Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Amy Krambeck. She's the Chief in the Division of Endourology and Stone Disease and a Professor of Urology at Northwestern Medicine, and she's here to tell us about quality improvement of surgical team communication of required percutaneous nephrolithotomy equipment.

Melanie Cole: Dr. Krambeck, it's a pleasure to have you join us again. You developed a PCNL equipment whiteboard. Can you tell us a little bit about the components of this whiteboard, how it was used in a PCNL case, and how it can improve communication accuracy of surgical equipment, streamline operative efficiency, and even possibly decrease unnecessary case equipment costs?

Dr Amy Krambeck: Well, yes, Melanie. Thank you for having me on the podcast again. This was a project that was really near and dear to my heart. I like to be efficient. I like to keep the operating room efficient and I like to limit costs. These procedures can get extremely expensive for the hospital, mainly because we're opening equipment that we're not going to utilize in the case.

So when I came to Northwestern, it gave me a good chance to try and minimize waste. So, we developed a whiteboard, very simple concept. It was just a large erasable board that we could take from OR to OR, and it had all of the equipment that could potentially be used during a percutaneous stone removal procedure. And we had two columns. We had a column where you could identify that the item needed to be opened and placed on the working table. And then we had another column that said "Just have the item in the room." And we would go down the list of all the items and mark whether to have it in the room or have it open on the working table. And we would discuss it with the OR team before the patient rolled into the room. We'd show them the whiteboard and then we would do the case.

With this simple measure of communication, we found that we were actually able to limit waste significantly. We saved $436 per case just by using a common whiteboard in check marks. Furthermore, the OR staff felt exceptionally more confident over the three-month period in their ability to anticipate our needs during the case. And furthermore, the surgeons felt more satisfied with the procedure because we were able to communicate effectively with the group.

Melanie Cole: That's amazing. So, you involved urology, nursing, surgical staff in the design of the intervention. Tell us a little bit about the process for implementing this initiative at Northwestern Medicine.

Dr Amy Krambeck: So initially, we just started with a simple questionnaire surveying the residents, fellows, nurses, scrub techs and surgeons in the operating room, asking about their level of satisfaction and their level of confidence in these percutaneous nephrolithotomy procedures. These procedures require a lot of equipment and they require a lot of knowledge about the specific equipment we needed.

Furthermore, I may call one wire a name, that the resident may call a different name, that the fellow may call a different name and the nurse call a different name. So, we're all calling the same item a different name, and we aren't able to communicate. So, we first assessed everyone in the operating room about their level of confidence and found that it was actually quite low. Then, we decided that the real issue was communication. So, we developed the whiteboard and developed a name for each item that was going to be utilized in a surgical case, so that we all could agree upon a common nomenclature. And then, we used simple visual cues like check marks, so that they could refer back to these visual cues as they prepared for the case to know what to have available and what to actually open and put on the table for us to use.

After we did this for three months, we then compared cost of the procedures using the whiteboard versus the average cost of the procedure before, and found that we were significantly saving money by limiting the waste. We then resurveyed everyone in the operating room and found that people were much more pleased with the communication, they felt more confident and they felt ready to participate in surgeries because the communication level was so much higher.

Melanie Cole: So, you checked it after the fact as well. So, was that you evaluating the initiative? Tell us a little bit about the findings and how you're measuring success of this ongoing initiative.

Dr Amy Krambeck: Yes. So, we actually just had every individual complete a survey and they ranked their confidence level on a scale of zero to 10. They also ranked their ability to accurately choose the right items for a case on a scale of zero to 10. And we found that their self-perceived accuracy went from 64%, before the surgery up to 88% after the surgery. Their level of satisfaction with the degree of communication in the operating room went from a six out of 10 before the surgery to a nine out of 10 after surgery. It was the same across the board with the surgeons, the residents, the fellows, everyone improved over the three-month period.

Melanie Cole: Dr. Krambeck, what potential challenges or barriers do you foresee with implementing this whiteboard and how would you consider addressing these?

Dr Amy Krambeck: The biggest challenge with implementing the whiteboard is that you have to stop your routine and do it, it takes time. you need to do it every day that you're operating too. It's part of the huddle that is required to be a good team. People don't think about the OR as a team, but we're really like a sports team. Everybody has a role and we have to communicate.

So for this to accurately work and to work well, the team needs to huddle together and discuss the game plan, which is the whiteboard. And you need to do that for every case. And I think, sometimes we fall into a routine, we get lackadaisical, we don't want to huddle. We think we know and we stop doing it. And so, trying to be consistent and do this every day you're in the operating room is where you're going to see the most benefit between you and your team.

Melanie Cole: Well then, along those lines, how could technology be utilized to enhance that communication?

Dr Amy Krambeck: So, we used a portable whiteboard, which is cumbersome. But many operating rooms have screens that you can interact with through the computer system. So, having a checklist that you could project onto the main screen, just like we do patient stats, we can create a checklist that is surgical equipment stats, that could also be utilized that way. And I think that would be the next step in this process to create an interactive computer platform that can be utilized in any operating room from the web.

Melanie Cole: And what advice do you have for other surgeons who are looking to implement similar processes in their practices? Are there any other strategies or tools you'd recommend for improving that communication? Any specific information that you think should be included on the PCNL equipment whiteboard?

Dr Amy Krambeck: Yes. I think, as surgeons, we tend to just get frustrated and upset when things do not go our way. But in reality, we could be the issue, because we're not communicating efficiently. And so if something is a touchpoint for you and something is an area that you feel is always a struggle, then slow down and stop, assess how everyone in the room feels about it, because I guarantee you're not the only person frustrated. And then, come up with a new way to communicate and then reassess after you've implemented this new way to communicate. You're never going to realize the fruits of your labor unless you do systematic assessments. And this was such a simple project, but it made such a significant improvement in the morale in the operating room, as well as having a significant cost savings.

Melanie Cole: Well, it's a brilliant initiative and it seems so easy, but it tackles such a difficult situation. Are there implications for other surgical procedures? Is there anything else you'd like providers to know about? And please just summarize the key takeaways from this initiative.

Dr Amy Krambeck: So, I think this initiative can be utilized for any surgical procedure that you perform, especially procedures that require a lot of disposable instruments that can become very costly and confusing for the OR staff. So if you are thinking about utilizing this, the very first thing you need to do is survey your OR team to understand how everyone in the room feels about it. And then, most importantly is develop a common nomenclature. Sit down with them and say, "We call this item A, and we call this item B," so that everybody has a name for the items that you're requesting and understands how to communicate with you.

And then, always assess the outcome afterwards. Maybe it doesn't work, so you don't want to continue something that is not successful. So, you need to assess what your intervention does. But overall, by utilizing a simple whiteboard to communicate my needs in the operating room for one specific procedure, we improved OR morale, we improved OR participation, and we drove down surgical costs. So, I think this is a win across the board.

Melanie Cole: It certainly is, and great work. Thank you again for joining us, Dr. Krambeck. You're such a great guest as always. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please always remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.