Strategies for Improving Your Surgical Practice

Educational Objectives

The goal of this program is to improve the practice of surgery. After hearing and assimilating this program, the clini­cian will be better able to:

Consider how culture change can be brought about in health care.

Evaluate the roles of perception, assumption, and communication in medical errors.

Describe unique ability and how it affects surgical practice.

Apply delegation and growth strategies to a surgical practice.

Discuss the frontstage/backstage model of surgical practice.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Adamson is on the Physician Advisory Panel of Allergan Canada. Mr. Nance and the planning commit­tee reported nothing to disclose.

Acknowledgements

Mr. Nance was recorded at the 23rd Annual Meeting of the American Society of Pediatric Otolaryngology, held May 2-4, 2008, in Orlando, FL, and sponsored by the American Society of Pediatric Otolaryngology. Dr. Adamson was re­corded at Clinical Frontiers in Otolaryngology, held January 16-17, 2009, in Los Angeles, CA, and sponsored by the Research Study Club of Los Angeles. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Aviation Safety: A Practical Paradigm for Improving Surgery

John J. Nance, JD, Founding Member, the National Patient Safety Foundation of the American Medical Associ­ation; Commercial Pilot; Aviation Consultant, ABC World News and Good Morning America, Tacoma, WA

Introduction: operating room (OR) closely parallels aviation experience; in aviation arena, accidents from mechani­cal causes minimized to almost zero

Professional culture: major issue; health care not focused on individual or individual’s position in human system as imperfect; cultural change in patient safety and quality takes 15 to 25 yr; previously, highly trained and highly motivated professional expected to be omnipotent, infallible, and without need for advice; present definition of leadership involves how well leader extracts, orchestrates, or utilizes available human talent

Dead man’s throttle principle:  example  —  pilot narrowly avoids accident; copilot saw but did not point out to pilot that he was approaching wrong runway; cultural change required in medicine  —   team members must be empow­ered to help catch errors made by individuals; team then able accomplish tasks unattainable as individuals; when building team, consider that person may not know how he or she comes across; people not honest with them­selves about how they are perceived and about limitations as humans; “every system is perfectly designed to get the results it consistently achieves”; must rewire essence of system and reevaluate all aspects of it; in medicine as in aviation, never one single cause but multiplicity of causes; normalization of deviancy  —creeping change in how things accomplilshed not caught in time to get back on track; assumption should always be that things can go wrong

How failure occurs: perception, assumption, and communication (one or more involved in all medical errors); indi­viduals mistakenly assume they are able to perceive things exactly right; in team environment, expectation that misperception can occur enables prevention of errors; 12.5% rule in communication  —12.5% of time, people who understand each other and speak same language misunderstand communication; expectation that physician always right major problem; another problem momentum of how things done (“this is the way we have always done it”); culture change means understanding fallibility as human beings; team not just collection of strong leader and good followers, but people who operate collegially, respect each other, and care about relationships; previously, attempt made to dehumanize systems; team members should check on each other as colleagues (creates level of perfection not achievable by individual by him- or herself); example of fatal airliner collision in which poor communication involved; example in which collision averted because junior officer warned pilot about danger

Tools for Becoming a Successful Surgeon

Peter A. Adamson, MD, Professor and Head, Division of Facial Plastic and Reconstructive Surgery, Depart­ment of Otolaryngology, Head and Neck Surgery, University of Toronto, ON

Unique ability: not only talent but also passion; oftentimes, rather than doing that in which we are interested and have talent for, we end up in positions in which we have no interest, trying to accomplish tasks in which we do not excel 

Activity inventory: unique ability  —  superior skill, gives person energy, person passionate about it, and constant im­provement occurring; excellent activities  —  person has superior skill and reputation for excellence in perfor­mance, but no passion; requires teamwork; competent activities  —  person meets minimum standards, but performance causes anxiety; person feels competition with others; task repetitive; incompetent activities  —lead to sense of failure, frustration, and conflict and stress; goal  —always focus activities on unique abilities and del­egate everything else

Advantages of concept: easy to grasp; life immediately more enjoyable; contributes to improved communication and cooperation; produces ever-increasing results; creates personal happiness; becomes superior ability others recognize and value; energizes and improves one’s self and others; when unique ability utilized,  person feels ca­pable, confident, focused, directed, content, and free

Analyzing current situation: are you negatively programmed by society, profession, hospital, boss, or practice situ­ation? are you doing things in which you are not interested and which you dislike? are you positively pro­grammed and doing what you are interested in and love? each person responsible for own future; all progress begins by telling truth, first to yourself; create own unique ability statement  —ask friends and colleagues to de­scribe your unique ability (theme becomes evident); list 10 best habits (things you habitually do that people rec­ognize); test on www.kolbe.com helps determine natural ability; list key words that describe talent and passion; write paragraph about own unique ability

Action plan: delegation strategies  —  stop doing task(s) you do not enjoy; find someone else to do it; trade with someone else; use technology; hire somebody; give up guilt; example  —  if goal to decrease administrative tasks, list necessary improvements, benefits, specific actions taken, and deadline dates; growth strategies  —  permit yourself to spend time using your unique ability; talk to people about your unique ability; seek new opportunities; ask others for support and ideas; look for resources to grow your unique ability; put structures in your life that support your unique ability development; make time for thinking, learning, and personal awareness; rule  —  always focus activi­ties on unique abilities and delegate everything else

Time management: thinking or wishing about doing something else (no matter what you are doing) means you are not present; do not be late (in speaker’s office, eg, consultation half price if patient kept waiting <0.5 hr, free if patient waiting >0.5 hr)

Managing days: free days  —  days off for rejuvenation and energy; no contact with office; focus days  —  in office seeing patients or in operating room; no other business or telephone calls; buffer days  —  for meetings and admin­istrative work; speaker prefers to minimize buffer days in favor of focus and free days; plan free days first, then, focus and buffer days; draft new schedule every 90 days; if unable or unwilling to do planning, have someone else do it for you

Lifetime goals: identify goals; set 20-, 10-, 5-, 3-, and 1-yr plan to reach goals; assess progress every 3 mo; every day, plan to achieve progress toward lifetime goals

Daily dilemma: often so much to do every day, unable to get everything done; daily plan  —  make daily list of tasks; prioritize list; start at top; carry forward undone tasks to master list; rule  —  make list first thing every day; share list with staff; delegate whatever you can; should not delegate everything to spouse/partner

Strategic planning: inability to move forward with major projects; strategic planner  —  identify goal; imagine result; list obstacles; generate strategies; chances of accomplishing job much higher if written down; set timelines

Getting it right: inability to get things done because not enough time to do them right; 80% maximizer  —tool for getting it right; eliminates procrastination and perfectionism; increases productivity; according to poet William Blake, excellence does not require perfection; 80% solution  —  should begin task without waiting for guarantee of ideal result; perfectionism leads to dissatisfaction with past and pessimism for future; eliminate procrastination and perfectionism; apply 80% maximizer

“The gap”: much of time spent worrying about what we do not have or goals not yet reached; understanding gap  —  level 1 (where we were); level 2 (where you are presently); ideal is our dream; gap is between where we are now and our dream for future; from ideal, generate things we wish to achieve; looking at past year, everyone has accom­plishments in any area measured; living in negative zone of what we do not have generates anger, frustration, de­pression, sense of failure, cynicism, lack of motivation, helplessness, loneliness, fear, and worthlessness; get out of gap by recognizing successes achieved; understand and accept that ideal is horizon (ever moving and unreachable)

Problems: every day, physician bombarded with problems that can be frustrating and demoralizing; positive focus  —  begin every personal encounter or meeting by recognizing positive element in situation; build upon positive ele­ments of situation and personal strengths of those involved to make further progress; creates teamwork and positive attitude; when problem-solving, always begin with positive focus, then move on to deal with details

Frontstage/backstage model: conceptual framework for sharpening organizational clarity; unique methods created backstage  —  include unique abilities of physician and staff, and, eg, methods for communication with patients, paperwork, website, consultation process, surgical ambulatory center process, follow-up care, marketing; these then create unique process; means looking for all things that support frontstage; requires teamwork and coordina­tion; constitutes overhead in practice; with improvement, backstage unique methods result in improved produc­tivity; frontstage  —  “experience” (not service) delivered to patient; creates value for patient; results depend on what occurs backstage; backstage determined, measured, and judged by how well it contributes to results of frontstage;  need communication between front- and backstage

Medicine and “new world”: practice of medicine changed because of Internet; problem with managed care and in­surance companies paying only limited amount; medicine no longer service, but commodity (reason for frustra­tion in medicine); commodity sells because of price; must create value for patients; must create experience for patients

Creating value for patients: improve support, eg, new hardware and software, new billing and booking systems, in­stall computer imaging, evaluate efficiency, improve teamwork; done by creating unique methods to support backstage and developing them through teamwork and coordination (results in increased productivity); look at frontstage to determine how to improve uniqueness of patient experience;  rule for backstage/frontstage method  —  create unique methods to support practice and develop them through teamwork and coordination (backstage); create unique process supported by unique methods to create unique experience for patients; pack­age experience and increase value (results in increased revenues); cannot happen in nonentrepreneural setting where growth of revenues and control of overhead not possible

Gratitude: many people enjoy many successes in life, but true happiness and contentment eludes them; gratitude necessary for happiness; gratitude principle  —  identify major accomplishments in life; identify small successes of day; take moment to enjoy feeling; every night, think of 5 positive things that happened during day; be grateful ev­ery day for life you live; celebrate successes

Suggested Reading

Catchpole K et al: Teamwork and error in the operating room: analysis of skills and roles. Ann Surg 247:699, 2008; Catchpole KR et al: Improving patient safety by identifying latent failures in successful operations. Surgery 142:102, 2007; Churchill LR et al: Healing skills for medical practice. Ann Intern Med 149:720, 2008; DeFran­cesco MS: Practice smarter…not harder! Obstet Gynecol 112:10, 2008; Donahue M et al: Medication administra­tion process assessment: applying lessons learned from commercial aviation. J Nurs Adm 39:77, 2009; Fabri PJ et al: Human error, not communication and systems, underlies surgical complications. Surgery 144:557, 2008; Fuller FW: The aviation paradigm and surgical education. J Am Coll Surg 202:200; author reply 200, 2006; Grogan EL et al: The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg 199:843, 2004; Muller M: Safety lessons taken from the airlines. Br J Surg 91:393, 2004; Nance JJ. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care.  Bozeman, MT: Second River Healthcare Press; 2008. Oriol MD: Crew resource management: applications in healthcare organizations. J Nurs Adm 36:402, 2006; Rosenfield LK et al: The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg 123:399, 2009.