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recommended dened triggers that mandate communication with an attending
surgeon; structured hand-offs and transfer protocols; and standard use of read-
backs. Our work complements these studies by specifying the intra-operative team
behaviours (briengs, information sharing, inquiry and vigilance) that should be
useful in preventing negative outcomes. Finally, a recent study reported a signicant
correlation between subjective ratings of teamwork with postoperative morbidity
(Davenport et al. 2007), a nding which lends more support to our conclusions.
Implications and Future Directions
Development of interventions based on changing teamwork behaviour and their
evaluation is a logical next step for research in this arena. Our study provides
general support for development of team training programmes for surgical teams.
Such programmes should be rigorously tested because they will require signicant
investments of time and money; some studies in other areas have found only
marginal benet for patients (Nielsen et al. 2007).
We believe that there are two broad lines of research that should be pursued and
that will ultimately converge in the form of effective team training programmes.
First, research should focus on implementation and evaluation of training
programmes. There is already a large body of knowledge that can inform the
content of such programmes (Baker et al. 2005, Clancy and Tornberg 2007). These
may focus on relatively specic processes of care, like neonatal resuscitation
(Thomas et al. 2006); they may try to address multiple processes within a site of
care like labour and delivery (Nielsen et al. 2007); or there are training programmes
(like TeamSTEPPS) which may be applicable across many locations, processes
and disciplines (Clancy and Tornberg 2007). However, given the inconclusive
results of initial evaluations of such programmes, it is clear that there is a need
for a second line of research which asks more fundamental questions about the
relationships between specic team behaviours and specic tasks carried out by
providers (Undre et al. 2006, Yule et al. 2006). Such knowledge should result in
training that teaches behaviours which are more likely to improve quality. This

would include studies that draw upon the ‘basic sciences’ of safety (Brennan et al.
2005). For example, human factors experts can perform task analyses to determine
exactly which behaviours might be most useful for specic tasks, and cognitive
psychologists can help link teamwork to prevention of mental slips and mistakes.
At Kaiser Permanente we are implementing a comprehensive surgical safety
programme (described below) which is an example of how these two lines of
research can inform the development and implementation of team training
programmes. At the University of Texas we have developed a team training
curriculum for the Neonatal Resuscitation Program which increases the frequency
of team behaviours during simulated resuscitations (Thomas et al. 2007).
The Kaiser programme was a direct outgrowth of the research described above
and is described in more detail below.
An Empiric Study of Surgical Team Behaviours and Patient Outcomes
275
From Science to Execution – Implementation of a Highly Reliable Surgical
Team Programme at Kaiser Permanente
The primary driver of the research described above was to develop strategies to
continually improve the safety of the care that we provide to our patients. The
secondary driver was to answer the question of whether or not the communication
and teamwork demonstrated by the surgical team had an impact on surgical
outcomes. Prior to performing this research our patient safety strategy for the peri-
operative area had focused on education and training related to human factors,
communication and teamwork and implementation of structured pre-operative
briengs. Based on this work, a pilot project was performed in the operating rooms
of one of our Southern California hospitals. The overarching purpose of the project
was to improve safety by enhancing teamwork, collaboration and communication
among team members in the peri-operative setting.
The pilot consisted of providing education and training in human factors and
communication and teamwork to the entire peri-operative staff. Following the
educational programme, a steering committee was formed and a structured pre-

operative brieng (including script) was developed. The hospital used four different
indicators of safety culture to measure the programme’s success: occurrence of
wrong site/wrong procedures, attitudinal survey data, near-miss reporting and
turnover data. Several areas of signicant improvement were noted. The most
notable result was reducing verication injuries to zero within a year; additionally,
there was a 19 percent increase in employee satisfaction and a 16 percent decrease
in nurse turnover; and the safety climate in the operating room increased from
‘good’ to ‘outstanding’ after implementation of the pilot study. Although this pilot
programme was successful and has sustained itself as an ongoing programme
at the one hospital, the efforts to spread the programme to other hospitals were
not successful. One of the major concerns expressed by leadership and clinicians
was that the data did not demonstrate that the effort put into communication and
teamwork and pre-operative briengs made a difference to surgical outcomes.
The evidence base provided by the Highly Reliable Surgical Team (HRST)
research project discussed above, coupled with the outcomes of the pilot
programme, provided us with a much stronger case for requiring a highly reliable
surgical programme in all of our hospitals. The HRST research project also had
a qualitative component (narratives of observations provided by the observers)
that allowed us to provide leadership and clinicians with information related to
potential threats to patient safety that existed within our system. The primary
‘threats’ included: interruptions and distractions; inadequate brieng and/or time
out; incomplete or no transfer of information during transfer of patient, shift change
or break; equipment and material problems including malfunctioning equipment,
potential operator error and incomplete or wrong supplies and equipment for the
task at hand; lack of respectful interactions among surgical team members; and
interdepartmental coordination and communication challenges. These qualitative
data enriched the quantitative ndings, and armed with these data, we were able
Safer Surgery
276
to convince both leadership and clinicians that improved communication and

teamwork including pre-operative briengs would not only improve attitudes but
also improve the safety of the surgical care that we provide to our patients. When
the data were presented to executive and physician leadership, the consensus
was that the combination of the evidence presented a compelling argument for a
mandated programme.
The information from the research was presented at our initial expert surgical
groups that were charged with developing the programme, clinicians who had
previously been sceptical and concerned that strategies such as pre-operative
briengs would do nothing but slow down procedure start time began to discuss
how, in fact, interventions could potentially end up saving time.
Once the pilots were initiated we began to receive ‘stories’ from clinicians.
An early story shared by a surgeon at a meeting of surgical leaders related to
how, during a brieng, it was discovered that the team did not have all the
equipment that was needed for the procedure. The surgeon indicated that in the
past, not having the correct equipment was in many cases not discovered until a
point when the operation was underway. The surgeon went on to say that when
missing equipment was not identied early on this not only led to delays in the
procedure and increased operating time but also potentially impacted the safety
of the patient.
In 2007, in conjunction with peri-operative leadership, the Northern California
regional leadership required all 19 of the Northern California medical centres to
initiate the Highly Reliable Surgical Team Program. Expert groups consisting of
surgeons, anaesthesiologists and nurse managers met to develop the programme
and in the spring of 2007 a regional surgical summit was held. Peri-operative
teams from each medical centre attended. The summit opened with sharing of the
results from the research project along with the current state of surgical safety in
Northern California (e.g., days in-between surgical events, our medical malpractice
experience). Education and training during the summit related to human factors,
communication and teamwork, and the importance of the highly reliable surgical
team programme. Participants were provided with all of the tools necessary to

initiate the programme at their individual medical centres. The expectations for
2007 required that each hospital develop and implement the infrastructure and
processes necessary to support highly reliable surgical teams. The four requirements
for each medical centre were:
Develop and implement a surgical safety committee that would lead the
programme.
Implement scripted peri-operative briengs where all members of the team
had a speaking role. A whiteboard with all team members’ names was also
required.
Educate and train the entire peri-operative team in human factors/
communication and teamwork – every medical centre closed the
operating rooms for 2–3 hours for this training. The training included
1.
2.
3.
An Empiric Study of Surgical Team Behaviours and Patient Outcomes
277
presenting national, regional, and medical centre specic data related to
surgical safety and set the ‘burning platform’ as to why this programme
was important. Additionally, experts in the area of communication and
teamwork discussed the importance and fundamentals of human factors,
communication, and teamwork. The session ended with planning for how
to implement the programme in every operating room for every specialty.
Additional elements such as debriengs and ‘glitch books’ were discussed
as potential additional programme elements.
Institute regular observation audits to ensure that the briengs were taking
place and all required elements were included. One of the lessons from
our research was the importance of observation by someone not directly
involved with the procedure. Often, behaviours in the OR are the reality
in which the surgical team works and, digressing from the appropriate or

required way of doing things is not recognized. By doing the observational
audits and reviewing these with the teams and OR leadership, we are able to
point out how the teams can improve the communication and teamwork.
The success of the surgical summit exceeded our expectations. Teams
remained after the summit to work on plans for implementation in their medical
centres. Formal evaluations indicated that 100 percent of the participants found
the programme had met its goals and 96 percent felt that the programme met
expectations. More convincing evaluations, however, were the anecdotal comments
noting that the summit had moved people to take further action to improve surgical
safety. Completion of the process requirements outlined above was monitored
and quarterly reports were submitted to the medical centre executive committee
and regional leadership. All medical centres met the requirement that these four
elements be in place by the end of 2007. In addition to the above process measures
an outcome measure of days in-between verication injuries was also utilized.
The days in-between events related to verication has substantially increased
since the inception of the programme. In the latter part of 2007, the requirements
were further rened to make the briengs pre-induction, thereby including the
patient in the process (when appropriate). The Surgical Care Improvement Project
safety checks (Bratzler and Hunt 2006) were added to the brieng checklist to
enhance reliable protection from infection, Venous Thromboembolism (VTE) and
Miocardial Infarction (MI).
Building on the successes achieved in 2007, the programme was expanded in
2008. Each one of the elements required the input from a multidisciplinary expert
team whose job was to research current literature, dene recommended practices,
perform small test of change and develop tools/playbooks to guide the change in
practice. The additional elements included:
Renement and monitoring of the surgical brieng and debrieng to build
communication, teamwork and eliminate verication events – this included
use of the script; team engagement; and leadership of the surgeon.
4.

1.
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278
Administration of the Safety Attitude Questionnaires (Sexton et al. 2006a)
to measure the culture of safety and teamwork at each medical centre.
Continued monitoring of the Surgical Care Improvement Project (SCIP)
bundles.
Implementation of peri-operative practice changes that will eliminate
retained foreign bodies (RFO).
Implementation of a brieng protocol specic to intraocular lens implants
(IOL) to prevent wrong lens implants in all settings where cataracts are
performed. Establish a protocol to eliminate wrong side thoracentesis
procedures in all settings.
Provide a second surgical summit in the fall to celebrate successes and
inspire the operative teams to continue to sustain the programme.
In conclusion, the quantitative and qualitative data from our research project
were critical to get buy-in and inform the design and implementation of our Highly
Reliable Surgical Team programme. The key contributors to the success of this
programme have been:
Immediate utilization of the Highly Reliable Surgical Team research to
develop and implement the programme in all operating rooms in the 19
hospitals of the Northern California Region of Kaiser Permanente.
Strong executive and physician leadership.
Provision of tools and project management to the medical centres.
Independent observational audits of the surgical brieng by staff who are
not members of the peri-operative team.
Regular dialogue and communication with the peri-operative nursing
directors and managers.
Development of a surgical safety scorecard measuring compliance rate with
the SCIP bundles, brieng elements of script, engagement and leadership

and listing of surgical never events by facilities.
Future work will expand and rene these efforts for both surgical and non-
surgical teams.
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Appendix: List of Potential Complications Referred to by Data Abstractors
when Reviewing Medical Records
This list was not all-inclusive – abstractors recorded additional complications as
indicated. Complications were grouped into outcome categories based upon the
impact on subsequent care and harm to patients.
Accidental puncture or laceration.
Surgical burn (heat-producing equipment, chemical).
Adverse drug reaction.

Wrong patient/procedure/site/side/device.
1.
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3.
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282
Retention of foreign object.
Transfusion reaction.
Pressure ulcers.
Peripheral nerve damage/short-term neurological decits.
Complications of anaesthesia (anaesthetic medication error, reaction or
endotracheal tube misplacement, regional anaesthetic complications,
broken teeth).
Iatrogenic pneumothorax.
Pneumonia.
Selected post-operative infections (ICD-9 CM codes 9993 or 00662).
Post-operative haemorrhage or haematoma.
Post-operative pulmonary embolus or DVT (deep vein thrombosis).
Post-operative DIC (disseminating intravascular coagulopathy).
Post-operative respiratory failure (acute).
Post-operative sepsis.
Postoperative wound dehiscence.
Post-operative fracture (excluding unrelated post-operative falls).
Post-operative physiologic/metabolic derangement.
Post-operative cardiac arrest.
Post-operative hemodynamic instability.
Myocardial infarction.
CVA.
Other undesired outcome, not otherwise specied (e.g., excessive and

prolonged pain, unanticipated restriction in range of motion, musculoskeletal
injury).
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Chapter 17
Counting Silence: Complexities in the
Evaluation of Team Communication
Lorelei Lingard, Sarah Whyte, Glenn Regehr and Fauzia Gardezi
Purpose
Many in the domain of surgical performance research have developed tools
to objectively evaluate team communication. Our own tool has been used to

describe communication failure patterns in the context of a pre-operative team
brieng intervention in four urban teaching hospitals. Using examples from this
research programme, this chapter explores a critical problem in the objective
evaluation of team communication: how do we ‘count’ silence? Because it is
relatively easy to document ‘presence’ (communications that can be directly
observed), our conventional approaches are not well equipped to deal with
‘absence’ (communicative silences). Yet silence abounds in the operating room,
and a comprehensive accounting of team communication must grapple with the
meanings of silence, including both its functional and problematic dimensions.
Drawing on theories of discourse and power, this chapter will describe recurrent
patterns of silence in the operating room, consider the actions and relations that
these silences embody and discuss their implications for sophisticated evaluation
of the communicative behaviour of operating room teams.
Background
Communication has been a dominant focus in the study of operating room (OR)
team performance. This focus has emerged largely in response to evidence
suggesting that preventable adverse events happen at unacceptably high rates in
the surgical setting, and that ineffective or insufcient communication among
team members is often a contributing factor (Kohn et al. 2000, Helmreich 2000,
Helmreich and Davies 1994, Joint Commission on Accreditation of Healthcare
Organizations 2003).

However, despite the general agreement that ineffective
communication threatens patient safety, until recently there was little evidence
regarding what specic team communication practices and attitudes compromise
safety, what methods might effectively change these patterns, or how the outcomes
of such changes might be measured.