Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we are highlighting Surgical Safety Beyond the Checklist. We have a panel for you today with Dr. Melanie Morris. She's a colorectal surgeon and a professor and Vice Chair of Perioperative Services in the UAB Department of Surgery; Dr. Helen Krontiras, she's a professor, breast surgical oncologist, and the Director of the Division of Breast and Endocrine Surgery; and Dr. Adam Beck, he's a professor and the Director in the Division of Vascular Surgery and Endovascular Therapy. And they are all associate chief quality officers for UAB Hospital.

Doctors, thank you so much for joining us today. This is a really, really great topic, specifically for other providers and institutions to hear about the expertise and what you're doing there at UAB. So, Dr. Beck, I'd like to start with you, and as we know, surgical safety is often associated with a checklist. But what does that mean beyond that? What I just said in my intro, start with safety as a continuous system, not just a single moment for one specific surgery. And when you're done, Dr. Krontiras and Dr. Morris, I'd love for you both to chime in.

Adam Beck, MD: Thank you for having us. That's really a great question. Of course, checklists are really important, but they're really just one piece of what we do for surgical safety. Surgical safety is really a continuum of care. It's not just a single moment in time, and it starts in the preoperative setting when we see the patient in clinic, and we decide to proceed with surgery. We have to preoperatively optimize the patient, of course, pick the right patient and the right surgery for that patient, and it really continues well beyond the operating room afterwards.

Helen Krontiras, MD: Yeah. And I build on that by saying that we really have to move away from what's called the hero culture. Safety really shouldn't be dependent just on one individual, one highly skilled individual. It should really come from kind of a really well-functioning team that works within a highly reliable system.

Melanie Morris, MD: Those are great points. And I would just like to add that we really use checklists as a tool. So, it's a reminder to make sure that we don't skip any steps. We're really focused within our safety of culture at UAB of standardizing processes so that we can take the human element out of it in a way that we don't forget something. So, these checklists often prompt us to make sure that we have thought through every single aspect of a patient's care or a surgical procedure to ensure that we have the safest outcomes possible for our patients.

Melanie Cole, MS: What a great way to think of this. Now, Dr. Morris, I just want to touch on something you just said, take the human element out of this. That's such an interesting statement because it makes so much sense for surgery. But when we think of the patients, that is the human element. So, what does that surgical safety look like across that patient's journey?

Melanie Morris, MD: We think about, as Dr. Beck mentioned earlier, both the preoperative, intraoperative, and postoperative care of our patients. And we try to standardize processes across that, both across surgical teams and across the patient's journey so that the patients are getting everything that they need. It's all communicated in a standardized fashion. They're getting the same care. So, we eliminate any disparities in care that could potentially exist. And then, we are all pointing the patient in the correct direction during their journey so that we can all hopefully achieve the very best outcomes for our patients.

Melanie Cole, MS: Yeah, that makes so much sense. Now, Dr. Beck, you're in this exciting field. How does data and quality infrastructure actually improve that surgical safety in real life and real time?

Adam Beck, MD: I've been involved in something called the Society for Vascular Surgery Vascular Quality Initiative for a long time. It's a registry that we use to look at procedures that we do in vascular surgery. And sometimes people will tend to focus on one area of how we generate evidence in surgery.

For example, we do research to determine what we can do safely. We use clinical practice guidelines to decide what we should do. But registries are really important to tell us what we're actually doing in practice every day. And so, personally, I think it's important to focus on all of those things. And I'm a big proponent of surgical registries and using those to feed back into what we actually should be doing and use them for the science and evidence generation.

Helen Krontiras, MD: Yeah. And I would expand on that a little bit more, using that data for feedback, right? So, we're trying to learn from our previous experiences in kind of a very structured way so that we can improve care. Ultimately, that's what we're all here for, is for the patient and to assure that the patient has the safest journey possible.

Melanie Morris, MD: I agree with Dr. Krontiras completely. You know, at UAB, we take care of the sickest of the sick, patients who have nowhere else to go. Using accurate data allows us to both risk stratify our outcomes so we can really show that UAB does care for these very sick patients and benchmark ourselves against peers across the country. That way, again, we can target areas where, wow, we're taking care of these really sick patients, but maybe we could do even a little bit better in this space. And that allows us to have targets for our quality improvement efforts.

Melanie Cole, MS: Isn't this an interesting conversation? And Dr. Krontiras, as we think of surgeons, when you're speaking to other providers, what habits do you think that distinguish surgeons who consistently build these safer teams and better checklists?

Helen Krontiras, MD: I think one of the most important things that we can do as surgeons, we often are thought of as the quarterback of the team, is to really empower every member of the team to understand that they have a voice and that it doesn't matter if you're a nurse, a resident, or attending, that surgical safety applies to everyone and everyone should have a voice to enable us to provide the best care for our patients.

Melanie Cole, MS: What does that look like, Dr. Krontiras? How do you let them know that they have a voice? Because as you said, you're thought of as the quarterback. And from people that are not in your exact position, all the team that surrounds you, they look to you. What does giving them a voice look like?

Helen Krontiras, MD: Yeah. We have to provide that psychological safety. They have to feel comfortable, speaking up without a fear of blame or retribution. Patient safety has to come before performance or pride. It's a culture, a culture of safety, that should be instilled in everyone.

Melanie Cole, MS: So, Dr. Morris, we're using this word culture. That seems to be a major driver of safety. What does a safe culture look like in surgery?

Melanie Morris, MD: That's a great question. I'm really proud of our culture at UAB, in all aspects, but especially in the operating room. We really have an all-hands-on-deck true teamwork approach in the ORs. And I'm proud that every person who touches a patient during their surgical journey, whether it's the preoperative check-in process, the nurse who's preparing the patient for surgery, the anesthesia team who's getting ready to safely provide anesthetic care to these patients, and our whole surgical team, including our OR nurses, our RN first assists, everyone is really focused on the goal of providing safe and efficient care to our surgical patients. And, again, I think that comes from the top down, and just the fact that leaders like Dr. Beck and Dr. Krontiras and I are here speaking about how important this is, I hope, shows and sets the tone that we really do take this seriously. And it really is the patient is in the center of everything we do in the operating room, and the supporting cast and supporting team just comes around that patient to again provide the safe, effective care with the best possible surgical outcomes.

Melanie Cole, MS: So, Dr. Beck, when we think of your specific field as a vascular surgeon, and we know that vascular procedures can become high risk pretty quickly, how does what we're discussing—surgical safety, that checklist—look different when seconds could matter? So, how do you prepare your teams for sudden intraoperative instability, anticipation, the role that that plays to prevent catastrophe? How does your team, when time really matters, set themselves up for better outcomes?

Adam Beck, MD: I would say that every surgeon is a leader, whether they like it or not, and they set the tone in the operating room. And one of the great things I would say about our practice is that we tend to work with the same team all the time. We really know the nurses and scrubs in the operating room very well. So, they know when things are going the wrong direction. And they can kind of tell by the way we're behaving, that things are turning in the wrong direction, and everybody needs to kind of be on guard for something bad happening.

As far as resetting the tone for the culture, everybody does that a little bit differently of course. But this is actually where the checklist does help a little bit. Because when we start the operation, we confirm that we've got the right patient, the right operation, the patient's been consented, we're doing it on the right side, and everybody in the room is engaged in that kind of timeout process. And we all make sure that we know each other. Most of the time we know who we're working with, but we may not necessarily know the anesthesiologist, for example, and we'll try to make sure that everybody is engaged in that process and we all know each other's names. And that way, we at least are familiar with each other. But otherwise, we're working with the same team. And I think everybody kind of knows how we're going to behave under duress when it does happen.

Melanie Cole, MS: That's a great model. And, Dr. Morris, how do surgeons model those safety behaviors for younger physicians? Speak a little bit about not only training residents and getting them to understand the importance of those surgical safety checklists, but also a little humility in the OR and understanding that this is a learning situation. We're all learning together, and we're helping the patient the best that we absolutely can. So, how do you teach that?

Melanie Morris, MD: Great question. One particular skill or tool I will use sometimes is sort of to ask people as we're finishing a case, "Is there anything else we need to do? Does anyone have any questions?" to make sure that there was not someone in the room who had a question in their mind but didn't quite feel comfortable speaking up. So, sometimes just pausing and asking for members of the team to see if they have anything else to add or any questions or concerns before completing a case.

I think also, you know, in the operating room, we have really a zero-tolerance policy for bad behavior. So, setting the tone from the top of we are in a high-pressure environment, in a high-stakes field, but we are all on this same team together, again, to provide the safest outcomes for the patient. And so, it doesn't matter what your title is, you are expected and must treat everyone in the room with respect.

And again, to what Dr. Krontiras said earlier, you know, with surgical safety being the number one priority and every one of us focusing on that common goal, and even as leaders being humble enough and open enough to ask questions, double-check things, making sure we're following the checklist and modeling that behavior for everyone in the room and all our trainees helps us to continue to disseminate that expectation and culture.

Helen Krontiras, MD: One other thing I'd like to add to that is, after the operation is done and after we all have some time to reflect on it, things like M&M conferences are really helpful for us to dissect out when things go well, but also when things maybe don't go as planned or there is something that could have been done differently. So, that offers us a space for us to come together as a group where we can reflect on the operation and the course, the journey of the patient, and identify where maybe we could have done a little bit better or maybe something could have been done to improve the care of the patient so that the next time we have this scenario, that hopefully we can learn from our previous encounters.

Melanie Cole, MS: Well, it's really about that level of professionalism, as Dr. Morris was just saying. And that, I think, is the crux of this discussion here today, is understanding that team and that everybody is a professional. You're all there for that patient.

So, Dr. Krontiras, speak a little bit about that multidisciplinary planning. We've talked about it, and it's been touched on in every question, but I'd like you to bring that home for us, why that's so important and how you're working with the anesthesiologists and the scrub nurses and the techs and everybody involved to bring together this cohesive group that works so well.

Helen Krontiras, MD: Everyone has an integral part to the care of our patients, like you mentioned, from the preoperative assessment with the anesthesiologist, from the preoperative assessment with the surgeon to assure that does this patient actually even need this operation? Is this something that is necessary and that's going to help this patient? Are they optimized from a risk and medical comorbidity standpoint? Can we do anything to make it safer for them to have surgery? And then, once they're in the operating room, even little things to help make the patient more comfortable, to improve their pain control, all of those things will allow for us to have better outcomes from our patients, and each member of the team contributes to that. Every nurse, resident, student, anesthesiologist, nurse anesthetist, everyone has a role in contributing to that.

Adam Beck, MD: If I could just say something, you said the word, humility a little while ago, Melanie. And I think that that's very important in surgery too, especially outside the operating room. I will often say that you should never let a bad outcome go to waste when you're talking about the conduct of the care in a morbidity and mortality conference. When an outcome kind of falls short of what we hope for you really need humility to honestly review your decision-making, your actions, acknowledge the limits of our knowledge. And, you know, stay open to the lessons that you may learn. You have to be careful not to dismiss it or explain it away. It's easy to blame it on the patient being complex or somebody else's actions, but you should really have sort of an extreme ownership of the outcome as a surgeon, in my opinion, and think about it and talk about it in that way.

Melanie Cole, MS: That's a really great thing to say, Dr. Beck, because I think that that is, again, one of the important points, is that you are the leader of this group. And yes, it's a multidisciplinary group and, yes, you're all working together. But at the end of the day, you're the one performing the surgery. So, that is amazing that you're able to look at it from that vantage point.

Now, one of the things that I think that throws a little wrench in all of this discussion that we're having here today is technology. And Dr. Beck, as we think of what's going on, I mean, AI-assisted risk prediction and the intraoperative imaging, real-time monitoring. There's electronic safety dashboards, there's robotic surgeries. How does a safety checklist and what we think of as your traditional-looking checklist that we would go through look like in today's world with all of these other factors coming in that are changing the technological aspect of your surgical suite?

Adam Beck, MD: Yeah. You know, it's really easy to get overwhelmed by all of the new devices, new dashboards, new checklists, all of those things. I'm hopeful that we'll have a confluence of a lot of these technologies over the next five or 10 years, with all of the interesting AI that we have getting integrated into our electronic medical record and even the registry data that we use and automatic abstraction. And we use AI even to help generate our notes in clinic sometimes, which can offload the physicians.

And so, I'm hoping that, you know, you can kind of imagine a scenario where you might see the patient in clinic, have an automatic note that's generated based on the data that you collect in clinic from your review of the imaging and your discussion with the patient. You'll have a what's known in the medical record, you'll have a risk assessment of the patient that's automatic that might generate a referral to another service so that they can be medically optimized. It might tell you what the best procedure is for that patient. It could generate a consent that is directed at the patient's level of knowledge so that you don't have to—you know, we have this concept of having consents that are directed at the patient's level of education. This could be automatically generated anyway. It's really interesting to think about what the future looks like in medicine with all of these new interesting technologies

Melanie Morris, MD: Those are really great points. And I think AI and the use of all the technological advances are going to help make surgery safer for our patients, but it's also going to free surgeons up to do what only surgeons can do. And that is look patients in the eye, hold their hand, reassure them, and build trust that we in the system are going to take care of them in the best and safest way possible. And then, the parts of our job that are more of a burden, like generating a clinic note, AI can handle that to let surgeons focus on what surgeons do best.

Adam Beck, MD: Yeah. It used to be this complaint that all of the new electronic medical record was really pulling us away from the patient, and it was. We're spending a lot of time sitting at a computer console documenting. And really, what the future looks like now is it's going to put us back with the patient, because a lot of that documentation burden is hopefully going to be taken away from us in the future.

Melanie Cole, MS: And as we look to five to 10 years down the line, defining the next evolution of surgical safety with what we've talked about here today, the technology, what do you think will happen? What do you hope will happen? And Dr. Beck, we can start with you.

Adam Beck, MD: We'll talk about technology again. And this is not something that we are currently doing at UAB. There are a few centers that are doing this now, but there are some places that are treating the operating room similar to a commercial airline flight where you have kind of a black box that shows what happened during the flight, and you can do a post-assessment using data. There are places that actually record movements in the operating room. You can even record conversations in the operating room, which may make some people feel uncomfortable, but that may be something that could happen in the future as sort of a black box type phenomenon in the operating room.

You know, as we pointed out before, I think there's certainly an opportunity to use technologies to not only offload what we do for electronic medical record documentation, but also to really assess outcomes in a much more objective way because it won't require surgeon- or nurse-entered data. It will be data that's automatically taken from the chart or from real-time activities in the operating room

Melanie Morris, MD: I can imagine a scenario down the road. If we think about our cars, you know, our cars have so much assisted technology in it now. So if I put my blinker on to change lanes, it lights up if there's a car in my blind spot that I can't see, or if a car immediately is stopping in front of me, my brakes already know to stop before I can get my foot on the brake pedal. So, there's some early data in the robotic and minimally invasive surgical world of capturing thousands and thousands and thousands of operations to try to teach machine learning in a way that if a surgeon is going to grab something or touch something, that this computer-assisted learning could tell you, "Wait a minute, pause and think about that. Do you really want to grab, do you really want to make this next move in your surgical procedure?"

So, I can imagine this world where we've both harnessed artificial intelligence and computer and machine learning in a way that really comes alongside the surgeon in the operating room with even technical aspects overlaying imaging such as CAT scans and MRIs onto the surgical field to help locate tumors that are difficult to visualize. We can currently already identify ureters and other blood flow to different structures intraoperatively.

I imagine that technology expanding so that again, they're really these seamless tools that surgeons then just use as they are making intraoperative decisions, again, to help enhance patient safety during the physical operation itself

Helen Krontiras, MD: A lot of this information, a lot of this technology can also help us to understand who we don't need to operate on. I think risk stratification with regard to breast cancer surgery, as an example, we have deescalated a lot of what we do in breast cancer surgery, and a lot of it is due to data that we find out from our risk stratifications.

And by doing that, having the patient undergo less surgery, especially if it's not necessary, allows them to have better outcomes and less side effects. And ultimately, that is what we want for our patients, is to have the best outcomes with the least side effects, so that they can live a long, healthy life.

Melanie Cole, MS: Well, isn't that a great place to end this discussion? What a great discussion this was today. I want to thank you all for joining us for this lively exploration of what a surgical safety checklist really can look like and beyond. So, thank you all so much for joining us. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.