In our work across the country, we are witnessing health care systems in different stages of the Covid-19 pandemic that are trying to address the backlog of elective or nonurgent surgical procedures that were postponed during the initial wave of the pandemic. To safely address it and prepare for future needs to adapt care and priorities based on the ongoing pandemic, systems need to recognize that basic human factors, exacerbated by Covid-19, can threaten the safety of patients and staff and then develop strategies to mitigate them. They include the following:
- Fatigue. During the pandemic, health care systems redeployed many providers for months to treat Covid-19 patients, and they witnessed extraordinary levels of morbidity and mortality. These providers may be physically and emotionally exhausted.
- Lack of routine practice. Most surgeons have not practiced at their normal rates (or at all) for several months. As a result, many haven’t had the normal daily or weekly engagement with their technique or their team and need practice to keep up their technical skills; this is most important for surgeons who perform complex procedures. Teams also need to re-establish effective communication patterns.
- Distraction. Health care systems are creating new procedures and policies because of Covid-19, and staff have not had time to get accustomed and incorporate them into their practices.
- Overload. Ramping up operating room capacity (some systems are aiming to reach 150%) means surgeries will occur off-peak and at unusual hours. It may also mean that staff are being asked to participate in new or multiple surgical teams. These conditions can make staff more vulnerable to making mistakes or forgetting to take critical steps.
- Stress. Some providers suffered emotional stress from caring for a deluge of Covid-19 patients, falling ill themselves, or suffering the illness or death of family or friends.
Fortunately, health care systems can identify these threats and mitigate them in order to ensure that surgical teams tackle the backlog of procedures in a failure-free fashion. The following steps, based on reliability science, provide a foundation for doing so:
1. Make risks visible. One of the greatest challenges in safety is not being able to physically see the possible risk prior to a problem arising. The individual surgical team needs to know how it is performing in the moment. In addition to the ongoing monitoring of the patient during the procedure, the surgical team should ask patients questions prior to the procedure to address their physical and mental health and plan for the pre- and post-op care. They cannot assume a patient’s circumstances from six months ago are the same now; patients may be hesitant to disclose changes to their ability to care for themselves or obtain the help they need after surgery.
National medical specialty societies can help make these additional risks visible by redoubling their efforts to get health care systems and physicians to track the high-level outcome measures specific to individual specialties daily, weekly, and monthly. Comparing their current performance to their past performance and that of similar systems in their area will allow them to identify whether safety-related risks are increasing.
Health care system executives should play a significant role in identifying risks and protecting both their workforces and their patients. They must create a dashboard that tracks safety and quality priorities, including adverse events and mortality; make sure it is updated daily; and look at it every day as an executive team. Executives should be able to identify trends in outcomes (positive or negative), be aware of key trigger points, and change course or stop the system if outcomes deteriorate.
2. Honor existing procedures and protocols and adopt new ones as needed. Surgical safety checklists and similar tools must be used with every surgery. We know that these tools help control for human factors and improve surgical outcomes. With increased time pressures there is considerable temptation to move through safety checks quickly and superficially, avoid them altogether, or have them performed by a single person rather than a team. All health care providers and administrators must resist the temptation to cut corners and skip established safety steps as they tackle the backlog of surgeries.
Due to Covid-19, health systems created new precautions to keep patients and staff safe. Prior to turning the surgical system back on at full or increased capacity, executives and care providers at all levels (e.g., frontline leaders and department heads) should ensure that these processes and procedures remain in place. Leaders and surgical care providers should continue to review these new or adapted processes as more is learned about this disease.
3. Double down on efforts that address psychological safety and the added stress. Health care systems should ensure that all supervisors are trained to accurately identify warning signs of psychological stress and make counseling services available to all of their clinical staffs. Some health systems have gone further and have created peer-to-peer “buddy” systems to provide extra support. Others have created mechanisms for clinicians to express a need for a break or further time for preparation without negative consequences.
Leaders of health care systems should ensure that their staffs have a way to raise a concern about an individual provider or provider team, call out a possible safety failure, and, if necessary, “stop the line.” They should make it clear that they not only want them feel safe to do this but also that it is their job to do so and they will be recognized for their vigilance.
4. Be transparent and account for the current environment. Health care systems should share their safety plans and outcome data publicly. Let your patients and their families know that your organization is safe, that you recognize the current environment, and that you are taking every precaution necessary to ensure that patients and family members remain safe with respect to both Covid-19 and the outcome they are expecting from their surgery.
This requires continuous tracking of the prevalence of Covid-19 in the local community (i.e., the positivity rate for the people who have been tested). Health care systems can use the data the states are tracking at the county or city/town level, the rolling weekly average case rate in the communities that the health system serves, and the inpatient case burden (i.e., the number of people currently hospitalized for Covid-19 as compared to overall capacity) both in their own system and in others in their area. Maintaining clear decision trees for when to shut down elective procedural care again and keeping patients and families informed of this possibility is vital to maintaining public confidence.
As health systems continue to adapt to Covid-19 and address the stress it is imposing, their leaders, along with their workforces, must intensify their focus on safety and quality. It requires a strong understanding of human factors — those always present and those exacerbated or created by the pandemic. And it requires implementing processes and procedures that make systems stronger and safer amid new and rapidly changing circumstances. Reopening safely will require attention to reliability science, ensuring physical and psychological safety of the workforce, and continuous monitoring of the state of the local Covid-19 pandemic. Only then will patients, their families, and providers feel safe to return.
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