Shannon Phillips, MD: So Rob, we are going to be bold and courageous in 2018, and really take on bringing high reliability to procedures we do around the system. The OR is your space, but ED, bedside care, and the idea being that we can bring predictability to our caregivers, so that they can bring everything about them as health care professionals to the care of that individual patient in the moment. Yes, it comes off of peer reviewed literature. It comes from the World Health Organization safe surgery checklist, but the concept that we could have guided predictable conversations across the care we're giving around a procedure so that we don't miss anything. We leave open the opportunities for people to speak up and clarify.

I'd love to have you introduce or talk a little bit about what those pieces are. As a patient comes in, they've seen you in the outpatient setting, and we're ready to have a procedure. That first piece might be called a time out. That first piece might be called a sign- in, or a pre-operative, or pre-procedural huddle. Do you want to talk a little bit about what that is and why it might matter?

Rob Ferguson, MD: Sure, what I like about this concept of having something consistent is that, that way someone like me just doesn't by dumb luck fall upon the things that would make a procedure go the way we want it to go. To actually then have consistently a way to have, like you called it a sign-in, an opportunity to create that teaming moment where the team is able to introduce themselves to one another, especially if they've never worked with each other before. Talk about what it is, what is going to be happening, and what are the expectations of the members of the team. What are things that are needed for the day. And just to be able to verify is the instrumentation there, are the implants there, whatever's needed before that patient then gets put to sleep or anesthetized, or the procedure starts itself.

Then the next step of, again, our more traditional time-out, of being able to verify, "Okay, we've got everything prepared and draped off. We have this small little segment of the patient that we can see." Are we able to verify that this is truly where we're supposed to be operating the procedure? Have the antibiotics been given? Whatever's appropriate for that procedure. Then at the end to verify, is there anything we're missing? During the procedure, we gave specimens, are those labeled correctly? What was the one classification, things that will be necessary in the sign-out as that patient goes to recovery room, or goes wherever else the next level of care will be for that patient. I think to have specifically deliberate phases would be helpful.

Shannon Phillips, MD: So this is really the opportunity to build into what we already do today, if you will, a pause, a chance for that team to connect on what they're doing in the moment.

Rob Ferguson, MD: And most proceduralists do something like that.

Shannon Phillips, MD: Okay.

Rob Ferguson, MD: They may do it to various degrees, or various efficacy. But I think having a structure will help make that more consistent.

Shannon Phillips, MD: That's a great point. If you and a colleague who does the same sorts of these procedures, in the same area, do this differently. To your point, everybody has something, but it's a little different. How's that for the caregivers that you're teaming with?

Rob Ferguson, MD: Yeah, it's an infamous statement that a proceduralist, a surgeon, whatever may be, can be heard to say, "I've been doing the same thing for the last 10 years every day." And that may be true to varying degrees, it may be true. But every other physician isn't doing the same thing. While it may be that a vascular surgeon is not doing the same thing as a neurosurgeon day in and day out, there are steps that we can have more consistent that doesn't matter who we're working with, we're all used to having those same steps, those same procedures.

Shannon Phillips, MD: I think that predictability is role clarity for people. I am to come to a sign-in, or a time- out, or a sign-out with this information. This is my space, this is how I can contribute, regardless of the person at the helm. I have used an analogy for a number of years, and I'll pick it to surgical, since I'm with you. You could, say there were 10 of you, 10 people doing plastics and reconstructive surgery, and for the same case, you did your dressings and janes this way, and every one of you had a nuance that was different. What you liked your dressing made of. How you tucked your drains and your dressing and so forth. Then the patient, not only does the OR team have to remember and stock all of those things, the patient then goes to the floor, and they have to remember, "Is that Dr. Ferguson's patient? Or Dr. Philip's patient?" Because what they need and how they handle it is different. Some consistency in that when there is no need to be special and different, may be reducing unnecessary variation.

Rob Ferguson, MD: So you're suggesting everyone do it the way that I do it?

Shannon Phillips, MD: Right, that's exactly what I was saying.

Rob Ferguson, MD: What every physician is going to think, okay, the way I do it is the way to do it.

Shannon Phillips, MD: Right.

Rob Ferguson, MD: I still think there's room for a level of autonomy in making specific decisions and the reasons for it. And yes, there are things that we, little-by-little are chipping away at that could be dogma, or not really understand why we do it. It's just how we grew up surgically, doing certain things, but there's not really evidence base for that. Yes, there are many things chipping away at that.

I do think something that across the board, that if we step back and look at it with regards to creating a high reliability organization would be to have specific steps in place to allow us to define things that we may already be doing, such as communicating with the team, what is needed for that patient, having a sign-in. A time-out where we pause and make sure that everything that we talked about in that sign-in has been initiated, and that the other things that we need are going to be there and ready for us so that the procedure can go well, as well as possible. Then the sign-out, a debriefing. Make sure that we really did have everything, and if there's something that needs to be changed for next time, we make that better. And make sure that the next phase of care is prepared to received that patient appropriately.

I think that is something that is worth looking at and making more consistent. I'll be honest, there are going to be several of us physicians, who would see that as a potential additional change, an additional imposition, additional mandate that is telling me how to do things, when really, for me personally at least, stepping back and looking at it, these are things that I already want. These are things that I'm already trying to do, and I see it as a help to create a framework in which I can define what those steps are and do that more consistently. If the nurses in text that I work with are used to doing that consistently with other physicians, they'll help me stay on my A-game as well.

Shannon Phillips, MD: Okay, so I'm hearing you say that keep an open mind.

Rob Ferguson, MD: Mm-hmm (affirmative).

Shannon Phillips, MD: Engage in what we're trying to do here. Again, be bold and courageous in the journey towards high reliability.

Rob Ferguson, MD: Wow, Shannon, you're making me sounds smart.

Shannon Phillips, MD: Well, sort of right?

Rob Ferguson, MD: Or at least…

Shannon Phillips, MD: Maybe you are. No, but keep an open mind, dig in, and understand how this might actually raise everybody's game in caring for your patients every day. That consistency brings people an opportunity to bring everything you need forward in their role. That can likely only make us better. Fair enough?

Rob Ferguson, MD: Yes.