Driving culture to improve safety in spine surgery

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Michael Vitale driving safety
Michael Vitale

Michael Vitale (New York Presbyterian, New York, USA) chairs the Safety in Spine Surgery Summit annual meeting, as well as having co-authored a book on the topic, Safety in Spine Surgery. Ahead of the fifth annual Safety in Spine Surgery Summit (13 March; New York, USA) Vitale talks to Spinal News International about the advances being made in the field of spine surgery safety and emerging challenges in the area.

Why was the Safety in Spine Surgery Summit established, and what is the primary aim of the meeting?

The Spine Safety Summit, which is now in its fifth year, is uniquely aimed at improving the quality, safety and value of what we do in the area of spine surgery. It is not a meeting about how to put in screws or which type of orthopaedic implants or plates to use, it is a meeting about how to take advantage of systems and how to drive culture and optimise teams to improve the care of patients undergoing spine surgery.

There is a widespread understanding that we really need to be doing better, there is too much variability in both indications for surgery, approaches to surgery, outcomes to surgery, and really too many complications threatening the value proposition of what we do for patients. So, this meeting has emerged and it has been really fun to see the enthusiasm that has resulted.

The meeting has led to a number of important products, things like best practice guidelines to improve response to intraoperative neuromonitoring whilst in the operating room, best practice guidelines to avoid wrong site surgery in spine, best practice guidelines to improve non-operative scoliosis care and it has also resulted in a book called Safety in Spine Surgery, so it has been a thrill to see all of this come together and to be a part of a group of people and a part of the change that needs to happen.

What will be the focus of the 2020 Safety in Spine Surgery Summit?

A lot of the meeting this year is about teams, and about how we can drive teams, how we convince people that it is important to invest in teams. There is always a push-pull with regard to having generalists who can do everything and having [dedicated] spine people. I can tell you, having gone through this transition, having dedicated spine teams makes spine surgery care better, safer, [with] fewer complications, better outcomes, better throughput [and] better efficiency. One of the things we are trying to do is share that experience and teach people how to get there. The people coming to the meeting are largely—but not exclusively—surgeons, they are hospital administrators, executives, spine service leads, that are all trying to learn how to create a spine programme.

Should a spine surgeon be solely responsible for patient safety in the operating room?

The concept of the pilot of the ship is anachronistic. We used to say that the Captain of the ship is in charge of everything—it is really not true. The surgeon—the pilot—has an important role in setting, driving, and sustaining culture, but without a well-functioning team you can’t get to sustainable, dependable, reliable, optimal outcomes. Culture is really the important thing. The famous quote is that culture eats strategy for lunch and I think that is true.

The surgeon has a critically important role in driving culture, in decreasing hierarchy in our operating room and our care system, creating diversity of opinion and being open to standardisation. Ultimately, to accepting the power of the group. When those things happen, patients have better outcomes.

In your view, will the increased use of advanced technologies, such as robotics, help to improve patient safety?

It is an interesting area. We have a section on robotics and navigation with worldwide leaders in the field. I think there is some controversy because over-reliance on technology can lead to problems. In fact, there is a concept called the Peltzman effect, which is that new technology often takes away people’s systems and people’s connection with the product that they are executing.

Over-reliance on technology that has a negative effect on the broader system, the culture, and our ‘airmanship’ skills, if you will. What I think people are concerned about is that some of the pilots that have only fly-by-wire navigated computer-controlled planes, don’t have the same connection to the plane, so that when something inevitably does go bad, they are not as able to fix it. There are concerns that we are creating a group of surgeons that may have lost their airmanship skills. This will be a very hot topic, and I think that the answer is still up in the air. Ultimately, we need to appropriately utilise technology as an incremental advantage without giving up our connection to the patient, and acknowledging the whole time that a systems, culture and team approach are critically important and not replaceable.

In the field of spine surgery safety, will the important considerations be fundamentally different in 10 years as today?

I think you are seeing it evolve very quickly, which is part of why there has been so much enthusiasm and interest in this area.

People are starting to come around and understand that it is not just about putting in the screw, it is about how you lead the orchestra, how you lead the whole group of people which includes the system and the culture. I think sometimes we are going to need to understand that some of the things we have been doing and some of the ways we have been doing them, are not sustainable, and some things we are doing in spine care probably need to go away.

The growth of spine surgery, particularly in the US, and the growth of expensive technologies really are not sustainable and in some ways, really are not justified by the outcomes that we are having. Until we are willing to look at this globally, holistically, we are not going to get to the best state of delivery of spine care to patients.

What, do you hope, will be attendees’ main takeaway message from the 2020 Safety in Spine Surgery Summit?

That it is not just about the knife. It is about how you orchestrate a complex, dedicated team, drive that culture and continually make work visible to improve safety in spine surgery. That is really the fundamental message of this meeting, which is different than any meeting I participate in.


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