LEADERSHIP IN THE OR Andrew L. Warshaw, MD, FACS, FRCSEd(Hon) W. - - PowerPoint PPT Presentation

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,
• utcomes)
• 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

• utcomes

Mazzocco et al, Am J Surg 2009

Effective leadership

• f 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

Interviews

(n=34)

Observations of surgical procedures

(n=78, 390 hours; Coded n of 22 for 1926 interactions)

Survey

(n=81, 70%)

Operating environment Surgeon leadership behaviors Team members’ perceptions of surgeon leadership

Deep Dive with Mixed methods

7 cardiac surgeons and 116 rotating team members

Contextual factors in the operating environment

Surgeon behavior

Cultural-historical factors Case-related factors Personnel involved in case Organizational factors Team’s perception

• f the importance
• f social and

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)

ENGAGEMENT FACILITATOR CONDUCTOR DELEGATOR SAFE SPACE MAKER ELUCIDATOR BEING HUMAN TONE SETTER

• Focus returning (+)
• Concern anticipation (+)
• Step mapping (+)
• Loop closing for confirmation (+)
• Need for clarification (-)
• Teaching (+)
• Constructive criticism (+)
• Explanation (+)
• Relevance giving (+)
• Private criticism (-)
• Negative criticism (-)
• Help seeking (+)
• Request (o)
• Consultation (+)
• Collaboration (+)
• Inquiry (+)
• Helping/supporting (+)
• Apology (+)
• Thanks (+)
• Compliment (+)
• Reassurance (+)
• Encouragement (+)
• Constructive humor (+)
• Conversation unrelated to the case (o)
• Frustration (-)
• Destructive humor (-)
• Non-surgeon willingness to initiate concern (+)
• Non-surgeon willingness to initiate questioning (+)
• Non-surgeon willingness to share information (+)

7 leadership functions 33 forms of leadership behaviors

• Self-questioning (+)
• Showing fatigue (o)
• Musings (o)
• Jargon (-)

CONDUCTOR DELEGATOR SAFE SPACE MAKER ELUCIDATOR BEING HUMAN TONE SETTER

• Focus returning (+)
• Concern anticipation (+)
• Step mapping (+)
• Loop closing for confirmation (+)
• Need for clarification (-)
• Teaching (+)
• Constructive criticism (+)
• Explanation (+)
• Relevance giving (+)
• Private criticism (-)
• Negative criticism (-)
• Help seeking (+)
• Request (o)
• Compliment (+)
• Reassurance (+)
• Encouragement (+)
• Constructive humor (+)
• Conversation unrelated to the case (o)
• Frustration (-)
• Destructive humor (-)
• Non-surgeon willingness to initiate concern (+)
• Non-surgeon willingness to initiate questioning (+)
• Non-surgeon willingness to share information (+)

7 leadership functions 33 forms of leadership behaviors

• Self-questioning (+)
• Showing fatigue (o)
• Musings (o)
• Jargon (-)

ENGAGEMENT FACILITATOR

• Consultation (+)
• Collaboration (+)
• Inquiry (+)
• Helping/supporting (+)
• Apology (+)
• Thanks (+)

“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)

ENGAGEMENT FACILITATOR CONDUCTOR DELEGATOR SAFE SPACE MAKER BEING HUMAN TONE SETTER

• Focus returning (+)
• Concern anticipation (+)
• Step mapping (+)
• Loop closing for confirmation (+)
• Need for clarification (-)
• Help seeking (+)
• Request (o)
• Consultation (+)
• Collaboration (+)
• Inquiry (+)
• Helping/supporting (+)
• Apology (+)
• Thanks (+)
• Compliment (+)
• Reassurance (+)
• Encouragement (+)
• Constructive humor (+)
• Conversation unrelated to the case (o)
• Frustration (-)
• Destructive humor (-)
• Non-surgeon willingness to initiate concern (+)
• Non-surgeon willingness to initiate questioning (+)
• Non-surgeon willingness to share information (+)

7 leadership functions 33 forms of leadership behaviors

• Self-questioning (+)
• Showing fatigue (o)
• Musings (o)
• Jargon (-)

ELUCIDATOR

• Explanation (+)
• Relevance giving (+)
• Teaching (+)
• Constructive criticism (+)
• Private criticism (-)
• Negative criticism (-)

ENGAGEMENT FACILITATOR CONDUCTOR DELEGATOR SAFE SPACE MAKER BEING HUMAN TONE SETTER

• Focus returning (+)
• Concern anticipation (+)
• Step mapping (+)
• Loop closing for confirmation (+)
• Need for clarification (-)
• Help seeking (+)
• Request (o)
• Consultation (+)
• Collaboration (+)
• Inquiry (+)
• Helping/supporting (+)
• Apology (+)
• Thanks (+)
• Compliment (+)
• Reassurance (+)
• Encouragement (+)
• Constructive humor (+)
• Conversation unrelated to the case (o)
• Frustration (-)
• Destructive humor (-)
• Non-surgeon willingness to initiate concern (+)
• Non-surgeon willingness to initiate questioning (+)
• Non-surgeon willingness to share information (+)

7 leadership functions 33 forms of leadership behaviors

• Self-questioning (+)
• Showing fatigue (o)
• Musings (o)
• Jargon (-)

ELUCIDATOR

• Explanation (+)
• Relevance giving (+)
• Teaching (+)
• Constructive criticism (+)
• Private criticism (-)
• Negative criticism (-)

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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

• f 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?

4.2 4.8 5.2 5.8 5.9 6.0 6.2

1 2 3 4 5 6 7

S2 S6 S3 S5 S7 S4 S1 Non-surgeons rating of surgeons as leaders Surgeons

All mean scores based on 1-7 scale; higher is better

Average: 5.4

“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

• f 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

• ur 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)

PERCEPTION OF SAFETY IN THE OR

• Surgeon behavior determines culture
• Nurses perceive it more than surgeons
• Safety outcomes are related to surgeon

behavior Checklist completion (JACS, 2016) 30-day post-op deaths (ASA, 2017)

LEADERSHIP IN THE OR

Competence Communication Calm Comfort