Behavioural markers of surgical excellence
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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