Episode Nine: Creating an Extraordinary Patient Experience in the Operating Room

Shannon Phillips, MD: So Rob, thanks for joining me today. Tell me a little bit about yourself so everybody else knows who you are.

Rob Ferguson, MD: I am a plastic and reconstructive surgeon working at Intermountain Medical Center, and my area of expertise is in microvascular reconstruction, specifically in oncologic reconstruction as well as trauma and reconstruction.

Shannon Phillips, MD: That sounds complicated as a pediatrician. We met when I joined Intermountain, what was six, eight months ago, and I remember it distinctly because you shared a really special story with me that I think contributes to thinking about and raising the bar in the experience of our caregivers, our patients, and safety. Would you mind telling it again?

Rob Ferguson, MD: I hope I'm getting the right story.

Shannon Phillips, MD: Well, I'm counting on that.

Rob Ferguson, MD: So we had a patient who required a surgery to take out a cancer that was going to require a staged reconstruction, and of course cancer trauma, no one ever gets ill at a convenient time, that they put it on their calendar and block out that time for it. This particular individual was a little bit distraught because they had planned a family reunion that was out of state and was very much looking forward to this. It had been a couple years in the making, and so as we went through the plans, I had the goal of helping him still be able to get there despite some of the specific things that were going to be needed in his treatment plan. The day that we went to surgery was not my typical operating room day, and so as a result the procedure was scheduled in a different core, so a different area of the operating room that is typically neurosurgery and orthopedic surgery, and so this was a team that I hadn't worked with frequently. As we brought the patient in and had our time out to go over what we were going to be doing that day, I decided to do something different.

I added in there that this is Mr. Smith, went over the procedure, verified the site, et cetera, and I said, "And he has a family reunion that he's been looking forward to that he's really hoping to be able to make." The scrub tech piped up and she said, "Well, let's get him there," and there was this change in the feel of the room where suddenly it wasn't just a routine thing. You could tell that everyone felt like we're taking care of someone from our community, and we have a goal to make sure that we're not just treating the cancer, but we're treating this patient, and it was a really neat day in the operating room.

Shannon Phillips, MD: So even to hear you now and people can't see you, your face lights up. It touched you. What about the room, what about that day in the OR was different?

Rob Ferguson, MD: I think that as a physician, I'm able to see the patient before the procedure, during the procedure, in the hospital, and then back in clinics, so I can see what the outcome is and what the result is, so for many of the people that work in the operating room, they don't get to see those faces. There can be the risk of developing into more of an assembly line or a mechanic mentality, because all you see is this small little segment, and so what I found in that scenario was bringing the reality of the fact, this is a grandfather. This is someone who works at the local grocery store, that we're working on a person from our community. It created a bigger picture for the team, and they acted as if they were playing a large role in a larger picture, and it meant more.

Shannon Phillips, MD: That human connection, right? It wasn't just a person asleep in the room, but a sense of purpose to what people were doing. How did that change how your case went in terms of the intricacies, the controls? Did you notice anything different about the case?

Rob Ferguson, MD: There was definitely a tangible difference in the room with regards to the purpose, with regards to the big picture of what we were doing that day, and the tech who was helping me, as I said, I hadn't worked with her much before, so I don't know if she always had this level of detail, but she would ask questions during the procedure and point things out to me. Things really just went smoothly.

Shannon Phillips, MD: We ask people to use clarifying questions as part of our zero harm strategy, right? That may or may not feel comfortable in the moment you're in the OR, things are busy, the surgeon's very focused on what they're doing. That sense of community—it sounds like that got built and gives people permission maybe to ask questions, to participate differently than they might have otherwise. What do you think?

Rob Ferguson, MD: I definitely think it does, and I think that when someone has that larger picture in mind where they feel like a genuine member of a team, a caregiver taking care of one of our patients, I think that there's a bit more job satisfaction there as well. When you see that you really are making a difference in someone's life, and there are some roles that we play in taking care of patients where that's more of a challenge to do. That was an example to me how I can create that environment for the other caregivers that I'm teaming with. In addition, when they have that sense of ownership or sense of responsibility, then that caregiver is likely to be more mindful about what they're doing and feel safe in that environment. A small little thing that not only introduce the patient to that team of caregivers, but it also created a sense of safety or an invitation to speak up if there's a need to or to point something out that I'm not aware of or to ask a question during the procedure.

Shannon Phillips, MD: Wow, so you said we can deal with caregiver engagement and resiliency, we can be top of mind for safety, and make a human connection. That sounds like a pretty good deal to me. I always use the airline industry, so forgive me. Everyone's going to be booing about airlines and hospitals and healthcare. There's nothing, but if you'll forgive me the analogy, I'm going to get on a plane tomorrow, and the pilot and the first officer, good chance they're going to meet as they run up to the jet bridge together, and likewise the flight attendants may know each other and may not, and likely don't know the pilot and first officer. They to me embody teaming, so they come with roles in the moment that they're to take on. They don't know each other, and you just talked about walking into a core to do a case with people that you don't work with every day, and in that moment as they badge in and walk down the jet way, they find a way to connect with each other. The combination of teaming, of finding a moment to be together and role clarity about what they're here to do gets airplanes up and down every day, thousands and thousands across the country alone. Would you make the connection, or you can tell me no way.

Rob Ferguson, MD: Yeah, I would what you just said right there actually, I think it merits clarifying. We're using this term teaming, and so many times when we talk about a team or teamwork, it does create in our minds a sense of a team that day in and day out is doing the same thing. You're with the same people every time. You think of a football team, you think of a rugby team, and that's not really the environment, which in healthcare we always have. You are putting in a central line in the ICU, and you may be working with a nurse or a tech that you haven't had a chance to work with before. Or, like in my scenario, it's not your typical operating day and so you're in another part of the operating room with another team. The idea of teaming that you're talking about is having the ability to create a group to almost instantaneously be able to work together to establish a big picture, the goal, to step up, to play their role, have that communication, rather than have a team that that gets established over years. We can have both scenarios, actually, in taking care of patients, but I like how you're using the term teaming.

Shannon Phillips, MD: And if I reflect on the story you shared, that can be the purpose or the centering for people. To jump away from the airline analogy, in that moment, you're there today at that hour to take care of this person, and so that rallying point doesn't become, "Hey, you lived in New York and I did too when I was 25," but it's, “We're here to take care of Mr. Smith, and nothing will matter more to him than being at his family reunion,” and that becomes that way we build a relationship in the moment, and it opens the door for people to feel comfortable asking questions, speaking up, taking it to the next level as you described.

Rob Ferguson, MD: Sometimes, and we can have a whole different conversation about why this happens, but it seems sometimes there's the temptation when you walk into the room and you do say something about a patient before they come in, it could end up being a disparaging comment. It could be a discussion with regards to, "Oh my gosh, they are so unrealistic in their expectation," or "I can't believe that they showed up with their fake eyelashes on when I specifically said we're going to be working on their eyelids and don't have that." That ends up actually potentially doing the opposite of what we want to do, and if I stop to think about it, me as the physician who's going to be taking care of this patient throughout this entire care cycle, what do I want to have as the attitude around that patient in my operating room, and if I share something that is negative about that patient, whether I realize that or not, I don't think that's going to create an environment in which people are going to want to pay extra attention or feel a personal connection. Kind of the opposite.

Shannon Phillips, MD: Right. Captain of the ship, right? We are teaming, we're all a team, and absolutely as the physician you have the opportunity to set the tone and the connection we make with patients, so that's a great example. You used, you said sort of on the fly, the opportunity to share something about a patient. If you step back now, it's been several months since we met, and that story wasn't immediate to the time, how's it changed what you do? How's it made the care you deliver different?

Rob Ferguson, MD: In all honesty, I think I am still in evolution on how to implement this. I do try to be sure that if I'm in a room where I haven't worked with that anesthesiologist before, I start off my introducing myself and make sure everyone in the room knows each other. Then talk about something about the patient, something that's a little bit unique, and if there is something with regards to their health history that's unique then I'll also bring that up. Then the team is able to share some thoughts that they may have or considerations that I may not have taken into account yet, and so what's in evolution I guess is trying to find within my pattern of doing things to consistently have all those elements there regardless of who the members of the team are going to be in the room where I'm working.

Shannon Phillips, MD: So you're finding your way. We're big on, at Intermountain, high reliability rates, so bringing consistency to what we do every day, and I think there's opportunity in that because it allows people to know what's expected of them and be there consistently, and it also, because it's consistent, gives you space to I'll say improvise or think of things that others might not have, because it's predictable and you might be able to see things that you wouldn't have otherwise. So for example, in ORs around the world, something like the safe surgical checklist is used to bring I guess that consistency, that predictability to the space and to the work that people are doing. In light of the conversation we've had, how do you think something like that, a guide to a conversation, some predictability that's brought by the checklist, do you think that has a place in what we're doing today?

Rob Ferguson, MD: I do. I think it has a place. What I talk about with other physicians is that we may have a time out, we may have checklist that we go through, however if it is not done in a mindful way, then it is meaningless in my opinion. If the physician or any other member of the team doesn't really give it the attention that it deserves, then they're not mindful to the process, then that spreads to the rest of the team, and you don't have a scenario in which it's accomplishing its purpose to make sure that that patient is safe that we have in a high reliability scenario.

Shannon Phillips, MD: Do you think there'll be people who say that using something like a checklist is too regimented? It doesn't allow for flexibility, I guess, that that's too rigid? How would you respond to that and tying that into your story about the patient and sharing something real? Can you comment on that?

Rob Ferguson, MD: Well, I do think that there is the risk of falling into, I guess to use the term, a check the box mentality when you have a checklist. That's why I really would rely upon the members of that team keeping in mind why we do that to begin with rather than seeing it as something that is a barrier I have to get through to be able to get the scalpel in my hand or to start the cardiac catheterization, whatever the procedure may be, that it really is a moment to stop and clarify to make sure everyone is on board. I would think that if there is a structure in place that—not just right before you make that incision or access that vessel—if you have a way to make sure that everything is in place so that that procedure is going to go smoothly, and we've taken into consideration what may happen in that specific procedure with that specific so that things are ready. Blood may be ready, specific instrumentation may be ready, the pathology is labeled appropriately. There are multiple parts that even though we have a checklist per se, that is still going to be unique for every individual. I do think that that structure isn't so much rigid if we look at it as an opportunity to make sure that we are catering to that specific patient and what we are doing in that moment for that patient.

Shannon Phillips, MD: So I imagine, going back to your story, that it would be pretty amazing if in the sign out at the end of a case, we shared not only the expectations for drains and pain management, that we shared that Mr. Smith wants desperately to go to his family's reunion, and we're getting him there, and so as people hand off, whether the patient's going home or to the floor, or just out to the PACU after a surgery, that we actually share that. How do you think of a patient would feel if the nurse accepting them said, "You did really well, and you're going to get to your family reunion?"

Rob Ferguson, MD: You know, it's funny that you should say that, because I completely forgot about this aspect of it, that I was there. No, I was there in the recovery room when they were giving the sign out, and the nurse actually did say, "He's got this family reunion that we're trying to get him to," and the nurse receiving it kind of did one of the "Aw," responses, and as they were talking with the patient and recovering, they actually used that as something to taunt them about and make sure that they really were aware of what was going on, following commands, asking about their pain, but then began to talk about this family reunion, so the patient started talking about what their plans were and what they were going to do, and granted he repeated it three times because he's still recovering from anesthesia, but now that you say that, that kind of prompted that memory with me that I saw that in the handoff.

Shannon Phillips, MD: Right, and so we can use handoffs to be highly reliable about the things, the mechanistic stuff of a case and the specimens going out in some of that, and those intangibles, the things that Rob ably knit it all together. I think it’s really important. I think we're talking about culture, right? We're talking about you've done surgery for years now, and our colleagues across the system do what they do every day, and they do it exceptionally well. What should we do to be better at this? We've poked at a lot of things here. I don't think we've asked people to get up and do something totally different tomorrow, but you're talking about small things that make a difference and that make a difference for the patient, and I think you've made a good argument. Also, make it pretty cool for all of us as caregivers.

Rob Ferguson, MD: Well, what I said earlier too that for me this is a little bit in evolution still because the fact that there are principles that I understand, and I think it would be helpful then to have a structure or a routine that is consistent so that rather than just by dumb luck striking upon a technique that helped bring this team around this patient, that we can do it in a more consistent fashion, that we have a structure to that, and also that the expectation would be there that even though I haven't worked with this tech or this nurse or this anesthesiologist before, they're used to seeing this in their other operating rooms as well. For me, the consistency that I'd like to see is tapping into the expertise, the genius, the experience that every member of that team has, and the pieces of knowledge that they may have gleaned from the patient that I may have missed, and bring that to the table as we have a discussion on what we're going to be doing that day or in the midst of doing the procedure.

Shannon Phillips, MD: All right. Before I let you go, what does an extraordinary experience of care mean to you?

Rob Ferguson, MD: I may have a little different of a view of that, because of course we think about the patient having that extraordinary experience, so of paramount importance is that the patient gets excellent care consistently, and they know it. They know that the people around them care about them. They've been communicated with, and they know what they should expect and what the team around them is going to be doing to help them continue on this road to recovery. You can have someone that gets the best care, and of no one communicates with them, they have no idea what just happened to them. For me, the experience of extraordinary care with a patient is that not only do they get the excellent care, but they feel that the team members around them actually cared about them, and they've made a connection.

The other aspect of extraordinary care for me is that I create a moment, an environment in which the other caregivers also made that connection, that they saw the bigger picture instead of the one moment, mechanics of what we were doing, but the bigger picture of how they affected that patient, because I want them to, just like me, go home that day and think on it and say to themselves, "Yeah, that's why I do what I do." That's why I'm going to keep on taking care of patients the way I did today.

Shannon Phillips, MD: Thank you. Great conversation, and a privilege to work with you. Thanks.