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Table 1.  
Proposed Topics and Guiding Questions for Focus Groups
Proposed Topics and Guiding Questions for Focus Groups
Table 2.  
Topics and Identified Themes From Focus Group Content
Topics and Identified Themes From Focus Group Content
1.
Christian  CK, Gustafson  ML, Roth  EM,  et al.  A prospective study of patient safety in the operating room.  Surgery. 2006;139(2):159-173.PubMedGoogle ScholarCrossref
2.
Greenberg  CC, Regenbogen  SE, Studdert  DM,  et al.  Patterns of communication breakdowns resulting in injury to surgical patients.  J Am Coll Surg. 2007;204(4):533-540.PubMedGoogle ScholarCrossref
3.
McCulloch  P, Rathbone  J, Catchpole  K.  Interventions to improve teamwork and communications among healthcare staff.  Br J Surg. 2011;98(4):469-479.PubMedGoogle ScholarCrossref
4.
Makary  MA, Sexton  JB, Freischlag  JA,  et al.  Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.  J Am Coll Surg. 2006;202(5):746-752.PubMedGoogle ScholarCrossref
5.
Finn  R.  The language of teamwork: reproducing professional divisions in the operating theatre.  Hum Relat. 2008;61(1):103-130.Google ScholarCrossref
6.
Pucher  PH, Aggarwal  R, Singh  P, Tahir  M, Darzi  A.  Identifying quality markers and improvement measures for ward-based surgical care: a semistructured interview study.  Am J Surg. 2015;210(2):211-218.PubMedGoogle ScholarCrossref
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Research Letter
January 2017

Investigating Teamwork in the Operating RoomEngaging Stakeholders and Setting the Agenda

Author Affiliations
  • 1Wisconsin Surgical Outcomes Research Program, University of Wisconsin–Madison
  • 2Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison
  • 3University of Wisconsin Hospital and Clinics, Madison
  • 4Department of Systems and Engineering, University of Wisconsin–Madison
 

Copyright 2017 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Surg. 2017;152(1):109-111. doi:10.1001/jamasurg.2016.3110

The operating room (OR) offers a unique opportunity to explore concepts of teams and teamwork. Communication and teamwork contribute to adverse events.1,2 Attempts at intervention, such as crew resource management, have had mixed results.3 While survey-based studies have shown discipline-specific differences in perceived teamwork in the operative setting,4 we have a poor understanding of how unique aspects of operative environments, teams, and culture contribute to these problems. Quantitative and observational studies are insufficient to explore the complex function and behaviors of operative teams. Although qualitative evaluations of surgical care exist,5,6 to our knowledge, there has been minimal investigation of clinicians’ perceptions on topics of operative team identity, management of operative team member unfamiliarity, and intraoperative hand-offs. Engaging stakeholders and evaluating their perspectives is critical to setting an agenda for further investigation and the design and implementation of best practice guidelines or team training interventions.

Methods

This qualitative study received a waiver from the University of Wisconsin–Madison institutional review board as part of a quality-improvement project, including a waiver of written informed consent. We held focus groups of OR clinicians from 3 disciplines: anesthesiology (including anesthesiologist assistants and certified registered nurse anesthetists), nursing (including surgical technologists), and surgery, for a total of 23 participants. Both resident and attending physicians participated. Based on the need to better understand the importance of hand-offs and communication in team performance and safety, we explored topics of team identity, the effect and management of team member unfamiliarity, and intraoperative hand-offs using a semistructured format with open-ended questions (Table 1).

Sessions were audio-recorded and transcribed. Our multidisciplinary team independently performed open coding for qualitative content analysis. Codes were reviewed iteratively, and one author (L.L.F.) reviewed prior transcripts and applied new codes as appropriate.

Results

The 3 disciplines described different conceptualizations of “team identity” (Table 2). Nurses and surgical technologists identified other nurses and technologists as their team. Anesthesia professionals identified their team as anyone assisting in the provision of anesthetic care. Surgeons had the broadest definition of the team, including all clinicians in the OR, as well as clinicians involved in the patient’s preoperative and postoperative care and working “behind the scenes.”

Across all disciplines, clinicians indicated that when working with unfamiliar team members, they increased the frequency and quality of their verbal communication. Other tactics included slowing down, avoiding assumptions about the knowledge base of unfamiliar team member(s), and being more vigilant.

All clinicians agreed that intraoperative hand-offs represented a potential source of tension, information loss, and impaired safety. However, there was no consensus on the optimal management of intraoperative hand-offs. Some felt that the ideal hand-off was unobtrusive and discipline-specific. Others felt that it included a notification to the room. Proponents of each strategy could be found across all 3 disciplines.

The topic of “setting the tone” was not one that we originally set out to explore but arose during data analysis. Clinicians indicated that events in the preoperative phase of the case set the tone of the room for the rest of the case or even the rest of the day. Clinicians remarked that surgeons were key facilitators in setting the tone, as good communication led to an improved OR atmosphere. Conversely, early miscommunication or delays resulted in tension.

Discussion

This work is situated within a larger project evaluating teams in the OR and was designed to solicit stakeholder perspectives and guide analysis of observations of OR teams. As such, our findings require a deeper mixed-methods evaluation before definitive conclusions can be drawn.

However, this initial exploration identified concepts of teams and teamwork not described in the literature, and it serves an important role in hypothesis generation. Based on these findings, we propose several critical lines of inquiry for intraoperative teamwork and safety, including identification of the optimal design and timing of intraoperative hand-offs; exploring differences in verbal communication between familiar and unfamiliar team members; and clarification of the membership and functioning of operative teams.

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Article Information

Corresponding Author: Caprice C. Greenberg, MD, MPH, University of Wisconsin–Madison, 600 Highland Ave, BX 7375 Clinical Science Center, Madison, WI 53792-3284 (greenberg@surgery.wisc.edu).

Published Online: September 28, 2016. doi:10.1001/jamasurg.2016.3110

Author Contributions: Drs Greenberg and Frasier had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Frasier, Pavuluri Quamme, Booth, Wiegmann, Greenberg.

Acquisition, analysis, or interpretation of data: Frasier, Pavuluri Quamme, Becker, Gutt, Wiegmann, Greenberg.

Drafting of the manuscript: Frasier, Booth, Wiegmann, Greenberg.

Critical revision of the manuscript for important intellectual content: Pavuluri Quamme, Becker, Gutt, Greenberg.

Statistical analysis: Gutt.

Administrative, technical, or material support: Pavuluri Quamme, Greenberg.

Study supervision: Pavuluri Quamme, Gutt, Wiegmann, Greenberg.

Conflict of Interest Disclosures: Dr Frasier is currently supported by grant F32 HS022403 from the Agency for Healthcare Research and Quality. She also received support via grant T32 CA90217 from the National Institutes of Health/National Cancer Institute and the Association for Academic Surgery Research Fellowship Award. Dr Greenberg serves as a consultant to Johnson & Johnson’s Human Performance Institute. Drs Greenberg and Pavuluri Quamme receive support for an unrelated project from Medtronic Plc, formerly Covidien. No other disclosures were reported.

Previous Presentation: These data were presented as an oral presentation at the American College of Surgeons Clinical Congress Scientific Forum; October 8, 2015; Chicago, Illinois.

References
1.
Christian  CK, Gustafson  ML, Roth  EM,  et al.  A prospective study of patient safety in the operating room.  Surgery. 2006;139(2):159-173.PubMedGoogle ScholarCrossref
2.
Greenberg  CC, Regenbogen  SE, Studdert  DM,  et al.  Patterns of communication breakdowns resulting in injury to surgical patients.  J Am Coll Surg. 2007;204(4):533-540.PubMedGoogle ScholarCrossref
3.
McCulloch  P, Rathbone  J, Catchpole  K.  Interventions to improve teamwork and communications among healthcare staff.  Br J Surg. 2011;98(4):469-479.PubMedGoogle ScholarCrossref
4.
Makary  MA, Sexton  JB, Freischlag  JA,  et al.  Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.  J Am Coll Surg. 2006;202(5):746-752.PubMedGoogle ScholarCrossref
5.
Finn  R.  The language of teamwork: reproducing professional divisions in the operating theatre.  Hum Relat. 2008;61(1):103-130.Google ScholarCrossref
6.
Pucher  PH, Aggarwal  R, Singh  P, Tahir  M, Darzi  A.  Identifying quality markers and improvement measures for ward-based surgical care: a semistructured interview study.  Am J Surg. 2015;210(2):211-218.PubMedGoogle ScholarCrossref
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