during the intraoperative period was the
SSC.9 Literature for the intraoperative period was predominantly related to the implementation
or modification of the SSC or the evaluation of its effectiveness. The checklists
were available in write-in formats,15 electronic versions16 and posters.17 18 A shared
responsibility in completing the checklist was described; however, the team member
leading the implementation of the SSC varied. For example, the surgical residents
led the checklist in one study19 whereas the nurses led the checklist completion in
another.20 A few studies suggested that the implementation of the SSC in the perioperative
setting improved patient outcomes, improved patient safety, improved communication
and teamwork and decreased complications.18 21–25 Limitations were related to the
human factors that affected the implementation of the SSC.26 27
The SSC was adapted to the specific setting by adding or changing items, although
the removal of items was not recommended.15–17 28 29 For example, the SSC was systematically
adapted for use in robotic urological surgery, using a systems evaluation tool to
identify potential causes of error.15 The checklist was developed presuming that it
would undergo further iterations, given the innovative and dynamic nature of the field
of robotic surgery.15 A similar tool was developed and implemented for robotic gynaecological
surgical procedures, which led to significant reductions in 30-day readmission rates.16
Furthermore, displaying the tool on a large monitor in the OR provided a focal point
for the team to gather and could contribute to team cohesiveness.16
Other studies also commented on the applicability of the SSC to unique perioperative
settings, such as small ambulatory surgical settings; therefore some created a modified
SSC version that would be applicable to their case population,17 29 or frequent patient
needs such as advanced age or obesity.28 Literature supported the creation of intraoperative-specific
pathways for surgical settings, which reflected the specific communication needs of
these types of teams.16 19 30 31 In one instance, the SSC was adopted in addition
to a flow checklist designed to follow the patient trajectory throughout the surgical
journey from induction to the postanaesthesia care unit (PACU).32
Additional articles described the development of checklists distinct from the SSC,
which were also modified in terms of content or delivery. For example, the SURgical
PAtient Safety System (SURPASS) checklist was intended to decrease adverse events
for surgical patients, from admission to discharge.33 The authors validated this tool
through a process of observing procedures and noting deviations from checklist use,
which often corresponded to variations in personnel and logistics.33
The engagement of all team members, particularly nurses, was described as a facilitator
of success when a process and checklist were implemented to improve handovers between
the OR, intensive care unit (ICU) and PACU settings.34–36 Some articles described
modifications that participants made to checklists during the implementation period.
Most often, participants appeared to strategically omit particular checklist items;
for example, a subset of items continued to be routinely omitted in two studies,37
38 which could suggest that these items are perceived as non-essential during handover.39
Tool implementation appeared to contribute to longer time spent on handovers, which
could be viewed as a deterrent to tool usage.37–41 Particularly, a lack of compliance
to use the checklist by anaesthesiologists could be contributed to a gap in training
on checklist use.37 Furthermore, some anaesthesiologists expressed that they would
not likely integrate the checklist into their practice, as they described it as ‘insulting’
to their years of training, which could indicate a need for education to address attitudes
towards standardisation and safety.37 In contrast, two handover processes did not
significantly increase handover time, but improved team communication and information
transfer.42–44
Facilitators and barriers to uses of processes, tools or resources
Education and training
In a subset of the selected articles, the implementation of a checklist or procedure
was paired with a varied educational intervention to facilitate the change. To facilitate
the implementation of the SWITCH (surgical procedure, fluids, instruments, tissue,
counts and questions) tool, it was discussed at in-service meetings, HCPs were provided
with opportunities to use the tool in role-play activities, and resources were made
available in the OR. An educational intervention was developed to accompany the implementation
of an ISBAR (identification/introduction, situation, background, assessment, request/recommendation)
tool for handovers between the OR and PACU.45 These comprised 30 min education sessions
and the provision of visual cues on unit walls, which led to mixed results for compliance
rates.45 The authors suggest augmenting education and acknowledging the impact of
leadership and culture in different contexts.45
Multiple theory-informed educational interventions, including webinars, simulation
scenarios and refresher courses, were developed to ease implementation of a standardised,
electronic PACU handover tool.46 The authors reported that improvements in the quality
of PACU handovers were sustained up to 3 years after the intervention.46 Similarly,
month-long training and practice trials were referenced as a contributor for improved
outcomes related to information exchanges and improved patient outcomes, in relation
to the handover process from the OR to the paediatric cardiac ICU.47
Staff buy-in
Some of the described interventions incorporated input from HCPs prior to implementation.
For example, front-line HCPs from the OR and ICU settings were consulted when developing
a protocol and checklist to improve patient handoffs between these settings.41 In
a study that examined the postoperative handover process, the importance of eliciting
feedback throughout the implementation process was emphasised, as this opportunity
provided staff with a sense of ownership in regard to the change.48
Staff buy-in could also be a factor in who participates in the intervention. In a
study that described the development of a postoperative anaesthesia tool, the anaesthesia
residents did not participate in the research; therefore, only handoffs between CRNAs
(certified registered nurse anesthetists)and PACU registered nurses (RN) were evaluated.49
The researchers suggested that long-term implementation would be strengthened by buy-in
from all HCP groups.49 In another study, tool use was improved when a particular nurse
circulator was present, and the need for staff buy-in to support implementation was
noted.16
Regarding the implementation of a modified SSC for ambulatory surgical facilities,
it was suggested that poor tool uptake was due to introducing it as an institutional
requirement without previously consulting stakeholders.29 A hierarchical culture might
have contributed to RNs feeling hesitant to use the checklist, if not supported by
the attending surgeon.29 Similar cultural barriers during the original SSC implementation
such as culture and organisational hierarchy were referenced.15
Contextual factors such as high nurse turnover were described as a barrier.36 With
support from leadership and administration, the process of improving a preoperative
assessment clinic was described by improving staffing levels, aligning processes with
best practice procedures and modifying space to improve efficiency.50
Staff well-being
To improve the functioning of a preoperative assessment clinic, changes to patient-facing
policies and staffing structures were re-examined, which led to positive staff-related
outcomes, such as decreased sick time, decreased overtime and better staff morale.50
The importance of measuring non-clinical outcomes, such as teamwork and nurse satisfaction,
was acknowledged.51 Improved non-clinical measures, such as teamwork, were linked
to successful clinical outcomes.51 The professional differences in communication between
HCPs when developing a face-to-face handover process from the OR to the paediatric
cardiac ICU were described.52 Engaging all stakeholders improved HCP satisfaction
with handovers and contributed to the ‘feeling of a team approach’.52
Safety culture
Improved outcomes associated with their electronic checklist were not solely attributable
to the tool, but also to discussions generated by the tool in relation to safety-focused
attitudes and behaviours.53 Additional studies attributed successful tool implementation
to contexts with strong safety cultures; conversely, non-compliance could be in part
related to local attitudes towards safety culture.33 54
The implementation of a 19-item SSC resulted in a decrease in patient death from 1.5%
to 0.8%, and a 4% decrease in inpatient complications.18 The authors suggested that
the introduction of the surgical pause for a multidisciplinary briefing could be linked
to improved attitudes towards safety.18 In another study, which described a series
of evidence-based clinical care pathways specifically for patients having total joint
replacement surgery, all staff were trained in Lean Sigma Six principles.30 This could
promote a culture that values improving performance by leveraging a team approach.30
Ease of use
Multidisciplinary team members that implemented the SURPASS checklist suggested that
integration with the hospital electronic system could promote tool use.33 The implementation
of a standardised electronic checklist was described to improve intraoperative handoffs
between anaesthesiologists and transfers of paediatric surgical airway patients to
medical settings.53 55 The electronic format was particularly convenient, as the described
patient transfers were between institutions.53 Some authors emphasised the importance
of selecting tools that were short, to balance ease of use with team engagement.44
For example, the rationale for selecting the SSC was based on simplicity and cost-effectiveness;
whereas other tools such as the SURPASS checklist were viewed as difficult to implement
due to additional items.18 In contrast, some interventions were easy to implement,
but de-emphasised the role of team communication during the handover process.
Description of theory underpinning processes or tools
Few studies gave explicit reference to theory to support the development of handover
processes or tools. However, safety theory was noted in the development of the SURPASS
checklist to decrease adverse events for surgical patients, from admission to discharge.33
The SURPASS tool is built on safety and human factors literature within the field
of aviation.33 Two studies included reference to high-reliability organisations.49
51
Theory was also used to understand the effects of tool implementation. For example,
the use of 40.6% SURPASS checklists was linked with one or more intercepted errors.56
The authors referenced Reason’s Swiss cheese model to describe that the success of
the SURPASS checklist could be attributed to ‘spreading out’ the safety checks over
the course of the surgical trajectory.56 A few studies referenced the use of quality
improvement methodologies, such as Six Sigma.40 57 Team theory was referenced when
describing the use of the ‘I-5’ mnemonic to create a shared mental model during OR
to cardiac ICU handoffs.58
Discussion
This review provided an overview of the existing processes, tools and resources used
to improve communication in perioperative settings, as well as a description of the
ways in which they are used. More than half of the papers described tools to improve
intraoperative team communication, such as modified versions of the SSC. In a recent
editorial, Urbach et al highlight that although current evidence does not conclude
that patient mortality was decreased at the population level given SSC use, it has
been shown to improve team dynamics and staff satisfaction; however, the consideration
of contextual factors impacting the SSC implementation is critical to success.59 Recent
work has highlighted that the adoption of the SSC is informed by factors related to
the surgical team members’ perceived importance of the tool, the profession leads
the SSC use (eg, surgery, anaesthesia or nursing), and differences in workflow.60
Similar to this review, CPSI reported that most tools or processes seek to structure
or standardise communication, often in accordance with processes from high-reliability
industries, such as aviation, with a need to shift patient safety culture.61 In our
review, patient safety culture was often referred to as a barrier to process or tool
implementation. For example, the implementation of the same tool could lead to different
patient outcomes in different hospitals, and was attributed to different attitudes
towards safety culture.33 54
In exploring the role of culture, it appears that the promotion of safety culture
could inadvertently promote staff well-being or engagement. Some improved staffing
policies, among other changes, in an effort to improve patient outcomes at a preoperative
assessment clinic.50 This led to unanticipated positive staff-related outcomes, which
suggests that what is good for patients can also be good for staff.62 For example,
better patient outcomes can translate into staff that feel less frustrated and therefore
can better focus on care quality and safety.50 The importance of measuring outcomes
related to staff satisfaction and teamwork was emphasised.51 These insights align
with current conversations to expand the Triple Aim framework to attend to the well-being
of the healthcare workforce.63 64
There was limited exploration of the nature of teamwork either before or after implementation.
Few studies explicitly measured teamwork and few studies alluded to professional hierarchies
or ways of working as barriers. This is a clear area for further study given the lack
of available information within the context of the implementation of a communication
tool within a perioperative setting.
Joint recommendations were issued by CMPA and HIROC following a comprehensive review
of surgical safety.8 To address system-level factors, recommendations were to implement
standardised protocols, measure outcomes in order to evaluate protocols, support a
culture of safety that promotes open communication and to provide multidisciplinary
education to build skills related to teamwork and communication.8 From our review,
it appears that there has been successful implementation of a range of standardised
protocols to improve perioperative communication and distinct effort has been made
to evaluate the impact of patient outcomes. However, the need to improve safety culture
and provide multidisciplinary education persists. In the reviewed literature, the
education offered was more akin to training, as it was focused towards implementing
a specific tool or process. Education could be improved if understood more broadly
and acknowledge existing professional tensions that hinder teamwork, and ultimately
the push towards a culture of safety.
Conclusion
This review highlights the importance of effective communication within surgical settings,
as well as the difficulties of communicating within surgical teams. The large number
of processes and tools developed to improve team communication during all aspects
of surgical care highlights efforts to promote structured, yet open communication.
This balances the comprehensive nature of information transfer, while maintaining
spaces for team members to comfortably ask questions or dialogue. The findings indicate
that seminal tools, such as the SSC, are widely adopted and are frequently modified
to suit the particular needs of the surgical specialty or used in conjunction with
additional processes. In addition, contextual factors such as education, staff buy-in,
staff well-being, safety culture and ease of tool use can function as facilitators
or barriers to implementation. The use of safety or team theory could be more explicitly
addressed either in the development of implementation of these processes or tools.
This information could be useful for clinicians seeking existing tools or processes
to improve teamwork and communications in surgical settings or for those looking to
enhance the implementation process.