LEADERSHIP IN THE OR Andrew L. Warshaw, MD, FACS, FRCSEd(Hon) W. Gerald Austen Distinguished Professor of Surgery Harvard Medical School Surgeon-in-Chief Emeritus Massachusetts General Hospital
RESPONSIBILITIES OF THE SURGICAL LEADER FOR THE OR • Privileging (training, volume standards, outcomes) • Appropriate behavior (abuse, timeliness) • Overlapping surgical cases • Data collection and reporting • Residency training (teaching, progressive autonomy, role models)
FLIGHT 1549 • Flight 1549
Surgical excellence requires teamwork. Poor team behaviors negatively effect team performance and are associated with adverse events and worse patient outcomes Mazzocco et al, Am J Surg 2009
Effective leadership of surgical teams Sara J. Singer, MBA PhD Professor of Health Management and Policy Harvard T.H. Chan School of Public Health, Harvard Medical School, Mongan Institute for Health Policy/MGH
OPERATING ROOM TEAMWORK, SAFETY CHECKLISTS, PERFORMANCE AND SAFETY Surgeon buy-in Shared clinical leadership Open communication Case-related conversation Active coordination Mutual respect Singer et al, J Am Coll Surg 2016
Deep Dive with Mixed methods Team members’ Operating Surgeon perceptions of environment leadership surgeon behaviors leadership Observations of Interviews Survey surgical procedures (n=34) (n=81, 70%) (n=78, 390 hours; Coded n of 22 for 1926 interactions ) 7 cardiac surgeons and 116 rotating team members
Contextual factors in the operating environment Personnel involved in case Case-related Organizational factors factors Team’s perception Surgeon of the importance Cultural-historical of social and behavior factors technical competence
MOST POSITIVE SURGEON OR BEHAVIORS Elucidator- teaching, explaining, instructing, updating, constructive criticism Tone setter- constructive humor, compliment, reassurance, encouragement (Dominant and controlling behaviors are accepted in particularly difficult circumstances)
Focus returning (+) • Concern anticipation (+) • CONDUCTOR Step mapping (+) • 33 forms of leadership behaviors Loop closing for confirmation (+) • Need for clarification (-) • Teaching (+) • Constructive criticism (+) 7 leadership functions • Explanation (+) • ELUCIDATOR Relevance giving (+) • Private criticism (-) • Negative criticism (-) • • Help seeking (+) DELEGATOR • Request (o) • Consultation (+) • Collaboration (+) ENGAGEMENT • Inquiry (+) • Helping/supporting (+) FACILITATOR • Apology (+) • Thanks (+) • Compliment (+) Reassurance (+) • • Encouragement (+) TONE SETTER • Constructive humor (+) • Conversation unrelated to the case (o) • Frustration (-) Destructive humor (-) • • Self-questioning (+) • Showing fatigue (o) BEING HUMAN • Musings (o) • Jargon (-) • Non-surgeon willingness to initiate concern (+) SAFE SPACE MAKER Non-surgeon willingness to initiate questioning (+) • Non-surgeon willingness to share information (+) •
Focus returning (+) • Concern anticipation (+) • CONDUCTOR Step mapping (+) • 33 forms of leadership behaviors Loop closing for confirmation (+) • Need for clarification (-) • Teaching (+) • Constructive criticism (+) 7 leadership functions • Explanation (+) • ELUCIDATOR Relevance giving (+) • Private criticism (-) • Negative criticism (-) • • Consultation (+) • Help seeking (+) DELEGATOR • Request (o) • Collaboration (+) ENGAGEMENT • Inquiry (+) • Helping/supporting (+) FACILITATOR • Apology (+) • Compliment (+) • Thanks (+) Reassurance (+) • • Encouragement (+) TONE SETTER • Constructive humor (+) • Conversation unrelated to the case (o) • Frustration (-) Destructive humor (-) • • Self-questioning (+) • Showing fatigue (o) BEING HUMAN • Musings (o) • Jargon (-) • Non-surgeon willingness to initiate concern (+) SAFE SPACE MAKER Non-surgeon willingness to initiate questioning (+) • Non-surgeon willingness to share information (+) •
“ So there’s a coach, but then there’s a team around that coach that’s encouraged to be thoughtful, to be innovative, to speak up when they’re concerned. You have to appreciate that people are there to help you and the end goal is to provide the best possible care for the patient, and when you create an environment that shuts them (non-surgeons) down, you’re not getting the best out of them”. (perfusionist)
Focus returning (+) • Concern anticipation (+) • CONDUCTOR Step mapping (+) • 33 forms of leadership behaviors Loop closing for confirmation (+) • Need for clarification (-) • • Explanation (+) • Relevance giving (+) 7 leadership functions ELUCIDATOR • Teaching (+) • Constructive criticism (+) • Help seeking (+) DELEGATOR • Private criticism (-) • Request (o) • Negative criticism (-) • Consultation (+) • Collaboration (+) ENGAGEMENT • Inquiry (+) • Helping/supporting (+) FACILITATOR • Apology (+) • Thanks (+) • Compliment (+) Reassurance (+) • • Encouragement (+) TONE SETTER • Constructive humor (+) • Conversation unrelated to the case (o) • Frustration (-) Destructive humor (-) • • Self-questioning (+) • Showing fatigue (o) BEING HUMAN • Musings (o) • Jargon (-) • Non-surgeon willingness to initiate concern (+) SAFE SPACE MAKER Non-surgeon willingness to initiate questioning (+) • Non-surgeon willingness to share information (+) •
Focus returning (+) • Concern anticipation (+) • CONDUCTOR Step mapping (+) • 33 forms of leadership behaviors Loop closing for confirmation (+) • Need for clarification (-) • • Explanation (+) • Relevance giving (+) 7 leadership functions ELUCIDATOR • Teaching (+) • Constructive criticism (+) • Help seeking (+) DELEGATOR • Private criticism (-) • Request (o) • Negative criticism (-) • Consultation (+) • Collaboration (+) ENGAGEMENT S u r • Inquiry (+) g e o n t • Helping/supporting (+) o FACILITATOR S “ T c r h u i s b • Apology (+) o N p u e r r s n a e • Thanks (+) o t : t i n c g l e f a i e r . l d E v S i a s • Compliment (+) u e n n r g e i e x f o i t r t n a Reassurance (+) t • a t o s k e e F c y s e o “ o l n W u • Encouragement (+) l o d h p w , a l c : e t TONE SETTER o a u a s • Constructive humor (+) d r l e d e o t m i y h n o e a g u k ! f e i • Conversation unrelated to the case (o) Y e o s l d u u r ’ i r s e t e o c • Frustration (-) t l d e r y e t a f i i r n m y n g e b e Destructive humor (-) i ? • x d o T t l o o h i g n a y n g k b t s h y . a ” • Self-questioning (+) t . H y o o u w e • Showing fatigue (o) a v BEING HUMAN r e e r g o • Musings (o) i n g i m t o p • Jargon (-) r o v e ? ” • Non-surgeon willingness to initiate concern (+) SAFE SPACE MAKER Non-surgeon willingness to initiate questioning (+) • Non-surgeon willingness to share information (+) •
Non-surgical staff in the OR characterized teams as having relatively low levels of psychological safety, open communication, and social worth. Surgeons’ perceptions of the openness of communication and their own power and status in the OR were higher
Which behaviors best support teamwork • Surgeon behavior influences how staff perceive their leadership – Facilitating team member engagement most beneficial – Negative criticism most harmful • Findings suggest that non-surgeon team members seek collaboration, psychological safety, and opportunities to learn • Assigning appropriateness requires attention to context
Survey results How would you evaluate the general performance of this surgeon as a team leader? 7 Average: 5.4 6.2 Non-surgeons rating of surgeons as 6.0 5.9 5.8 6 5.2 4.8 5 4.2 leaders 4 3 2 1 S2 S6 S3 S5 S7 S4 S1 Surgeons All mean scores based on 1-7 scale; higher is better
“Bad physician behavior” had become normalized. Yelling, shouting and bullying were seen less as deviant behaviors warranting censure than as a “normal” part of the stressful business of cardiac surgery.
“This hospital needs to come up with a behavior policy that actually exists, is actually enforced, and appropriate interventions actually occur. We’ve tolerated bad relationships and disrespect down there for years. We should not be doing that” (anaesthesiologist)
PERCEPTION OF “IDEAL TEAMWORK” Focus on the Patient Flow—well-oiled machine, on the same page Competence—technical, relevant, task-related Appropriate Leadership—surgeon, anesthesiologist, other
“Everyone should come to the OR prepared” (surgeon) “We would expect each other to be experts at our job, trust each other to do our jobs well” (nurse) “The book knowledge is one thing; the idiosyncrasies of individual attendings and how they do it is a whole other thing to learn” (surgical trainee)
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