What’s your glove size, doc?

Tagged surgical team, learning curve, quality; Posted 10 years ago

Can you imagine one of these rowing guys turning up for the Olympic race and they ask the coach: "What boat shall we take today?"

A few years ago like any Monday morning I arrived in the operating theatres of one of the hospitals I regularly work to start my operating theatre list. I was greeted by a scrub nurse I have not met previously: “What’s your glove size, doc?”

I did not know what to say, so surprised I was. In the many years I was operating there every Monday, I never worked with this scrub nurse in my theatre previously.

Before I could get my thoughts organised again I was approached by yet another scrub nurse also unknown to me: “What type of Hasson canula do you normally use for your primary (laparoscopic) entry?”

I could not help myself than to believe I am in the wrong operating theatre. Not only I knew no one in this theatre but they also seemed to be very unfamiliar with my surgical routine (Note: I don’t use Hasson ever). I left and saw the nurse supervisor (who I knew well) to make sure we had a team available that knew what we (as a team) are doing.

We delayed the procedure for 30 minutes, which was enough time for the scrub team to familiarise themselves with the operation, to study the preference card and find out how my team normally does those procedures. That allowed us all to get back to normal. We had an uneventful day in theatre …. like any Monday.

I read with great interest and pleasure an article in HBR by Professor Rob Huckman from Harvard Business School. He claims that most managers underestimate the power of familiarity of teams. Utilising familiarity of teams could be used to drive performance in operating theatres, in engineering, defence, in virtually all parts of professional life.

He describes the case of an orthopaedic surgeon who can completes total knee replacements far quicker than any other colleague at his hospital at better outcomes and far lower complication rate. Instead of working with an ever-changing cast of nurses he works with two dedicated nursing teams for the last 18 years.

A software company yielded a 19% decrease in defects, a 30% decrease in deviations from budget and a 10% increase in performance as judged by clients by increasing team familiarity by 50%.

Flight crews experience a learning curve, too. They generally become better as their members become familiar with each other. Apparently 73% of commercial aviation incidents occur on a crew’s first day of flying together.

Why does familiarity have such a profound effect on outcomes?

Robert Huckman and Bradley Staats, the two authors of this article in Harvard Business Review see a few reasons for it and probably the most relevant in the specific context of surgery are those two:

1. Members who are new to each other don’t know when and how to communicate with each other.
2. Members who are new to each other don’t know what the other members know and what they don’t know.

This is completely consistent with my personal experience. Working in a well established team makes my surgery so much smoother. I don’t need to verbalise every single small step that is required because I am handed the equipment that I need at the right time. I don’t need to watch every single small step that one of my nurses or my surgical assistant do because they all know what their part is in the operation. I don’t need to request every single surgical device being in the operating room because it will be there, exactly on the same spot where it was last week and the week before. If I would need to request every single piece of equipment I’d be very tired at the end of my day in the operating theatre.

Robert Huckman also wrote another paper on the performance of cardiac surgeons [1]. Some surgeons provide outreach services and it is assumed that a great surgeon achieving great results will achieve great results everywhere. Huckman and colleagues examined the surgical mortality following cardiac procedures and compared it with overall surgical volume and with site-specific surgical volume.

The Harvard team found that an individual surgeon’s performance at a given hospital improved significantly with increases in the surgical volume at that particular hospital. It does not increase with an increase in volume of that particular surgeon overall (including at other hospitals). Hence, the impact of volume on performance is site-specific.

From the survey amongst Australian O&G specialists [2] [3] we completed last year it is well documented that some specialists struggle to assemble a regular surgical team. By contrast, I am very blessed with regular team members at two hospitals and maybe not so fortunate in two other hospitals. At the two private hospitals I have available a team of three to four regular scrub nurses, regular anaesthetists and regular surgical assistants who I work with for the last many years.

If for whatever reasons, one of my regular team members drops out – the remainder of my team will have no issue to compensate for the loss. If two of the regular team members are unavailable, e.g., the surgical assistant and a scrub nurse, I will notice. The operation will slow down significantly. I will need to verbalise instructions a lot more than I normally would need to. If three or four of my team members are missing and I am the only professional in the operating room that knows what’s going on, it’s simply unsafe to perform complex procedures.

Do you work with a regular team? What percentage of your major surgery is completed by your regular team? Please let me know. 

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[1] Huckman RS: The Firm Specificity of Individual Performance: Evidence from Cardiac Surgery. Management Science 2006; 52(4): 473-88.

[2,3] http://www.ncbi.nlm.nih.gov/pubmed/24359293