8.1 Introduction

Spine surgery has changed the lives of many patients, but medical errors still account for significant morbidity and mortality, impacting patient lives and the system at large. ^{1 , 2} Spine surgery is one of the most complex procedures in modern healthcare, and the operating room presents significant risks and opportunities for patient harm. Communication is the most likely root cause for most categories of medical error, yet we are woefully behind in efforts to develop structured communication and organizational infrastructure which supports coordination of processes in our complex spine surgery care system. Also, surgeons are often not fully aware of the depth of the problem. Numerous articles have found that surgeons typically overestimate teamwork compared to other surgical team members such as anesthesiologists and nurses. ^{3 , 4 , 5} Teamwork is an important step forward toward ensuring reliable outcomes for patients.

Dedicated, experienced teams improve the flow and efficiency of complex tasks. While intuitive, the adoption of dedicated operative teams has been slow and sporadic in our hospital systems, especially compared with other areas of industry. The efficiency and safety benefits of teamwork on complicated tasks are easily visible in jobs outside of medicine. During flight simulations, a NASA study compared fatigued crews who had experienced flying together with well-rested crews who had never flown with one another and found that the former made significantly fewer errors despite their depleted individual mental states. ² Similarly, an analysis of the National Transportation Safety Board (NTSB) revealed that 44% of airline accidents occur on a crew’s first flight together, with 73% of accidents occurring on the crew’s first day. ³ Examples from professional sports abound; for example, National Basketball Association (NBA) basketball teams win more games as their teams play together more often. ⁴

While there is limited literature on dedicated teams in spinal surgery, other surgical fields have demonstrated that consistent and well-trained teams have the potential to reduce errors and improve performance. A study of cardiac surgery outcomes in Pennsylvania investigated cardiac surgeons who had transitioned between multiple hospitals. At a given hospital, each procedure the surgeon performed lowered the mortality risk for that surgeon at that hospital, but when the surgeon began operating at a different hospital, the mortality risk returned to baseline. ⁵ The technologies and methods were the same at each hospital, suggesting that improved outcomes came from the process of practicing with a given team and learning to leverage the unique talents of each member. Rather than merely improving his or her surgical skills over time, the surgeon was adapting to a specific team and environment, where a more developed team relationship helped achieve peak performance.

A team generally consists of a collection of individuals working toward a common goal, especially working on complex tasks that cannot be completed by any one individual. High-performing teams include people with complementary skills who develop synergy through coordinated effort and mutual commitment. This relies on communication, psychological safety and belonging, and a clear understanding of goals and purpose.

8.2 Communication

The operating room is a complex environment with multiple levels of hierarchy, matrixed across multiple disciplines. Accurate communication occurs when an individual encodes a message and then decodes the information. Miscommunication occurs during a breakdown in those steps such as if information is inaccurately coded or sent at the wrong time, or if someone misinterprets and decodes the message incorrectly (Fig. 8‑1). ⁶

Miscommunication is one of the most common reasons for medical errors, and it increases when team members are not familiar with one another. Effective communication requires clarity, comprehensiveness, and confirmation that messages have been received. Checklists are one of the best tools to ensure effective communication. ⁷

Optimum communication requires both a supportive structure and strong culture. Communication is always better when there is “psychological safety.” Psychological safety exists when team members know and trust each other and are united in a common purpose and goals. Clearly stating the team’s needs and goals allows members to develop clear expectations and understanding. Teams begin to understand each other’s roles, duties, and abilities when they work together more often. This builds collective experience and trust in one another. This trust and sense of psychological safety means that individual members can anticipate when another teammate needs help and can improve coordination. When there is no trust or sense of safety, there can be a greater chance of poor performance and outcomes. Safety can also be lacking when members do not trust their teammates to fulfill their roles and responsibilities.

8.3 Building Safety and Belonging

When teammates trust and respect each other to do their job, several benefits are seen. ⁸ First, teammates will be more willing to ask for help or speak up, because they do not have the fear that others will penalize or humiliate them. Steep authority gradients and strong hierarchical culture can inhibit more junior team members from speaking up. Fear of speaking up is often a reason for errors that are not caught until it is too late. Another benefit is that speaking up will allow for conflict resolution, rather than an escalation of tension.

Psychological safety does not mean that team members should not be held accountable for their actions, though. In fact, conflict is unavoidable in a high-performing team. Instead, teams should focus on tasks and how they need to change to accomplish the overall goal. In creating a safer environment, leaders make clear expectations about the performance of the job at hand rather than part of an individual’s shortcomings. Leaders can help create these expectations and help team members focus on tasks by being accessible and approachable and being willing to work with team members directly on developing a solution rather than penalizing failure. It is important for leaders to also show vulnerability and acknowledge that they do not know everything. A leader’s job is to set goals and hold people accountable, not to do everyone’s job. Being as direct as possible and setting boundaries help to ensure that an individual takes ownership of his or her own job and contributes to the team’s overall success.

To facilitate better teamwork within their environment, surgeon-leaders should strive to create an environment where:

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  The team is psychologically safe enough for the most junior member to ask for help or speak up if things are unclear.

  
  
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  Teammates trust one another to do high-quality work.

  
  
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  Everyone knows the goals, roles, and execution plan.

  
  
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  Team members understand how their tasks are critical to ensuring overall team success.

  
  
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  The team participates in the outcomes: successes, consequences, and results of the team’s efforts.

8.4 Team of Teams: Creating Shared Consciousness and Purpose

In April 2017, General Stanley McChrystal presented a rousing keynote address at the Summit for Safety in Spine Surgery in New York City where he shared lessons learned in the Middle East War as they pertain to spine surgery.

As General McChrystal explained, teamwork is often inhibited by a feeling of “tribalism,” a belief of belonging to a particular subculture (e.g., anesthesia, surgery, and nursing) which trumps loyalty to the larger team. In redesigning the forces aligned against Al Qaeda in Iraq, he sought to disband these tribes by flattening hierarchy, improving communication, and creating a shared consciousness toward a common goal.

Teams need to understand how each member contributes to the ultimate goal and how their team’s efforts impact the overall organization’s goal. Just as General McChrystal brought together separate branches of the armed forces from separate offices into a shared open office, surgeons need to make sure that information is shared freely across siloes, for example, from their outpatient team to their surgical team to their inpatient team. Successful tools that have been adopted from the military include the concept of a daily briefing or huddle or a weekly conference bringing together the various teams to talk about each patient’s plan for treatment and recovery. These meetings, either physical or virtual, can improve transparency and build greater collaboration for everyone who impacts the patient’s care.

8.5 A Tale of Two Team Building Efforts: Children’s Hospital of Philadelphia and Children’s Hospital of New York

8.5.1 The CHOP Experience: The Value of Dedicated Surgical Teams: Bringing NASA and NASCAR Wisdom to Your Spine Operating Room

To translate the value of teamwork into tangible improvement in the operating room, surgeons and caregivers at the Children’s Hospital of Philadelphia (CHOP) initiated the Dedicated Spine Team for posterior spinal fusions (PSFs). In replicating best practices from athletics and aviation, the dedicated team sought to facilitate an operating room flow in which all members would know their role, have done their jobs countless times, coordinate perfectly with other team members, and take pride in the success of the operation.

The earliest version of the Dedicated Spine Team at CHOP involved a small group. To scale the dedicated team and achieve sustainable success, the team needed to extend the conversation to the hospital administration. Working with an improvement officer, the team created a shared consciousness and goal to complete two PSFs by a single surgeon with the standard operating room time block without the use of a concurrent operating room. The meaning and impact of this effort were made clear to the team. Doing two surgeries in a day would improve better access to other patients for this dramatic, life-improving surgery.

The official dedicated spine team started with a small group of surgeons and anesthesiologists and then scaled up. Phase I consisted of a single spine surgeon; four anesthesiologists; and a small group of registered nurses (RNs), certified registered nurse anesthetists (CRNAs), and technicians following a standardized protocol. After problem solving and working out inefficiencies, the group was scaled up to Phase 2, which involved 2 surgeons (and later 3); 12 anesthesiologists; and 1 expanded group of RNs, CRNAs, and technicians.

The initial team building involved using simulations to work out inefficiencies as well as the standardization of perioperative processes including positioning, preparing and draping, imaging, patient wakeup, and patient transport in and out of the operating room. There were weekly team meetings with hospital process engineers where all members were encouraged to make suggestions to improve efficiency and team environment. This facilitated buy-in and ownership from the team. Every step was discussed and diagrammed using “process mapping,” allowing the team to identify tasks that could be accomplished in parallel. A standard protocol would allow for everyone to understand their roles and create dependability.

In addition to standardizing processes within the operating room, types of cases had to be standardized to best communicate with the team and target patients who could most greatly benefit from the Dedicated Team’s standardized model. PSFs range in complexity. A simple T4–T12 fusion on a patient with no comorbidities can be easily standardized and completed in as little as 2.5 hours. A T2–pelvis fusion with vertebral column resection (VCR) in an obese patient who has had a heart transplant, however, can take all day even for the most efficient and standardized operating room team. To reflect these case differences, the Dedicated Spine Team classified PSF cases into four categories (Fig. 8‑2). Categories III and IV were excluded from standardization by the Dedicated Spine Team. By structuring the language within the team, the chances for a breakdown in communication was severely reduced, allowing each team member to better understand their roles for each case and ensuring that there was great dependability.

The impact of the Dedicated Spine Team was significant. Previous PSFs completed by nonstandardized teams (casual teams) took 335 minutes on average from wheels in to wheels out, while the Dedicated Spine Team took 222 minutes. This was an increase in time efficiency of more than 34% (Fig. 8‑3). When broken down by case type, Category 1 cases were 29.7% more efficient with a dedicated team. Increased efficiency also persisted with Category II cases, representing an 18.5% increase in efficiency. The Dedicated Spine Team saved an average of 22.0 (± 4) minutes per level fused for Category I cases, and efficiency improvements were seen for every stage of the case including preoperative preparations, operative time, postoperative wakeup, and patient transport (Fig. 8‑3).

A multivariable linear regression for BMI, number of levels fused, number of osteotomies, surgeon, and type of team indicated that the presence of a Dedicated Spine Team reduced case length by 91.5 minutes and made the largest statistically significant impact on the time of surgery. Importantly, saving more than an hour on these PSFs also allowed for the completion of two PSFs in a single operating room within the normal operating room hours, creating further streamlining of such cases (Fig. 8‑4). In both Casual and Dedicated Spine Team cases, clinical results were excellent and complications were minimal. While it is impossible to statistically prove that patients were safer with the Dedicated Spine Team, there were fewer adverse events (0/78 for the Dedicated Spine Team compared with 4/89 for the Casual Team). ⁹

From a value standpoint, the time savings will be translated to significant financial savings while maintaining positive surgical results. Some studies estimate operating room costs anywhere between $62 and over $100 per minute, meaning that even small improvements in team efficiency can result in significant savings. ⁶ The hospital estimated that the 1-to-2-hour decrease in operating room time for PSFs for a dedicated team resulted in a $6,000 to $9,000 savings per case. Specifically, savings with Category I patients were approximately $8,900 per case, and the savings persisted with Category II cases at approximately $6,000 per case. ¹⁰ This impact was communicated at all levels to the team members and helped reinforce the meaningful nature of belonging to a team.

Sustaining the Dedicated Spine Team can prove just as difficult as creating one. Hospital administrators are often hesitant to adopt and support Dedicated Spine Teams, as such teams limit flexibility of both staff and individual workers. Employees working on Dedicated Teams tend to gain specialized over general skill, and some teams are more fun than others. Administrators tend to like employees who are interchangeable cogs, easily filling open slots on a duty roster. When pitching either the creation or continued support of Dedicated Teams to hospital administration, it should be emphasized that what such teams lack in staff flexibility, they return in value, with more efficient use of increasingly limited operating room space and significant financial savings.

In addition to maintaining the interest of the administration, the constant turnover of trainees and new staff from all parts of the team can dilute the goal and reintroduce inefficiencies to standardized processes. It is important to make training materials and standardized protocols accessible, through a hospital intranet page, and to keep the team up to date with reminders and updates. The team culture must also be continuously nurtured. Often, the surgeon is the only team member with the privilege of following up with patients and perhaps receiving thank you notes or other small tokens of gratitude from the family. It is important to frequently share these thoughtful updates with the whole team to continue to cultivate a shared mission. Team building events like end-of-season parties or happy hours go a long way toward building team unity.

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