A study conducted by the Health Research and Educational Trust found that utilization of high performance work practices can improve patient outcomes in both safety and quality parameters [16, 17]. Building these high performance work teams requires having the right people in the right jobs. This begins with having expectations about safety incorporated into job descriptions, which are then used for advertising vacant positions and communicating during the hiring process. Candidate interviews should utilize behavioral-based questions that elicit the applicant’s understanding and experience with patient safety scenarios and working within a team environment. During the hiring process, the expectations of working within the organization’s safety culture need to be clearly articulated. While a candidate’s functional skill set is important, the ability to assimilate successfully into a safety culture is crucial. It is usually easier to learn a functional skill than to learn teamwork and change attitudes. Integration of patient safety and quality expectations into employee or partner contracts prior to hiring or renewal is valuable. Once hired, team members need to thoroughly understand that safety and quality are a priority. Integrating these expectations into the onboarding processes for hospital employees and contracted partners is essential. Video clips from senior executive leadership provide as strong message about the importance of safety and quality.

While executive leaders are responsible for establishing safety as an organizational priority, unit-based leaders are pivotal in assuring that patient safety processes are sustained as an integral part of perioperative care . Frontline leaders are strategically positioned to set performance standards and implement team-centered systems that support an overall safety culture and meet safety goals. Providing ongoing reminders during daily huddles, and communicating progress toward goals on a Managing Daily Improvement board integrate safety into daily activities and establish it as a norm. Staff meetings provide a valuable opportunity to discuss challenges and obtain staff input about strategies to overcome these challenges. These meetings should contain a standing agenda item to discuss progress toward safety goals.

Performance appraisals should include key expectations of safety. However, addressing noncompliance in a constructive, timely manner is critical. Principles of a just culture should be used to address inconsistencies between desired behavior and observed behavior. This also provides input into systems changes that promote desired behaviors.

The perioperative team’s progress toward goals should be shared with executive leadership . This integrates perioperative safety into the overall quality and safety program and instills a sense of accountability. This communication is often in the form of a scorecard, aligning perioperative safety goals with the overall strategic plan for the organization.

Lastly, developing a safety culture at the surgical microsystem is a journey requiring continuous reinforcement and support [18]. Progress toward goals should be recognized and celebrated. Having healthy competition between perioperative teams can serve as an additional incentive, and may make the journey toward a safety culture more enjoyable.

In perioperative settings , all levels of providers should be involved in the journey to a safety culture. Due to the complexity of the departments and the episodic nature of interactions, it can be difficult to design a mechanism for meaningful collaborative engagement. Most surgical settings have a multidisciplinary committee charged with overseeing the functioning of the operating room and facilitating communication between perioperative disciplines. Key responsibilities of the OR Management Committee include:

This committee’s meetings provide a venue for tracking the progress of safety initiatives and other key metrics and dedicated time for sharing safety concerns. Balanced scorecards are often used for this purpose. The content of this report is tied to the organization’s strategic plan. Although these reports vary between facilities, some elements of a perioperative score care may include:

Although membership of the OR Management Committee varies somewhat between types of facilities and networks, the structure usually includes the triad of perioperative nursing director, anesthesia director, and surgeon director. This oversight requires effective collaboration between members of the committee, sharing data to and from their respective departments, discussing initiatives, and addressing issues with their departments. Incorporating the committee members into the ongoing surveillance of safety initiatives helps to underscore the importance of building and maintaining safety initiatives.

The availability of the perioperative team to manage the daily schedule and acute emergencies is essential for patient safety. Having too few staff for a patient surgery or having personnel who are not competent in the particular aspects of the procedure and patient care requirements increases the risk of harm to the patient.

Planning staffing for an operating room (OR) is considerably different than for an inpatient care unit. While staff working in an inpatient unit care for multiple concurrent patients within a specific medical specialty, OR staff care for patients sequentially for multiple surgical specialties.

Designing perioperative services for safety requires an understanding of the science underpinning safety. Education about safety should be provided for all personnel and contracted partners working in perioperative services . Content from perioperative leadership and executive leadership should be included. This can be done by inserting a video clip into presentations . The content of this education should include:

A culture of safety also requires assurance that healthcare personnel have the knowledge and technical skills to make sound clinical decisions, perform tasks needed for their roles, routinely function as a team, effectively work together to manage emergency situations, and maintain these skills over time. Simulation and spaced education are two strategies to accomplish this [27].

When implementing new programs or processes or redesigning those in place in the perioperative setting, it is important to identify potential failures and, when possible, proactively prevent these from occurring. This strategy is a proactive risk analysis. Unlike a root cause analysis that retrospectively examines a single failure, a proactive risk analysis involves a “deep dive” examining a process and identifying and correcting potential failures [41]. In this way, the learning is from what could go wrong, rather than what went wrong in single event [27]. Two tools to conduct a proactive risk analysis are: Failure Modes and Effects Analysis and the VA Center for Patient Safety’s modification of this tool, a Healthcare Failure Mode and Effect Analysis (see Table 19.2) [42, 43].