In Part 2 of their research feature, Profs. Yufei Huang, Emmanouil Avgerinos and Ioannis Fragkos drill into the special surgical team mix that saves more time, more lives.  

18 minutes, 37 seconds: Surgical Teams by Tom Gamble. Return to Part 1 of this article

Vertical familiarity

Within the operating room, surgeons tend to enjoy more prestige than other physicians (such as anaesthesiologists) and have the highest status. Not surprising given the 11-15 years of study it takes, not to mention practice. This awe-inspiring intellectual and operational baggage naturally lends itself to creating a granted hierarchy within the surgical team. And this, combined with the high-stake nature of cardiac surgeries, can make subordinate members such as nurses or perfusionists unwilling to take responsibility.

Typically, then, such hierarchical relationships can at times lead to a lower capacity to share information, leading to situations such as nurses hesitating to speak up openly to surgeons even if they suspect that something might be wrong. Little impact then, if members of a surgical team become familiar through working together on regular operations.

Because although individual members of the team from top to bottom may make decisions relevant to their specific task, the vertical nature of a cardiac team with its barriers and status order means that the surgeon calls the cards. Moreover, past research has shown that in high-pressure environments, improvements and important decisions tend to be hierarchical and not democratic. According to an interviewed surgeon, ‘If you do a democracy, patients will suffer. You don’t take a vote on what to do with the patient.’

A check up on the horizontal

But what about people who get to work with each other and who are on the same level – in other words, in a horizontal-type familiarity? Well, while relationships between surgeons and non-surgeons can be quite formal and hierarchical, research has found that relationships among people of the same status or hierarchy are likely to be more casual.

This means that surgeons relate better and more openly to other surgeons or assistant surgeons, while the sub-teams consisting of doctors, experts and nurses also manage to gain greater cohesion through familiarity too. In both cases, stronger links, more open communication, and shared motivation develops. The bottom line is that while frequency of interactions between individuals could be identical, their hierarchical relationship influences the extent to which such interactions result in higher productivity.

Putting surgeons and assistant-surgeons together gives a large boost to productivity. Putting scrub-nurses, anaesthesiologists and perfusionists together likewise gives a large boost. A lesser degree of performance is gained when you expect the two to rub shoulders and create bonds.

Familiarity and failure

Failures – or non-successes – have already been mentioned as a way to lead to the adoption of new policies and strategies in teams – learning from our errors, as the old adage goes. But researchers Yufei Huang, Emmanouil Avgerinos and Ioannis Fragkos decided to go further and apply that to the particular context of hospital teams and cardiac surgery teams in particular.

Moreover, failure in the context of a surgical operation is not simply a matter of the unreached financial or deliverable objectives that teams in other sectors might encounter. Here, the outcome is graver – that of the death of a patient.  In fact, a frequently used measurement of failure in the hospital sector. 

But in order to measure the impact of failure, it’s also necessary to look at the opposite – the impact of success. While actually saving a life means satisfaction, success also tends to make people feel that they already have the necessary knowledge to complete similar tasks in the future, thereby limiting their search for additional information. Rather than change, team members are likely to refine existing approaches.

In this sense, failure is positive. First, the death of a patient can change the way in which team members communicate and process the rights and wrongs of the experience. Information-seeking leads to understanding and leads to increasing knowledge and learning. In addition, whereas technical expertise in surgical teams can be measured, non-technical expertise – soft skills such as interpersonal, insight, foresight, emotional intelligence – often the cause for communication breakdowns and errors, is harder to grasp.

Sharing and discussing non-success leads to trust-building, improved familiarity and openness, ultimately giving team members the ability to better appreciate who is truly good at what and not who could be good at what. And ultimately bringing greater motivation and effort to reach a success – and saving a life – next time round.  

18 minutes, 37 seconds

Altogether, the results of Huang, Avgerinos and Fragkos’s research seem to point towards a whole set of instruments with which to improve team performance in the operating theatre. Managers in charge of composing teams might take note that assigning members of the same hierarchy with high levels of past shared experiences seems to be more impactful than assigning members from different hierarchy levels that share common experiences. Similarly, familiarity among high-status surgeons and assistant-surgeons seems to be more impactful than familiarity among subordinate members.

The stats gleaned from research among 6,206 cardiac surgeries from a private hospital in Europe, give surgeon-to-surgeon interaction generating 18.37 minutes of saved time per operation. Little as this may seem, when added up it gives 21.84 hours a month and a staggering 53.11 operations per year.

When applied to non-surgeon familiarity, the figure reaches a lesser time reduction per operation of 0.51 minutes: 0.61 hours per month and 1.48 additional operations per year. In addition, composing teams of members that have shared experience of failure (patient death) in the past, seems to be more efficient than building teams with individuals that have only met with success: 6.50 minutes per operation are saved, giving 7.73 hours per months and a princely 18.8 additional operations a year from the saved time. 

Very practically, this means that hospital managers could assign assistant surgeons using their familiarity with the lead surgeon – and then select those with the highest number of past failures in the case of two assistant surgeons who are equally familiar with the surgeon.

Experience of failure can also be applied when assigning other members to the team: anaesthesiologists, perfusionists and nurses. As for fast turnover and newly hired staff, a rotating schedule can be set up so that the newly hired individuals will build familiarity and failure/success experience as a future team mix criterion. Could such an approach be applied to other high-stress, high-stakes teams – fire fighters, aircrews, ships’ crews or accident investigators?  

The researchers say yes, with caution – for more research has to carried out to prove it. However, one thing is almost sure: the new heroes of our times may need such methods if governments still fail to hear the cry of healthcare systems which are themselves striving to return to normal health after thirty years of lean diet.

Return to Part 1 of this article

Useful links:

• View Prof-Dr Yufei Huang’s academic profile
• Link up with Yufei Huang on LinkedIn
• Discover Trinity Business School, Trinity College Dublin
• Read a related article: Does laughter boost team performance? It depends…