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.

Developing the Wrong Site Surgery Checklist

Far too often, healthcare fails to provide the level of reliability that is expected around a patient’s sense of quality. Even meeting quality and safe patient care 99.9% of the time may not be enough. For reference, if 99.9% was an appropriate threshold, Amazon would still be failing to deliver 1,600 packages per day and the US Postal Service would be losing 506,000 parcels per day.

Yet, healthcare can learn to apply many of the principles in high reliability to improve patient care. One of the lessons we consistently present as part of S3P’s efforts is the story of the Boeing Corporation Model 299.

At the time in World War II, it was a newly developed “flying fortress” that could carry five times the bombs of Martin and Douglas planes, and could fly both faster and twice as far. By all accounts, the US government believed that this was the plane that would help them end World War II.

Unfortunately, the plane proved to be unreliable and dangerous, killing the test pilot in the first attempt to fly it. According to other of the air force’s top test pilots, the controls were so complex with its fly by wire systems that it was considered “too much plane for one man to fly.” This complexity was leading to what Shojana refers to as “mistakes by good but fallible people in dysfunctional systems”

As a result, the Boeing 299 development team worked with the test pilots to create a checklist of all the steps required for takeoff, flight, landing and taxiing, using principles of human factors engineering and ergonomics to ensure it was as easy to use as possible. After implementation, 1.8 million test miles were logged without incident. Ultimately, the Army bought 13,000 aircraft, which became a key part of the bombing campaign that led to Nazi defeat in WWII.

The use of checklists, when properly considering stakeholder and surgeon input and appropriately implemented, can help us eliminate errors, improve team communications and reduce complications. S3P has used these with experts in the field to create several evidence and consensus-based checklists including:

• Pre, intra, and postoperative processes to prevent Surgical site infection
• Responding to intraoperative neuromonitoring changes during spine surgery
• Preventing wrong level spine surgery

While the original Boeing checklist was used on paper, as are many OR checklists, S3P is looking to adapt to the 21st century and catch up to Aviation’s digital checklists built into the controls of many airplanes. These checklists are tied directly to sensors within the aircraft and can respond with intelligent logic when items are needed and not needed. Today, these are being tested within the OR to help reduce burden on the team, while feeding back real-time, critical information for feedback and quick prototyping.

We look forward to sharing the results of these experiments to make care better with you as we all progressing to improving quality, safety, and value in Spine Surgery.