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As part of the evaluation of the Health Quality & Safety Commission’s Safe Surgery NZ programme, a baseline national survey of district health board (DHB) surgical staff has been undertaken.

Since 2012, the Commission has had a goal of reducing surgical harm. Research suggests teamwork and communication failures are at the core of many medical error and adverse events.

To date the focus of the surgical safety programme has been to support implementation of the World Health Organization’s surgical safety checklist. Currently, all three parts of the checklist are being used in 97 percent of operations.[1]

The Commission is rolling out a package of programmes aimed at helping improve teamwork and communication in the operating theatre. The Surgical Culture Safety Survey was conducted to provide baseline data on attitudes and the quality of teamwork in operating theatres. It closely replicates analysis developed by the Harvard School of Public Health.

Nearly 850 survey responses were received.

The findings are generally positive, although particular areas identified for improvement include communication between surgical team members, and clinical leadership.  On several measures NZ seems to be doing better than the USA.

The culture survey results show that in most instances, team members work relatively well together. Eighty-eight percent of participants agreed that plans for patient care are adapted as needed and that surgeons and anaesthetists work together as a well-coordinated team. Eighty-two percent said they are encouraged to report patient safety concerns and 80 percent agreed that decision-making is shared among disciplines in response to conditions or issues that arise during operations.

However, there is room for improvement in the area of communication. Only 40 percent agreed surgical team members from different disciplines always discussed patient conditions and the progress of operations and 31 percent did not think surgical team members made sure their comments or instructions were heard. Inattention was an issue during team meetings in the operating room.

We anticipate that, by working with every DHB to improve communication and better use of tools such as the checklist, briefings and debriefings, the ability of surgical teams to work together can be strengthened, and the communication of important clinical information will be shared more consistently. Over time, we expect to see a reduction in surgical adverse events and an improvement in patient safety.

Key findings:

  • 84 percent of respondents say the time out checklist is being used by every surgical team
  • 96 percent say they would want the checklist to be used if they were having an operation
  • 85 percent do not think surgical team members appear to struggle or are unwilling to ask for help
  • questions around coordination suggest that in most instances team members work well together
  • theatre nurses and anaesthetists had the largest response rate, accounting for 36 percent and 21 percent of responses respectively (forty-five percent of respondents have worked in hospitals for 10 years or more)
  • key issues are that some DHBs are not yet doing briefings and debriefings at the start and finish of each theatre list and, for those DHBs that are doing briefings and debriefings, their effectiveness could be improved
  • another key issue is the attitude of some doctors during surgery – 58 percent of respondents do not think all doctors maintain a positive tone throughout operations.

The findings show considerable evidence of widespread engagement in the need for improvement in teamwork and communication but underline the need for the Safe Surgery NZ programme’s continuing focus on this. They also support its focus on improving the use of checklists and implementing briefings and debriefings more widely (some teams already do this very well), to ensure surgical teams have a shared understanding of the requirements for the day’s surgical cases.

The survey will be repeated in 2016–17 in order to measure change and form part of the evaluation of the programme. The Commission will work closely with DHBs to ensure they make the most of the opportunity to contribute to the national picture and inform future work to prevent surgical harm. 

[1] The Health Quality & Safety Commission’s Quality & Safety Markers show the checklist was used in 97 percent of operations from April–June 2015. For more information see http://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/quality-and-safety-markers/qsms-april-june-2015/


Statement from Waikato DHB

Currently 90 per cent of Waikato DHB operating theatres are using the Surgical Safety Checklist. All our theatres undertake checks prior to starting surgery, but the Surgical Safety Checklist is an opportunity to standardise these checks. We are planning a comprehensive Surgical Safety Checklist education programme starting in January which will include all staff involved in patient care in our operating theatres. We will be using visual material and a simulations in an operating theatre so clinical staff have the chance to practice these paperless checklist techniques in a realistic environment. We are starting with Orthopaedics, and other specialties will follow in coming months and the aim is have a paperless surgical checklist in place across all operating theatres in Waikato and Thames hospitals by July 2016.

– Mark Casey, Project Lead, Improving Surgical Teamwork and Communication

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