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The Surgical Master-Plan in the Operating Room: Have we ever had it, and can it be created?

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    October 10, 2016

    As a surgeon, I naturally understand that each surgical case is a team-based process that requires coordination of everyone in the operating room. Except in rare, emergency cases, I already have a therapeutic relationship with my patient; as a result, I’m entering the OR with the most familiarity and clearest plan about what must be accomplished. But on the day of the operation, the anesthesiologists, nurses, and other staff often will be meeting that patient for the first time; intrinsically, they rely on me to clearly communicate the anticipated needs and my plan for the case. But am I doing the best job possible in relaying my expectations, and is my team equipped and excited to execute against that plan?

    Of course, communication is important for any operation. But when a complex case demands a “non-routine” approach, explaining the expectations and details of a customized plan is even more crucial. For example, in particularly long cases, it is common for team members to “hand off” their work to a replacement team member. There’s a risk for information loss and decreased situational awareness at these moments. (see Christian et al. study of OR safety).

    Yet, I’ve observed that there is no standard, central information repository for surgical workflow, and it seems that this typically results in a myopic transition between same-role team members (e.g., nurse to nurse). Rarely have I witnessed the whole team using these moments to check in on the case from a holistic perspective, answer questions and ensure the new team member is oriented. I’ve been guilty of this oversight, also. Despite the fact that the full operative plan is securely logged in my brain, I’m often so focused on the procedure I’m performing or taking my resident through a new approach that I don’t have time to integrate a new team member. This can result in delays, missteps, and equipment not being available when we need it. This potential for uncaptured information troubles me, and I worry that other team members are hindered to anticipate the course and timing of upcoming surgical steps.

    Outsiders are often aghast when I tell them about this issue. People not acclimated to the OR appropriately assume that surgical workflow systems have been in place for decades. I've really had to consider this as I've pursued this academic endeavor. I think that the problem lies in the successful outcome. At the end of the day, the surgical team is tasked with taking care of a patient and fixing their problem. If we do well, it is rare that anyone questions our approach. Why would they? The patient is happy and healthy. But the era of "if it ain't broke don't fix it" must come to an end. Surgeons should be taken to task for efficiency. Plans must be created that decrease time under anesthetic. Nurses must be tightly integrated into a case plan. We all must adopt the outsider outrage that no formal surgical workflow system is in place and get on board in cementing one into the surgical lexicon in the future.

    Much like a pro sports team, what we need is a common "playbook" for the surgery. Today, team members tend to rely on information germane only to their roles – even when I’ve clearly articulated the complete surgical plan in advance. Nurses, anesthesiologists and surgeons all have different notes, “cheat sheets” and electronic medical record (EMR) portals for the same case, so for most of the case (literally) none of us are on the same page. The notable exception to this is the surgical "time out" - a moment when all team members turn their combined attention to a perioperative safety checklist. This checklist was first conceived in 2008 by Atul Gawande and colleagues for the World Health Organization's Safe Surgery Saves Lives Programme. However, even these time outs are often not performed correctly.

    Despite the mishandling of “time outs” and team members’ lack of situational awareness, the surgical process actually still works pretty well; we’re all highly-trained professionals making it happen for the patient under our care. But I'm convinced that without a clear playbook, there is wasted time, missed steps and confusion.  Too many questions loom about our ability to execute against the surgical master-plan. Does each team member’s view of the case align precisely with the specifics of this patient, or are we just following a template of this genre of surgery? Does it include the exact instruments I want to use? Are we sure we’ve factored in the time for that extra maneuver needed based on this patient’s anatomy? Such anxieties should not happen in modern surgery, yet I’ve found, in frustration, that there is not a clear forum to coalesce everyone’s plans, preferences and questions. We need to prioritize holistic understandings of roles and responsibilities for each case.

    These problems were a few of the challenges that caused me to partner with my colleagues to form the Operative Performance Research Institute (OPRI). We are dedicated to studying the inner-workings of the operating room and testing potential solutions for better efficiency and communication in a setting that is so critical to patient care, procedure outcomes and institution efficiency. We’ve recently developed the ExplORer system, the first real-time surgical workflow management tool that will serve as a centralized information source for all operating room team members; these sort of solutions that take the whole team into account will help usher in the future of surgery.

    If you are experiencing similar frustrations, or have interest in studying the operating room at your institution, please contact us at By working together across disciplines and institutions, we can forge a better operating room and safer, more efficient surgical treatment.

    Alexander Langerman, MD FACS is a Physician and Head and Neck Surgeon at Vanderbilt University, and former Director of the Operative Performance Research Institute at the University of Chicago. This content was originally written by Dr. Langerman and published on the OPRI website.

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