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Building highly reliable office-based surgery

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September 27, 2018
by David E. Eibling, MD, FACS

[Excerpted from the Keynote Address presented at the Annual Meeting of the American Society of Geriatric Otolaryngology, Scottsdale, Arizona; January 19, 2018.]

With a shock I watched the mouth of the 1-week-old infant fill with blood. It had seemed so simple when my senior partner said, “You don't need to go to the OR. Just snip it,” in response to my query as to whether the infant with tongue-tie should be booked for formal division and closure under general anesthesia. Although I had performed frenuloplasty in the OR on numerous occasions, I had never “just snipped it,” nor had I ever considered performing the procedure on a 1-week-old in the clinic. But I recognized that I had made a serious error when I made the second snip to make it perfect. Until that moment I had never considered the implications of performing the supposedly simple procedure in the clinic, several hundred yards through a rabbit's warren of hallways from the well-staffed OR suite.

Reviewing options quickly, I picked up the infant in the crook of my arm, grabbed a 4 x 4 gauze sponge, and applied pressure with my index finger. Telling my technician to call the OR and tell them I was on my way, I stepped through the door to face several dozen pairs of curious eyes, and two frightened faces. In as calm a voice as I could muster, I said “I got a little bit of bleeding so am going to take him to the OR for a stitch. Come along with me and we will do the paperwork when we get there.”

The rest of the story was uneventful, but when reflecting on the event over the intervening three and a half decades, I realize that I had failed to fully consider the implications of what my partner had proposed before I was doing it.

I suspect events such as the one related above are not rare. Moreover, I suspect many readers of this editorial will have similar stories from their own practices or those of their colleagues. This commentary was driven by the assumption that the recent increase in the numbers and complexity of office-based procedures has likely led to an increase in both the frequency and severity of unanticipated, and occasionally devastating, events. The death of Joan Rivers in an outpatient endoscopy suite focused public attention on the risks of performing common procedures in uncommon settings.1

Interestingly, in its infancy otolaryngology was a leader in office-based (and even kitchen-table) procedures. Over the century or so of the specialty's existence, otolaryngologists have performed many procedures in their offices. Patients who underwent tonsillectomy at home “on the kitchen table” are still encountered occasionally, and many practicing today recall rigid bronchoscopy and esophagoscopy performed in the clinic “back room” during their residencies.

Changes in technology, desire for patient comfort, and recognition of the danger of some procedures eventually led to the migration of many procedures into the hospital. Many of these were performed initially as inpatient procedures, but over the past 4 decades, they were increasingly done as outpatient procedures. A plethora of “surgicenters” has dramatically changed surgery.

Driven by forces affecting all of medicine and facilitated by new technology, procedures once done in the operating room are moving into the office setting. Therefore, we need to reexamine systems of care, to ensure that these procedures can be performed in the new setting as safely as possible. One strategy to achieve this may be to study and apply the principles of high-reliability organizations.

High-reliability organizations (HROs) operate in high-risk, high-tempo, and high-stakes environments but have an accident rate far lower than would be expected. These organizations can be considered “positive deviants” and are worthy of investigation to determine the “secret sauce” that enables them to function as they do. In fact, they have been studied extensively by organizational psychologists, most notably in the investigation of flight operations on U.S. Navy aircraft carriers conducted by a research team at UC Berkeley in the 1980s.2

Combining the knowledge gleaned from frontline operational leadership and frontline deck personnel with direct observations led to the findings of the UC Berkeley team, which are now accepted as valid and form the basis of ongoing investigation and scholarship. They concluded that the following characteristics are essential: sensitivity to operations, reluctance to simplify, preoccupation with failure (asking what could happen), commitment to resilience, deference to expertise (not always apparent who has it), and commitment to perpetual training. These observations represent the foundational science of HROs.

Some authorities have proposed that leaders of healthcare organizations study HROs and attempt to integrate their characteristics into their own operations, with the goal of improving patient outcomes and avoiding untoward events and accompanying bad outcomes.

A recent “how to” text by Sculli and Paull at the Veterans Administration National Center for Patient Safety provides insight into how this might take place.3 As a guide for leadership, the text provides specific recommendations, often in the form of checklists, to assist in integrating HRO principles into one's organization.

Sculli and Paull provide several key recommendations that could improve patient safety in office-based surgery. They note that sensitivity to operations, also referred to as situational awareness (SA), is harder to achieve than it would appear. They emphasize that frontline workers often possess extensive knowledge that is unknown to leadership. Andriessen and Fahlbruch emphasize the importance of establishing formal networks to ensure transmission of informal information “up the chain.”4 More recently, Marx5 and Dekker6 have pointed out that organizations must “buy” this information from frontline staff by establishing a “just culture” in which employees feel comfortable in sharing what is often unwelcome information.

Sculli and Paull point out that checklists are invaluable in maintaining effective SA, to augment short- and long-term memory. Just as checklists are now standard in the OR environment, so should they be used in office-based surgery. In fact, multiple checklists are necessary to meet the needs of patients and their families, the office's business and technical staff, and those responsible for instrument setup, teardown, and reprocessing. These checklists should be drafted and reviewed by appropriate stakeholders before beginning to perform the procedure(s).

HROs have a reluctance to simplify. They do not fall prey to the natural tendency to simplify what is complex, thus mistakenly downplaying the risks. HROs are painfully aware that many situations are more complex than they initially appear. This should not be surprising to those of us in the medical profession, as nearly every disease process or treatment algorithm is found to be more complex than it initially appears. An HRO constantly seeks to dissect and understand complexity in hopes of improving the organization's ability to predict failure points in processes.

The peril of oversimplification applies when one is setting up an office procedure. For example, one might simplify the post-procedure period to “we will watch them for 30 minutes.” In actuality, “watching for 30 minutes” involves determining where the observation will occur, who will do the observing, what they are observing for, what instrumentation might be needed, what is the family's role, will patients be escorted to their vehicles, etc. It is useful to enumerate these steps and requirements before the fact.

The HRO characteristic of deference to expertise mandates that preplanning to identify complexities should include all likely stakeholders.

Regarding preoccupation with failure, an HRO continuously is alert for “things that might go wrong.” HROs are concerned about failures they can anticipate, but they are even more concerned about the possibility of failures they have not considered. In other words, they anticipate and expect that unpleasant surprises are inevitable. Therefore, an HRO is constantly looking for an early variation that might indicate an approaching failure. The term “failure to rescue” in our healthcare environment often implies that what really happened was “failure to recognize early signs of approaching disaster.”

A useful exercise as one sets up office-based surgery is to consider and list the multiple possibilities for failure associated with a procedure. Not only can this enhance an office staff's ability to predict, recognize, and respond to events, but it also serves as a reminder that an unpleasant surprise might lurk just ahead.

Closely linked to preoccupation with failure is the HRO's commitment to resilience, its willingness to identify “Plan B.” Resilience is affected by many factors. An HRO is constantly asking the “what if” question, to better prepare. The recent emphasis on in situ crisis management simulation training in hospitals is an example of a strategy to enhance organizational resilience. Considering actions that might be required can be easily incorporated into the process of listing possible untoward events while setting up office-based surgery.

Being resilient includes asking what resources will be needed if a “what if” occurs. For example, is a cardiac monitor needed? What drugs are necessary for resuscitation if needed? Who should be involved, and what are their roles? What resources are nearby, such as a cardiology office in building? Who will notify the family in the waiting room, and how? If emergency medical services must be contacted, where are they, where is the phone number kept, and what is their typical ETA? Who is responsible for contacting the emergency department (ED) of the receiving facility, and where is that phone number? Considering (and listing) what might be needed before the fact is essential to establishing safe and reliable office-based surgery.

As mentioned earlier, deference to expertise-the expectation that anyone, even the lowest ranking sailor, can immediately halt operations if he or she suspects an untoward event might be developing-is a critical component responsible for the low accident rate during active flight operations on an aircraft carrier. Not only is there an expectation that anyone will speak up quickly, but also that the individual will not be criticized if he or she is found to have been incorrect. In fact, they are praised for speaking up, which encourages them to speak up again.

Cultures that criticize those who speak up when events seem to be degenerating effectively guarantee that no one will speak up until they are completely sure an adverse event is about to happen, which may be too late. Unfortunately, this is common in medical establishments. However, it is possible to encourage employees to speak up by continuously reminding and reinforcing the behavior. This behavior is susceptible to extinction if senior team members criticize other team members. In the author's institution, all personnel are encouraged to call for help even if they are unsure whether an adverse event is developing. Maintaining this culture requires constant re-education, especially of those who arrive from institutions that do not have the same expectation.

An HRO recognizes that human performance will decline over time unless constantly reinforced by commitment to perpetual training. This decline is encountered particularly in skills required to address rare events. Integrated into the establishment of an office-based surgical practice should be a consideration for continuous training to enable staff to manage untoward events optimally. Setting up periodic refresher training to include low-fidelity simulation is an ideal strategy. If the office uses cardiac monitoring, low-cost apps are available that can be used to simulate common events such as bradycardia, etc.

In conclusion, the increasing numbers and complexity of office-based surgical procedures inevitably will lead to more challenges for otolaryngologists seeking to institute these procedures in their own offices. Even though the procedure itself may be identical to that done in a hospital or well-staffed surgicenter, there are different challenges inherent in the move from OR to office that may escape detection until some unforeseen event occurs. An awareness of the characteristics of HROs, and adopting some of the strategies they use when establishing office-based surgery, has the potential to improve outcomes, reduce the likelihood of unexpected adverse events, and increase the likelihood of rescue should such events occur.


  1. Yahr E. What went wrong with Joan Rivers's last medical procedure: Lawsuit. Washington Post. January 28, 2015. Accessed Aug. 14, 2018.
  2. Rochlin GI, La Porte TR, Roberts KH. The self-designing high-reliability organization: Aircraft carrier flight operations at sea. Navy War College Review; 1987.!sdhro.html/. Accessed Aug. 14, 2018.
  3. Sculli GI, Paull DE. Building a High-Reliability Organization: A Toolkit for Success. Brentwood, Tenn.:HCPro; 2015.
  4. Erik Andriessen JH, Fahlbruch B (eds). How to Manage Experience Sharing: From Organisational Surprises to Organisational Knowledge. Amsterdam:Elsevier Science Ltd.; 2004.
  5. Marx D. Whack-a-Mole: The Price We Pay for Expecting Perfection. Plano, Texas:By Your Side Studios; 2009.
  6. Dekker S. Just Culture: Balancing safety and Accountability. Boca Raton, Fla.:CRC Press; 2012.
Professor and Vice Chairman of Education, Department of Otolaryngology-, Head and Neck Surgery, University of Pittsburgh School of Medicine
Ear Nose Throat J. 2018 September;97(9):266