Elsevier

Safety Science

Volume 41, Issue 5, June 2003, Pages 409-425
Safety Science

Behavioural markers of surgical excellence

https://doi.org/10.1016/S0925-7535(01)00076-5Get rights and content

Abstract

This paper applies the concept of behavioural markers of performance, previously used to understand the characteristics of the most successful aviation crews (Connelly, E.P., 1997. A Resource Package for CRM Developers: Behavioural Markers of CRM Skill From Real World Case Studies and Accidents. University of Texas Crew Research Project Technical Report, pp. 97–103; Helmreich, R.L., Merritt, A.C., 1998. Culture at Work in Aviation and Medicine: National, Cultural and Professional Influences. Ashgate Publishers, Aldershot, UK), to a surgical domain. A framework of ‘behavioural markers’ of surgical excellence was developed based on existing research. This framework was used to explain differences in ‘procedural excellence scores’ amongst a group of sixteen UK paediatric cardiac surgeons who had participated in a multi-centre UK study on the influence of human factors on surgical outcomes. Procedural exellence scores were derived from multivariable logistic regression models of the number of major and minor events (i.e. errors) per case, adjusted for known patient risk factors. Two binary outcomes were predicted; death and death and/or near miss. Results showed that those surgeons with the best scores (surgeons 3, 5, 8 and 14) were characterised by more of the behavioural markers than surgeons with lower scores. It is concluded that although behavioural markers have proven a useful method to explain performance differences between surgeons, further research is needed to validate and quantify the markers developed in this study and to test their applicability in other medical domains.

Section snippets

Human factors in health care

Systems analyses of adverse events (i.e. deaths, critical incidents and near misses) have been carried out in several health care domains, including anaesthetics (Runciman et al., 1993), obstetrics (Taylor-Adams et al., 1999), emergency medicine (Schaefer et al., 1994, van Vuuren, 2000) and drug delivery (Leape et al., 1995). Although such studies are very important, a singular focus on failure does not allow us to learn about the adaptive strategies which individuals, teams and organisations

Background

In cardiac surgery, outcome studies have traditionally focused on identifying patient and procedural risk factors that lead to increased death rates and long-term complications (Quaegebeur et al., 1986, Kirklin et al., 1992). Little attention has been paid to the role played by human factors on surgical outcomes. A multi-centre UK study was therefore carried out to investigate the role of human factors on surgical outcomes using a neonatal open heart procedure, the neonatal arterial switch

Process excellence

Given the finding that major and minor events are predictors of surgical outcomes, it is valid to use them to develop performance measures. Therefore, the number of major and minor events per case, and whether or not they are compensated for, was taken as a measure of ‘process excellence’. This is the degree to which the intra-operative process was error free, as reflected in the number of events per case and whether or not they were compensated for. It is hypothesised that there would be

Major and minor events per surgeon

Fig. 1 shows the frequency of major compensated versus uncompensated events per surgeon. The surgeons can be categorised into three groups:

  • 1.

    Surgeons who had no major uncompensated events (surgeons 3, 5, and 14).

  • 2.

    Surgeons who had a greater proportion of compensated versus uncompensated major events (surgeons 4, 8, 12, 13, 16).

  • 3.

    Surgeons who had more uncompensated major events than compensated major events (surgeons 1, 2, 6, 7, 9, 10, 11, 15).

Fig. 2 shows the frequency of compensated versus

Discussion

The results show that the surgeons with the highest (3, 5, 8, 14) and lowest (6, 9, 13 and 15) procedural excellence scores were consistent across both indices. Surgeons 3, 5, 8 and 14 achieved ‘process excellence’ whereby there were fewer errors and more compensation than expected after adjustment for known patient risk factors.

The differences in procedural excellence scores across surgeons and their teams may be explained with reference to the behavioural markers shown in Table 1. A complex

Conclusion

In addition to learning lessons from adverse medical events we must also try to understand success, and in particular to identify the individual, team and organisational markers that underpin excellence. Our analysis shows that the behavioural markers approach may be an appropriate method via which to evaluate surgeons and their teams. Further research is needed to validate the behavioural markers used in this study and to test their applicability to other medical domains.

Acknowledgements

Research at the Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust benefits from Research and Development funding received from the NHS Executive. This research was supported by a research grant (PG94166) from the British Heart Foundation.

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