ASCs can prevent errors and improve quality through completing an annual culture of safety survey.

Poor communication and lax adherence to standards can result in operating room mistakes. However, it’s not just the lack of communication between staff and surgeons, but between different physicians, says Kecia Norling, RN, MBA, CNOR, CASC, administrator at Northwest Ambulatory Surgery Center in Portland, OR.

Even asking a newer surgeon to question a more experienced surgeon can be uncomfortable, Norling notes. “It’s a really interesting dynamic, and it’s one that needs to be addressed more frequently,” she says. “We talk about it all the time at our surgery center.”

For instance, Norling’s ASC made a medical error that likely resulted from poor communication between staff and the surgeon, she recalls. “Communication wasn’t as strong as needed, and the staff did not feel comfortable speaking up to the surgeon.”

One preventive action would be to continually remind the surgery team that their work is important and they have permission to speak up if they see a problem, Norling offers. “Tell the team you are dependent upon their doing their best work and that it takes the entire team and all of their input to oversee any issues. If surgeons said, ‘I depend on you to help me do my job well,’ then people might be comfortable speaking up.”

After the ASC’s adverse event, the facility used that example in a physician meeting, emphasizing the need to learn from the mistake.

“We talked about culture, which is a non-punitive way to discuss it,” Norling says. “It’s not [an individual’s] fault, we just need to look at our own processes, starting with administering a culture of safety through a safety survey. A lot of ASCs don’t know what their culture is, so they can do a survey through the Agency for Healthcare Research & Quality (AHRQ).” (Editor’s note: The AHRQ checklist is available at:

Administrators can download the checklist and administer it to all surgeons and staff to get an idea of the ASC’s baseline on operating room safety, Norling advises. The survey’s findings might be an eye-opener. For instance, studies have shown that while seven out of 10 surgeons will say physicians maintain a positive tone throughout operations, only 34% of other staff believes this is true, Norling notes. An ASC’s weaknesses are revealed through the survey. This gives a facility the opportunity to develop plans to fix its problems by forming a committee that focuses on a culture of safety. “Determine which areas you are going to work on and do this continuously, not just a one and done,” Norling says. “Then, do the survey each year and adjust goals for that year; it’s never-ending, constantly tweaking it and improving it.”

Below are some best practice strategies for using the survey and creating a culture of safety:

Develop measurable goals. The AHRQ culture of safety survey asks specific questions that can help an ASC pinpoint its weaknesses. For instance, the first section relates to the employee’s experience working in the facility. Each statement is answered by a checkmark in one of these five categories: Never, Rarely, Sometimes, Most of the Time, Always. Here are a few examples of statements:

- Important patient care information is clearly communicated across areas in this facility;

- We feel comfortable asking questions when something doesn’t feel right;

- We have enough staff to handle the workload;

- Our ideas and suggestions are valued in this facility;

- There is enough time between procedures to properly prepare for the next one;

- We feel rushed when taking care of patients.

If an ASC’s survey shows that a significant percentage of staff answered that they never or rarely have enough staff and enough time between procedures to properly prepare for the next one, or that they always or most of the time feel rushed when taking care of patients, then the ASC could develop a measurable goal related to staffing and spacing patients.

“Or, say our survey shows that our staff does not feel like their input matters when decisions are made, then that would be a place to start,” Norling says.

When physicians answer the same questions differently, an ASC director will begin to understand how there’s a difference in what leadership perceives and what employees see. “Typically, there are surprises,” she says. “Even the best teams will say, ‘Wow, I wasn’t aware of that, and we can work on that.’”

Determine priorities for improvement. After writing measurable goals, based on the survey’s results, an ASC culture of safety committee should determine two or three areas for improvement over the next year. “These are areas where you can make the most change, based on where you had the lowest scores,” Norling suggests. “Then, you decide how you’re going to implement that change, measure it, and follow up.”

For example, Northwest Ambulatory Surgery Center has been conducting culture of safety surveys for four-plus years, giving the ASC comparison data. “We can compare one year to the next, and we can compare our culture of safety results with data from our corporate partner and other ASCs,” Norling explains.

Based on these metrics, the ASC found that its staff didn’t feel included in the survey results. They might have missed the staff meeting during which the culture of safety results were discussed. Because of this feedback, the ASC created binders containing the survey results in each department. Each binder holds the current year’s results, as well as comparisons with previous years and the results from other ASCs within the corporate organization. “Every person has to sign off when they read the results,” Norling says. “Then, we sit and have a meeting to discuss what we want to work on with them. For example, one area was better communication between teams.”

Specify solutions to issues raised in the survey. In its second section, the culture of safety survey focuses on teamwork and training, asking staff to rate the organization on items such as: when someone in this facility gets really busy, others help; staff feels pressured to perform tasks on which they haven’t been trained; the facility allows disrespectful behavior; and staff members work together as an effective team.

Through these teamwork questions, an ASC might learn that one area of the organization feels that another area is not pulling its weight and vice versa. “They don’t understand their different roles, seeing someone at a desk and just sitting because they’ve finished a phone call with a patient,” Norling says. “But the operating room person walking by doesn’t know this.” For example, there can be frustration between the post-anesthesia care unit (PACU) or pre-op team and operating room (OR) team. “People can feel disrespected and like they couldn’t perform their jobs because of the other team,” Norling says.

This means the organization needs better team involvement and improved communication between departments. Maybe the OR should allow pre-op enough time to admit the patient, giving the patient a good experience through that, and the pre-op team should ensure the patient is returned to the OR when the surgeon expects the patient, Norling offers. “Typically, these come down to small communication issues.” Sometimes, the solution involves new technology. For instance, Northwest Ambulatory Surgery Center maintains an electronic board that informs staff when a patient is ready.

Remind employees of goals and outcomes. An ASC administrator might say, “The patient safety surveys are coming up next month. Let’s talk about everything we’ve done this past year.”

“Link what you’re doing and label it so when [staff members] see that question come up on the survey, they can say, ‘Yes, we addressed that this past year,’” Norling says.

This process of reminding employees must include all staff, including those who work in the business office. “Our business office didn’t have enough information about everything we were doing around patient safety because we were leaving them out,” Norling says. “So, that’s an area we’ve really worked on this year — making sure the business office knows everything we’re doing.” For instance, business office staff might not be aware of how OR staff handle a time out before surgery as part of the surgical checklist. It’s up to the administrator to explain this process to them.

Make difficult changes when needed. When ASC leaders dig into a culture of safety survey’s findings, they might discover a problem that relates to one person’s actions or personality. This issue must be addressed, although it can be challenging.

“We had a surgeon who was a good surgeon but had a challenging personality,” Norling recalls. “So, the OR staff felt frustrated with him; his paperwork frequently wasn’t complete, and we viewed this as a possible weakness that could increase the probability of an adverse outcome.”

The solution was to address the issue with the surgeon directly, letting him know the staff’s concerns. “We changed the way he scheduled patients,” Norling adds. “Instead of sending us a fax, we had his office use our software system through which the office could schedule directly into our software system, and that helped his office be more accurate.”

ASC leaders encouraged staff members to speak up if they saw any issues during surgery. “We showed staff we were listening to them and heard them,” Norling says. “It was a win-win for everyone.”