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Thank you for participating in Safety in Spine Surgery Month! We closed out the month with an excellent April 29 webinar on Leveraging the Team to Make Spine Surgery Safer. The replay will be available on our website next week.
Our last week of safety videos included some outstanding content & practical tips. We heard from:
- Dr. Nicholas Fletcher on Mean Arterial Pressure Parameters
- Dr. Sumeet Garg on Getting the Team on the Same Page
- Dr. Jean-Pierre Mobasser on the Risks of K Wires and Guidewires in Spine Procedures
- Dr. Michael Glotzbecker on Overcommunication
- Dr. Massimo Balsano on his safety tips
- Dr. Suken Shah on the Surgeon Performance Program
- Dr. David Skaggs on Setting up Systems
- Dr. Roger Härtl and Dr. Jacob Goldberg on Emergency Workflow Training
As always, you can review all these videos, plus our library of past talks, for free on the website.
We want to thank this week’s contributors, as well as this week’s partner organizations: SMISS, ISASS, SRS, Setting Scoliosis Straight Foundation, and POSNA.
We hope you’ll join us for next year’s Safety in Spine Surgery Summit (Spring 2022 in New York).
View all this week’s videos here.
Did you catch these highlights from Safety in Spine Surgery Month, Week 3? Our April 15 webinar was packed full of practical advice on implementing checklists and guidelines, and the faculty included leaders from the SRS, the AANS, POSNA, and more. We jammed a lot of education into those 2 hours! You can catch the replay on our website here.
Since we are talking about checklists, do you know about all the free safety in spine surgery resources on the S3P website? We have risk severity scores, checklists, pathways, and more.
We also continue to post daily videos about safety from a variety of leaders across all our social media channels. I think these videos are getting better and better! This week’s videos included:
- Carlton Weatherby from Medtronic talking about their steadfast commitment to unmatched quality.
- Dr. John Smith sharing about the success he’s seen in dedicated surgical teams and checklists—they make surgery “much more efficient, safer, and fun.”
- We posted a clip from Dr. Roger Härtl’s 2020 talk about the market approval process for new technology.
- Dr. Kevin Shea told us about the POSNA Safe Surgery Program. Learn more here.
- Dr. Rick Sasso explained the No Strikeout Protocol he developed at the CSRS. This resource is free to download, too.
- Dr. Chris Hardesty shared about peri-op care protocols, which “help remove variation in practice, which can help decrease variation in outcomes.”
- Finally, we capped off the week with General Stan McChrystal, our Keynote Lecturer at the 2018 Safety in Spine Surgery Summit, sharing his thoughts on how teams impact safety.
As always, you can review all these videos, plus our library of past talks, for free on the website.
We want to thank this week’s contributors, as well as this week’s partner organizations: Medtronic, Pediatric Spine Study Group & the Pediatric Spine Foundation, POSNA, and the CSRS.
We still want to hear from you! Post safety tips or questions on your own social media—tag us, and you might win a $100 gift card! Winners are drawn each week from all social media channels.
View all this week’s videos here.
We had some amazing videos sharing the message about safety in spine surgery, with both top-level commentary as well as practical tips. This week our daily safety tip videos were seen by over 11,000 people, and our overall audience grew by 40%. Highlights included:
- Dr. Lehman asked us, “Why is it safer to fly in an airplane than to have surgery?,” in his video on Safety By the Numbers.
- Prof Carl-Eric Aubin shared about the biomechanical considerations in assessing spinal instrumentation for safety.
- Vafa Jamali from Zimmer Biomet shared about their support of the Safety month.
- Dr. Hey shared about the importance of spine surgery checklists, including a link to the downloadable checklists he’s created.
- And finally, Dr. Elowitz explained the connections between communication, patient safety, and medical malpractice.
Several of these daily tip videos are taken from longer talks presented at past Safety in Spine Surgery Summits. Did you know we have a library of these talks that you can browse & watch for free? Visit the videos tab on our website, or start here with the 2020 Safety Summit videos.
We also had over 500 people register for the April 15 webinar Checklists & Guidelines Which Make Spine Surgery Safer, which featured 4 of our Award Winners for the Best New Methodologies and Techniques to Enhance Safety in Spine Surgery, as well as a “who’s who” of surgeon leaders representing spine safety efforts from leading societies including the SRS, AANS, and POSNA.
We want to thank this week’s contributors, as well as this week’s partner organizations: NewYork-Presbyterian, Medtronic, Zimmer Biomet, NeuroPoint Alliance, Hey Clinic, and CareGuard.
We want to hear from you, too! Post safety tips or questions on your own social media—tag us, and you might win a $100 gift card! Winners are drawn each week from all social media channels.
View all this week’s videos here.
The Safety in Spine Surgery Project is pleased to announce the First Annual Safety in Spine Surgery month, taking place in April of 2021. The goal of this project is to improve safety in spine surgery by sharing guidelines, techniques, and protocols that make care better, and to share lessons learned from participants who have developed specific, successful safety protocols. This event will feature 2 live webinars and an industry-wide social media campaign throughout April.
Under the leadership of Michael G. Vitale, MD, MPH and co-chairmen John Flynn, MD; Roger Härtl, MD; Larry Lenke, MD; Rajiv Sethi, MD, S3P is partnering with surgeons, allied health care providers, organizations, hospitals, and medical device companies in this effort. It is the belief of the program directors that all major healthcare stakeholders are obligated to invest their expertise and funds to enhance patient safety.
Submission of abstracts and projects summaries is underway for Best New Methodologies and Techniques to Enhance Safety in Spine Surgery. The 10 best submissions will each be awarded $1000 and be featured during one of the live webinars. We encourage our colleagues to submit not only scientific papers, but also any project that has made a difference in spine surgery quality, safety, or value. Submissions are due to Kate Laney by February 19, 2021.
Registration is open for two live webinars, taking place April 15 and April 29. The first will focus on predictive analytics, enabling technology, and innovative techniques to make the OR safer. The second will highlight checklists, guidelines, and tricks to avoid complications and improve neurological safety. Registration is free and can be accessed at this link.
We encourage you to get involved in this effort by submitting abstracts, attending the webinars, and getting active on social media during the month of April. Post your successes and difficulties with the hashtags #safetyinspinesurgery and #s3p. Follow us on Twitter, Facebook, Linkedin, and Instagram for further information.
If your practice, organization, or medical device company would like to partner with us, please contact Kate Laney.
We are looking forward to an exciting month of collaboration!
Follow us:
Save the date for the 5th Annual Safety in Spine Surgery Summit: April 13, 2020 in New York City.
Chair:
- Michael G. Vitale, MD, MPH
Co-chairs:
- John M. Flynn, MD
- Roger Härtl, MD
- Rajiv K. Sethi, MD
An ESSENTIAL program for:
- Spine surgeons
- Surgical spine team members
- Hospital execs responsible for patient safety
Registration details will be posted on the Event’s Page.
How Lessons from Cycling Can Inform Efforts at Continuous Improvement
A recent conversation with an avid cycler helped me draw interesting parallels between how sport and the pursuit of skill so often intersects with our mission to make care better in healthcare. Britain’s national efforts in cycling provide such an interesting case study, taking a program who had never won a single gold medal in its 76 year history to winning seven out of 10 gold medals in two consecutive Olympics and applying the same discipline to lead one of the most successful professional cycling teams ever.
Sir Dave Brailsford, the coach responsible for these efforts, took the principles of the Toyota Production System, also called lean, to infuse the team with the spirit of Kaizen, or continuous improvement. He thought that if the team broke down everything they could think of that went into competing better on a bike, and then improved each element by 1%, then these marginal gains could achieve a significant aggregated increase in performance. This came from everything to the traditional areas of experimenting in wind tunnels for aerodynamic, to applying 5S techniques to the mechanics team truck and painting the floor white to prevent slips from grease, to teaching athletes about proper hand hygiene from a surgeon. This even went as far as requiring all athletes to sleep on team provided mattresses and pillows so athletes could sleep in the same posture with the same support every night. Taken together, they felt that it gave a competitive advantage.
These principles of looking at strategy, human performance, and continuous improvement have the same applications to how surgery is performed. For strategy, so much cognitive effort needs to be spent on understanding patient’s unique attributes, understanding plans for surgery, and involving the team. This can also involve slowing down the machine and working with a multidisciplinary team to understand the approach. With S3P efforts, this include recommending using multidisciplinary indications conferences with anesthesia, medicine, and nursing to fully discuss a patient’s treatment plans.
For human performance, this truly involves a surgeon treating themselves as athletes, caring for their physical conditions and optimizing their movements. But this also involves attention to behavioral psychology and creating an environment for optimum performance. This may involve routines the evening and morning before surgery to cognitively rehearse the procedures but also can include preventing heuristic biases from affecting decision making. At S3P, this involves the development of formal risk stratification scores to formalize the requirements and opportunities for “slowing the machine” and optimizing patients’ modifiable risk factors.
The final aspect of continuous improvement plays heavily into Sir Dave’s efforts at finding marginal gains. The same principles are applied within my own OR. For the past year, we have been using the comprehensive unit-based safety program to work with my operative team to fully map out the steps involved in preparing a patient for surgery to incision. From there, we brainstormed ways to drive more efficiencies. Things included marking with tape the position of the table and posting laminated photos of the way the lights should be set up. While each step would only save several minutes at most, as we found more and more opportunities for efficiencies, this began to increase our time to set up by up to 20%. Today, we are applying this across the entire continuum.
Identifying these principles as critical success factors and ensuring they are in place can allow everyone to focus on improvements and reach an optimal place to improve quality, safety, value, throughput and efficiency.
One of the questions I often received prior to the first annual spine safety summit in 2016 is “why organize another Spine Surgery conference?” My answer is inevitably, “how could we not?”
The time could not be more urgent. At every talk I give, I always like to put the audience in the right mindset, which is “how will the next patient be harmed?” Somewhere out there, there’s a patient coming to your waiting room or in a cab or on a plane that may be harmed. The question isn’t if, but when.
In reality, no one is safe, the patient or the surgeon, including the emotional toll that comes from potentially harming a patient.
As a field, we are not doing well. Even if we pride ourselves with 99.9% positive outcomes, we are still left in the dust by others who are doing better. As a framing picture, we would find this unacceptable if:
- Amazon failed to deliver 1,600 parcels each day
- USPS lost 506,000 pieces of mail each day
- 1,019 surgeries went wrong every month
We always need to ask ourselves, how far would you be willing to go to avoid harm? Often times, the answer isn’t from punishing physicians and nurses. It’s not an issue of bad physicians or nurses harming patients, but a poor system setting up good physicians and nurses that eventually harms patients. Even the most technically skilled and fantastic of surgeons can’t do a great job, unless they have the infrastructure to support them and a team surrounding them with good communication. More and more, with lessons from high reliability organizations such as aviation and nuclear power as well as from the peer-reviewed literature, we are learning that over focusing on the concepts of individual skills undervalues the reality that care is a result of the entire episode of care, requiring a systematic approach to managing everything within the realm of influence, from preoperative access to recovery and rehabilitation.
Just like Jim Reason’s timeless model, the Swiss Cheese Model of Medical Error, if we think about all of the elements of risk, host, technique, systems, and culture, then we realize that medical error and complications occur only when all of the holes line up just right.
As we start this blog, I am hopeful that the Safety in Spine Surgery Project (S3P) will evolve into a platform where we can engage the wisdom of the entire industry to shrink the critical holes that too often lead to poor outcomes for our patients:
- Variability
- Lack of Infrastructure
- Individual Thinking & Decision Making
- Lack of Information in a Data Rich System
- Poor Culture
S3P will provide an infrastructure and platform in which we can work together to tackle some of these issues throughout spine surgery and hopefully implement strategies across the board. But we need participation and buy in at ever level, from industry partners, hospitals, peers and colleagues, and each individual physician. Patient safety and quality starts with physicians, but it doesn’t end there.
This is such an exciting time and we would love your feedback on how S3P can take quality in spine surgery to the next level. In future blog posts, we’ll talk more about some of the frameworks for change we envision and the efforts that have evolved as a result. We look forward to hearing from you.