An Analysis of Perioperative Communication Patterns in a Large Military Medical Center

BACKGROUND: Medical errors in hospitals are a critical problem, resulting in grave consequences including patient injury and premature mortality. Approximately 200,000 to 400,000 people die each year from preventable medical errors, making them the third leading cause of death in the United States. Adverse events and medical errors frequently occur in the operating room (OR), accounting for two-thirds of all errors. Communication errors are the most frequent root-cause of adverse events and serious injury to surgical patients worldwide. The Joint Commission conservatively estimated that communication errors cause 70% of reported sentinel events. The OR contains a unique and complex culture of multidisciplinary clinicians with different levels of education, experience, and authority. These differences result in authority gradients and hierarchical power disparities among clinicians that contribute to errors and patient harm. Previous researchers have not considered the many complex social factors that influence surgical communication including authority gradients, culture, hierarchy, and team structure. We will address this knowledge gap and advance the understanding of OR communication by building upon the TSNRP-funded preliminary work that we conducted in a small military outpatient surgery center.
SPECIFIC AIMS: This study will implement a novel approach, social network analysis (SNA), to map the structure and consequences of interpersonal relations. Our proposed network-centric study will characterize the OR communication network at the individual, interpersonal, and group levels in a large military medical center.

The specific aims are to:
Aim 1: Characterize the network factors that shape clinician communication in the OR setting
Q1: What is the association between clinician relationships (e.g., interaction, close working relationships, socialization, advice, and speaking-up/voice) and clinician communication effectiveness?
Q2: What are the social network analysis indicators that influence communication effectiveness (e.g., degree, betweenness, geodesic distance, homophily, density, and centralization)?
Aim 2: Identify how team structure shapes communication effectiveness
Q1: What is the relationship between communication effectiveness and surgical team consistency, surgical team size, and clinician mix (students/residents)?
DESIGN: We will use an exploratory, prospective, cross-sectional, network-centric approach. This design will allow us to pinpoint communication strengths and weaknesses to clearly reveal the underlying factors that shape OR clinician communication in this high-risk setting.

METHODS: Targeting an 80% response rate, will use total population sampling to recruit all clinicians (active duty or civilian nurses, surgeons, anesthetists, surgical technicians, students, residents) who directly provide surgical care in the OR at Womack Army Medical Center. We will administer an electronic sociometric survey to complete teams at the end of the surgical day. From the survey questions, we will develop six relational networks (interaction, close working relationship, socialization, advice-seeking, advice-giving, speaking up/voice) and three models that represent communication effectiveness ratings for each participant and team. We will use social network analysis, bivariate statistics, multiple linear regression, and quadratic assignment
procedures to characterize the network factors that shape clinician communication in the OR setting. To identify how team structure shapes communication effectiveness we will use bivariate statistics and multivariate modeling.

RELEVANCE TO MILITARY NURSING: Military leaders are committed to a continuous cycle of process improvement and a culture of safety to transform the military health system (MHS) into a high-reliability organization (HRO). The OR is a key driver for hospital's fiscal health, a critical factor as the MHS transitions into the Defense Health Agency. Effective communication among OR personnel is a potent enabler to improved surgical outcomes, decreased medical errors, and the overall refinement of the surgical teams. Optimizing communication at the organizational and microsystem levels will improve health care quality and safety, decrease adverse events, improve readiness, increase patient satisfaction and is a crucial step to becoming an HRO. Moreover, with an operation's tempo requiring the military to deploy small, agile, surgical teams, effective interpersonal communication among these teams is vital to providing life-saving care on the future battlefield.