The operating room (OR) constitutes a complex setting where surgical, anesthesia, and nursing staff must collaborate to ensure a safe and successful patient outcome, often in a time-constrained and high-stress environment. These challenges are complicated by varying levels of personnel experience, case needs, and preoperative preparation, all of which can disrupt case flow, impair communication, and generate inefficiency. Hence, success in the OR mandates an effective and reproducible teamwork-oriented strategy.1
Both the National Academy of Medicine and The Joint Commission have cited lack of teamwork as a principal cause of inefficiency and medical error in the OR, and highlighted improved communication as a major priority in this arena.2 In addition to the potential patient safety benefits, increased OR efficiency could translate into reduced costs, earlier finishes, and/or increased case volume, all increasingly important in the current cost-conscious era.1
Over the last several years, the senior author (S.E.M.) has required the surgical resident in her cases to complete a large, easily-visible whiteboard within the OR that details the patient's history and physical and full operative sequence. Anecdotal satisfaction from OR staff has noticeably improved with this strategy. Theoretically, facilitating preoperative and intraoperative communication via such a whiteboard strategy offers profound benefits, including augmenting case flow by identifying subsequent operative steps to all team members, improving case efficiency by avoiding opening of unnecessary equipment or other potential sources of delay, improving case involvement by making staff more satisfied, and enhancing case preparedness by requiring the assisting resident to outline all the pertinent patient background information and operative steps.
Based on this experience, we performed a pilot innovation study to see if use of an OR whiteboard improves team dynamics along the dimensions of case flow, efficiency, involvement, and preparedness, and whether these metrics are further improved by the addition of a supplies category listing needing equipment.
This pilot study included all cases scheduled for over 1 hour performed by the senior author at our institution from October 2016 to January 2017. Cases were stratified into 1 of 3 interventions: a control group with no whiteboard, a group with a standard whiteboard, and an additional group with a standard whiteboard plus an addendum. Institutional Review Board approval was obtained.
The standard whiteboard measured 3 by 4 feet and consisted of 2 columns. On the left, the full patient history and physical were listed, including age and handedness, presenting symptoms, past medical and surgical history, allergies, pertinent medications, pertinent social history including occupation, as well as relevant physical examination findings and diagnostic studies. On the right, the planned operation and sequence of anticipated operative steps was listed by the first surgical assistant, with highlighting of key steps in the procedure (Fig. 1). The “addendum” whiteboard component consisted of the standard whiteboard as well as an additional supplement listing the equipment and sutures needed during the principal parts of the operation and including the final dressing (Fig. 1). In either scenario, the whiteboard was completed during the preoperative period by the surgical trainee (resident or fellow) assigned to the case, and reviewed by the nursing stuff and senior author prior to the formal surgical timeout and incision.
The primary outcomes of interest were case flow, case efficiency, case involvement, and case preparedness. These were assessed by questionnaires filled out by circulating and scrub nurses at the conclusion of each case. Nonparametric Wilcoxon rank-sum or Kruskal–Wallis tests compared continuous variables with 2 or multiple categories, respectively. Fischer exact test was used to compare categorical variables. Two-sided α=0.05 indicated significance in all tests.
Fifty questionnaires were collected: 15 in the control group, 17 in the standard whiteboard, and 18 in the addendum whiteboard. OR staff in a case with either the standard or addendum whiteboard were significantly more likely to express improvement in case flow (P < 0.0001), case efficiency (P < 0.0001), case involvement (P = 0.0002), and case preparedness (P < 0.0001) when compared with the control group. In addition, operating room staff with the addendum whiteboard were more likely to express improvement in case flow (P = 0.0046), case efficiency (P = 0.0005), case involvement (P = 0.0008), and case preparedness (P = 0.0003) than with the standard whiteboard (Fig. 2).
Teamwork remains the foundation of every successful and safe surgery.3 In each operation, surgeons, anesthesiologists, and nursing staff must continuously interact and collaboratively navigate a variety of challenges together. These challenges include anesthetic demands, management of comorbidities, positioning, technical complexity, and personal safety.4 Furthermore, the OR can be resource-limited, time-constrained, and high-stress. To that effect, improving communication, enhancing efficiency, and optimizing workflow in the OR remain critical areas of investigation, with profound benefits pertaining to patient safety, resource utilization, and staff satisfaction.1,4 In this pilot innovation study, we present how implementation of an OR whiteboard could constitute a reliable, structured, individualized, and low cost strategy that may significantly improve intraoperative team dynamics.
Teams working in higher stress and intensity environments make fewer errors than individuals.5 Open and transparent communication remains critical, as communication errors are the leading cause of sentinel events and mistakes within the OR.5,6 However, discrepancies persist between perceptions of teamwork and openness of communication between surgeons and nursing staff within the OR.6 Our findings are consistent with this theme: in our control group, the self-reported rating of case dynamics by nonsurgical staff was average, at best, ranging from 4 to 6 out of 10.
However, all of these metrics improved significantly with the addition of the whiteboard, and further improved with a supplementary supplies category, increasing to near-perfect. Given that the “important characteristics of a reliable team include the ability to adapt to changes within the work environment, to maintain open and flexible communication, and to anticipate the needs of each member of the team,”7 it is easy to rationalize how displaying concise, high-yield, case-specific information on a large, easily visible whiteboard within the OR can enhance case flow, efficiency, involvement, and preparedness. Since the surgical trainee writes the operative sequence step by step, and the surgical attending then reviews and annotates this description prior to incision, the surgical team is more likely to work in sync while performing technical aspects of the procedure. This can be extended to nonteaching environments as well, with surgical assistants working in conjunction with the attending surgeon. Furthermore, the attending surgeon can highlight potentially challenging areas of “frustration” and key “slow down” portions of the surgery.
In addition, displaying anticipated equipment obviates intraoperative delays where circulators have to obtain supplies. Moreover, since the information is easily and publicly visible, some questions can be answered by looking at the board without having to interrupt the case. Lastly, use of a whiteboard may lead to “flattening” of the traditional OR hierarchy. Fear of speaking up has been well validated as a common cause of patient safety errors in medicine.8 But using a whiteboard could counter some of this hierarchy; for instance, if the surgical team fails to note special items needed during the case, then the surgical team and not the scrub nurses can take ownership. The third author and Director of Peri-Operative Services at our institution has anecdotally relayed that staff feel more empowered to express questions or concerns when the whiteboard is present. In fact, team-oriented transformational leadership strategies have been shown to produce improved team behavior over more traditional, task-focused styles within the OR.9
The efficacy of whiteboards to support collaborative endeavors derives from visibility, expressiveness, and ability to display transition points.10 An OR whiteboard may provide additional benefits. The operating room can be a significant source of waste. Failure to have required items readily available can increase operative time and even jeopardize outcomes, while opening of superfluous items can increase costs unnecessarily. But a detailed and visible list of equipment needed for critical portions and final dressings could potentially decrease operating time, avoid opening of unnecessary supplies, and decrease costs. Another powerful benefit includes education. It is the duty of the surgical trainee to fill out the whiteboard, which usually required about 10 minutes during the preoperative or interoperative period, and does add to the trainee's workload. However, this responsibility mandates preoperative preparation, requires a clinical integration of patient background information with diagnostic workup leading to treatment decisions, and ensures understanding of operative sequence. In addition, after the completion of this study we have since added a whiteboard component specifically addressing postoperative pain control with multidisciplinary surgical and anesthesia input, which could decrease unnecessary opiate use and reduce chance of eventual addiction.
We note this is a pilot study demonstrating that this whiteboard strategy is feasible. Our cases were all elective and limited to a single surgeon, specialty, and institution. We advocate for broader, multispecialty, and multi-institutional studies that can refine or extend our findings before they are accepted. However, successful teamwork remains the cornerstone of any safe surgery. In this study, we demonstrate how implementation of a large, visible whiteboard that displays case-specific information relating to patient preoperative workup, intraoperative steps, and necessary supplies may dramatically improve team dynamics, as measured by staff surveys.
The authors would like to acknowledge the Barnes-Jewish Foundation for funding the whiteboards used in this study. No funding was recieved for the study itself or provided to the authors.
1. Fong AJ, Smith M, Langerman A. Efficiency improvement in the operating room. J Surg Res
2. Baker DP, Day R, Salas E. Teamwork
as an essential component of high-reliability organizations. Health Serv Res
2006; 41 (4 pt 2):1576–1598.
3. Malangoni MA. Assessing operating room efficiency and parallel processing. Ann Surg
4. Porta CR, Foster A, Causey MW, et al. Operating room efficiency improvement after implementation of a postoperative team assessment. J Surg Res
5. Salas E, Almeida SA, Salisbury M, et al. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf
6. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork
among physicians and nurses: teamwork
in the eye of the beholder. J Am Coll Surg
7. Lerner S, Magrane D, Friedman E. Teaching teamwork
in medical education. Mt Sinai J Med
8. Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res
9. Hu YY, Parker SH, Lipsitz SR, et al. Surgeons’ leadership styles and team behavior in the operating room. J Am Coll Surg
10. Xiao Y, Schenkel S, Faraj S, et al. What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med