I’ve struggled to write this post – mostly because I know just how hard it is to work in the operating room, and I know how burdensome it can be to have to implement a new policy or checklist every other week. Oftentimes our policies and procedures read like the person who wrote them has never worked outside of an office, much less actually worked in an OR. When you’re trying to balance all of the paperwork, checklists, charting, setting up, cleaning up, and you’re constantly being pushed for faster turnover times, adding another policy or checklist to the mix seems absurd.

We’re busy. We’re constantly being reminded of our performance metrics – on-time starts, delays, turnover times, etc. And right now, with staffing shortages sucking the wind out of so many of us, we’re drowning under surgical volumes that we don’t have the staff to support.

Our busyness and heavy workload should drive us to assess why we’re doing what we’re doing. Is something redundant? Can we remove it from the list? Is there a way to improve? What evidence do we have to support this change? There’s definitely a time and a place for evaluation of cumbersome policies and procedures, and for making evidence-based changes that improve workflow without increasing risk or causing harm. But, our busyness should never lead us to cut corners, skip steps, or to ignore established guidelines for the sake of speed, convenience, or because we think a particular rule or guideline is stupid.

How do we really do things?

I can’t tell you how many times I’ve heard someone say to a new employee, “Ok, that might be how we’re ‘supposed’ to do it, but let me show you how we really do it.” What’s the real message we’re sending when we say this to someone? Now, I recognize that there’s flexibility in how we do certain things, and the order of operations is generallly up to personal preference, but there are other things that just aren’t up for interpretation. When an attitude or culture exists within an OR that allows, or even prioritizes, personal preference or convenience over following established guidelines designed to ensure patient safety or prevent infection, we’re setting ourselves up for disaster.

This is most evident when an auditor, Joint Commission, or other accrediting agency shows up. The director you haven’t seen in a month is suddenly all over the OR, all of the meds are labeled, instruments are kept clean during the case, the time out is flawless and everyone participates, counts are done correctly…. you get my point. We’re being watched, and everyone’s stressed and on edge to make sure that everything is done correctly.

No one likes being watched. It’s stressful, to say the least. Especially when Joint Commission shows up and everyone from the OR director up to the CNO is hanging around, also watching, stressing us out even more, making sure that we don’t mess up. There’s nothing quite like the feeling of knowing you’re being critically assessed, and your performance could get your whole department in trouble. They say they’re “observing,” but they have a clipboard and they’re taking notes. Feels like a bit more than just observing, if you ask me… it’s terrifying.

But in their observation, do they see “business as usual,” even if it’s mixed with tachycardia and nervousness? Or do they see a perfectly rehearsed ruse displaying all of the proper steps that belies the fact that the day-to-day routine is nothing like what they’re seeing?

Which brings me to my point:

If we can perfectly portray the right way to do things any time that an auditor is watching, why can’t we always do it? Why is it a struggle to get everyone to shut up and stand still for the time out? Why do some nurses and techs refuse to count laps or sponges individually, instead just calling out a “5” or a “10” while holding the whole stack? Why is it so hard to label medications, or to use sterile water to clean instruments on the back table? Generally speaking, how hard is it to wait three minutes for the prep to dry before draping? I could keep going, but my point is this: Everyone knows how to do the right thing when they’re being watched, when an observer is holding them accountable for their behavior.

We have to set a cultural standard for our operating rooms that demands adherence to established guidelines. New staff, whether they’re medical students, surgical techs, nurses, or residents, emulate the behavior that is demonstrated to them. If the experienced team treats the timeout like an afterthought, says it’s ok to not label medication, or documents a count that never actually happened, then the new staff come to see this is acceptable behavior, and they repeat it. And while they’re also taught how things are supposed to be done, what they witness is “how we really do things” and that is what becomes the norm, instead of the correct way.

Following established guidelines only feels like a burden when it’s not the normal way of doing things. If we consistently do things the right way, then it becomes the habit. And the more you do something, the easier it is to do. To the point that an auditor could walk in at any given moment and nothing would change because our OR teams would be committed to following established guidelines and the accepted practice would be to follow them.

So how do you make this happen…for real?

First, let me say, that it’s difficult. There are many moving parts, multiple people, and a multitude of rules to follow. The hierarchical nature of our department doesn’t help, either. Those at the top often act like they’re above the rules. Yes, I’m calling surgeons out here. Not all of them, by any means. I’ve worked with some wonderful surgeons throughout my career. But we’ve all worked with those who act like they’re above the rules, and no one will stand up to them and require them to follow established guidelines. Usually it’s out of fear that they’ll take their business elsewhere and profits will be lost, let’s be honest. But let me be very clear: Surgeons aren’t the only problem. Anyone, surgeon, resident, student, nurse, or scrub tech who thinks that rules don’t apply to them, or feels like they don’t have to follow a rule if they think it’s stupid, is part of the problem.

In the time that I spent in management, I did alot of things wrong. By observing other leaders (good and bad) and with reflection and more experience, I’ve realized where my priorities should have been and how my leadership could have improved my own department in this area. Here are a few of my observations:

OR Leaders

• Be present. I can’t stress this enough. Don’t get so bogged down in meetings and locked behind your office door that your employees don’t even know what you look like. Show up more than just the week that Joint Commission is in the building, too. Show your staff that they’re important 365 days a year, not just the week of your survey. I know there’s alot pulling on your time, but prioritize being in the OR as much as you can.
• Hold everyone accountable. Title or position are irrelevant. When something isn’t done correctly, don’t ignore it, correct it.
• Be consistent. If something is important enough to correct with one person, it’s important enough to correct with someone else.
• Support your staff and empower them to speak up. We take alot of crap from surgeons sometimes when we try to do everything correctly. When leadership bows to the surgeon instead of supporting the staff who tried to do things correctly, it sends the message that staff are unimportant and the rules can be broken when it’s convenient.

While I think that the tone of the OR is set by OR leadership, they don’t bear this burden alone.

We are all adults, and all responsible for how we act. When we know the right thing to do, and then choose to ignore it, or choose to take an easier route, we’re risking our patient’s safety, and we’re risking our own licenses and careers. The idea that “it won’t happen to me” is a delusion we let ourselves believe. One day, it could be you, or it could be your patient. The rules and established guidelines exist to help prevent those errors. They’re not a burden, they’re a safety net to support you and to protect your patients.

OR Staff

• Educate yourself. Learn the “why” behind the guidelines. AORN is a great resource, so is your OR educator, if you happen to have one. Ask questions, and be open to learning new things.
• Do what you know is right. It’s sad that we always have to say, “Grow a backbone, because you’re going to need it.” But it’s true. The surgeon who won’t stop sewing when there’s an incorrect count, the RNFA who refuses to wait for the prep to dry before draping, or the staff who won’t stop setting up during the timeout – they have to be called out, and it’s not fun to have to be the person to do it.
• You’re not alone. Escalate issues to leadership, and ask for support. Get the help that you need, so that you’re not the only one demanding compliance. If you don’t find support from your OR leadership, maybe it’s time to go somewhere else.
• Recognize that insisting on following the established guidelines won’t make you the most popular person, it might even get you thrown out of a room or two. Your patient’s safety and your license are more important than public opinion.

Actions speak louder than words

Michelle Malkin said, “What you permit, you promote. What you allow, you encourage. What you condone, you own. What you tolerate, you deserve.” (source)

What we allow sets the tone for the culture within our ORs. Our actions truly say alot more about our priorities than our words do. So foster an atmosphere that prioritizes everyday compliance. It’s difficult to fight against the status quo, and alot of work to change an engrained set of bad habits. But the benefits to our patients and to our department are worth the challenge.

Until next time,

Melanie

Tune In!

Want to learn more about the importance of OR leadership visibility? Tune in to the First Case interview Present & Accounted For: The Importance of Visible OR Leadership

Read More:

1. You Must Make Yourself A Priority
2. A Proper Time Out is Always Best Practice
3. The Impartiality of the Operating Room Table