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Department-wide Communication Compact Standardized How Apps Escalate Intraoperative Events
Overview
What was the reason for the change?
With APPs (CRNAs and AAs) of varying experience levels, some who worked elsewhere, some who were locums staff, there was confusion about what intraoperative events were to be communicated to the anesthesiologists. Further, there was dissatisfaction from the APPs regarding getting the collaboration they desired when communicating certain intraoperative events to the anesthesiologists.
What were we trying to accomplish?
Standardize the communication of certain intraoperative events from APP to attending anesthesiologist, the method of communication, and the subsequent response from the attending anesthesiologist as a result of the communication. This would be done through the creation of a communications compact – making the implicit and assumed explicit. It would be drafted by a small group representative of the department as a whole, voted upon by the department as a whole and agreed upon by all parties to uphold the terms.
How will we know that a change is an improvement?
We utilized the organization-wide annual safety survey.
Implementation
How long did it take to get up and running?
8 months for all meetings, voting, and creation of final communication compact.
How was readiness assessed & required resources identified?
Meeting room, non-clinical time to facilitate meetings, electronic voting/survey tool (we used Qualtrics), professional printing and lamination services.
What were the missteps and lessons learned along the way?
Process took longer than expected. Success and sustainability is critically dependent on leadership getting behind this 100% and enforcing non-compliance. The initial non-compliance with the compact was more significant on the attending anesthesiologist side than the APP side.
Solution Design
What changes can we make that will result in an improvement?
Beyond the safety survey, check-ins with attending anesthesiologists to determine if they are getting called for critical events (e.g., high pressor requirements, need for blood transfusion, etc.) and check-ins with APPs to determine if anesthesiologists are coming to the OR to assist with things that they would like help with (e.g., extubation of difficult airway patients, etc.)
What was your implementation strategy and critical steps?
- Form a team representative of the demographics of the department (APPs and anesthesiologists)
- Have them brainstorm critical events
- Have the team consolidate the list to around 20-30 events
- Have the entire department vote on a top 12 list and what the response should be from the attending (communication alone will suffice, come to the OR for discussion of management options, come to the OR urgently)
- Review the voting and have the team break any ties
- Create a final communication guide on the top 12 events and what the response should be for each event
- Have every member of the department sign an enlarged version of the guide to acknowledge understanding.
Adoption & Sustainability
How did you communicate the tactic to those affected by it?
It was introduced during a one-hour department wide meeting and followed up by an email. During the process, status was discussed at every department meeting. Emails were sent monthly summarizing progress. The voting/survey was sent out and conducted anonymously, but the software allowed for repeat notifications for those who did not respond.
How did you design for sustainability of the change?
Frequent re-messaging through multiple formats. Targeted reviews of instances in which events were not communicated or responded to appropriately to determine barriers. Department leadership holding those who frequently did not adhere to the compact accountable.
Downloadable Resource
QI Report
Evidence & References
Other References
- Arriaga AF, Elbardissi AW, Regenbogen SE, Greenberg CC, Berry WR, Lipsitz S, Moorman D, Kasser J, Warshaw AL, Zinner MJ, Gawande AA. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg. 2011 May;253(5):849-54. doi: 10.1097/SLA.0b013e3181f4dfc8. PMID: 21173696.
- Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007 Apr;204(4):533-40. doi: 10.1016/j.jamcollsurg.2007.01.010. PMID: 17382211.
- Kornacki, M. J., & Silversin, J. B. (2015). A new compact: Aligning physician-organization expectations to transform patient care. Health Administration Press.
- cognitive aid
- communication
- crisis management
- professionalism
