How can we enable the sharing of best practices between high-performance surgical teams? It starts off with just another day in the office…
It’s a busy shift and the list is growing fast. You scrub in, check the instruments, balance the camera. Despite the chaos slowly mounting, everyone is aligned and moving together, defaulting to what training and experience tell us is the best way to proceed.
‘Best practice’ is a familiar concept in surgery, albeit one defined by change. In theatre, juniors are unlikely to question why their first views inside the abdomen are now on-screen, rather than glimpsed through blooded gloves and an open incision. On the wards, the words enhanced recovery have become a standard part of hospital language, serving as daily shorthand for the routines of elective surgical care. Consolidation of new developments into changes in practice drives surgery ever forward in search of better outcomes, fewer complications, quicker recovery and more efficient ways of doing things.
Instinctively, this sits well. Doing something the best way is something surgeons take pride in. If someone, somewhere, is doing something demonstrably better, we should all strive to adopt this (as much as is feasible) in order to deliver the highest standards of care for our patients.
Do We Follow Best Practices in Surgery?
Despite our intuition, variation in surgical practice is well established in the NHS, as it is across the world. Some is, of course, legitimate, warranted; for example, different techniques may be seen between a small general hospital and a specialised tertiary unit due to radically different case mix and patient demographics. Much, however, remains unexplained after evidence-based factors have been accounted for. This has been termed unwarranted variation, where there is a clear best-practice strategy but real-world actions do not uniformly follow it
In a 2018 opinion piece, ex-BMJ editor Richard Smith asks whether we would tolerate the kind of variation typical in surgery if, for example, the duration of flight varied over a matter of days according to which airline you flew with.
The piece goes on to introduce Professor Tim Briggs, CBE, former president of the British Orthopaedic Association and national lead for Getting It Right First Time, a programme tasked to identify and reduce this kind of unwarranted variation in the NHS. In the programme’s infancy, Briggs gathered extensive orthopaedic data from all hospitals in England and presented countless examples of large deviations from evidence-based standards. Working with clinicians and management to reduce this — and slashing the associated costs — his initial 2015 report led to a £60m NHS Improvement investment to expand the programme to 40 medical and surgical specialties.
Similar patterns in practice variation are evident across the world. A Harvard-based study looked at arthroscopic knee surgery performed by surgeons around Massachusetts, finding large differences in surgery rates between those who followed best practice guidelines, and those who didn’t. Other studies show similar patterns in hip surgery, tonsillectomy, and coronary revascularisation, showcasing that unwarranted variation in surgical procedures can often be strongly associated with poorer outcomes.
This observation is directly at odds with how we think about our own practice. Why would I do something one way if there is a better way to do it?
Silos of Information
For many reasons, barriers to information sharing can develop fast. A well-recognized product of ever-increasing (sub)specialisation in business and commercial practices is the development of information silos. Sometimes called the ‘black box phenomenon’, this describes groups that tend to function as a more-or-less autonomous unit within an organisation. This is often unconscious, whether driven by a competitive element or geographical or in-house compartmentalisation. It can also be used strategically to segment information management or protect critical data. Communication within an information silo is vertical, making it problematic (or impossible) to work with unrelated systems. This can create redundancy and misinformation and may serve to propagate outdated or undesirable practices.
Clinical research, academic publication and consensus guidelines, of course, exist in part to counter the siloing of information, facilitate knowledge sharing and drive standardisation. In the day-to-day provision of surgical care, however, it would be fair to say that many hospitals and operating departments keep a rigid and hierarchized organisational structure. This can reflect the interface of different disciplines, training programs, levels of seniority, professional groupings, geography, budgets and resources, among numerous other factors. Even within the same institute, different ways of doing things are common between different teams and different surgeons. Communication can indeed be vertical. Knowledge can become trapped within teams.
Beyond just stating the obvious, or pointing out systemic shortcomings, recognising a silo mentality in surgery can be useful to suggest a particular focus for efforts to promote best practice: sharing is key. But to share this kind of best-practice information, we must first capture it.
Capturing a Surgical Profile
Surgery is cleary a product of many things. Each successful procedure represents the interface of multiple workflows, patient factors, equipment, materials and techniques (to name but a few).
In similar safety-critical industries, these kinds of interactions are studied through the science of ‘human factors’, examining the relative influences of team dynamics, environments, organisational culture, communication, and decision-making (often in aviation and nuclear power). When things go awry, it tends to be because multiple factors — seemingly unimportant in isolation — interact in just the right (or wrong) way to change the outcome.
The geography of an operating theatre, for example, is a key factor in successful imaging, favourable ergonomics, and effective communication. Patient positioning, draping, instrument setup: these are all moving parts in the complex environment where surgery takes place.
Each component must align reliably and reproducibly in the context of the human factors and environmental stressors that are part and parcel of daily life in an operating department. The profile of a procedure needs to be captured, optimised and then shared to enable team-wide best practices to be followed, creating the best possible systems to deliver the best standards of care.
High-Volume, Team-Wide Solutions
The kind of systems-based approach outlined above has also allowed sophisticated assessments of resource allocation, costs and efficiency. By examining the parts that make up a surgical procedure — and the systemic outcomes these have — methods developed in industry and manufacturing have been successfully adapted to identify sources of waste and remove drivers of inefficiency. Since 2015, just in orthopaedics, the GIRFT programme has:
- Reduced inpatient stay by a fifth, releasing over 368k bed days
- Reduced revision rates every year (for all procedures, even while total activity and demand grow)
- Released £696 million of operational and financial opportunities to trusts
GIRFT now covers 42 clinical specialties, making it the UK’s largest healthcare quality improvement programme. As part of the elective recovery following COVID-19, 89 new surgical hubs were created with the oversight of GIRFT (40 more are planned over the next two years). These focus on high volume, low complexity (HVLC) surgery, bringing together skilled and highly focused teams in protected facilities and theatres. End-to-end pathways for HVLC procedures have been created, outlining standardised team workflows for multidisciplinary best practices.
So … Where Are We Now?
Best practice, it transpires, is a team activity. Understanding it can be complex, but applying it can be hugely impactful. Barriers to information sharing can be unconscious and institutional, siloing practices away from mainstream consensus. Learning from high-performing units is key to benchmarking and driving up standards across the board.
Capturing, curating and — perhaps, most importantly — sharing a the profile of a surgical procedure remains a logistical and technological challenge. Protocols and workflows are page-heavy and often gated, version control soon becomes problematic, and access by individual staff can be low. For scalable, sustainable and team-wide impact, tools must be easy to access, intuitive to consume, and straightforward to implement. Different types of teams will be needed, including experts in user experience, eLearning, and product design.