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Friday, November 18, 2016

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>> i want to thank julie and i want to thankeverybody else responsible for this conference. this is an amazing opportunity to be a veterinarianin sheltering today and have all of these resources, all of these knowledge resourcesgathered together. this is a very exciting time. i was a shelter executive director in19921993. i was two years out of veterinarian school and resources like this did not exist.those of you that have been in sheltering for that amount of time will recognize thatthings have improved dramatically and i think the knowledge base that we have, the consultingresources that we have and the direction of sheltering is very exciting. so for the veterinarystudents here today things are looking very strong for being able to get the upper handon some of these problems where we've been

struggling in a lot of communities withoutthe proper tool kit. this is my son's note from last fall. camehome on a thursday night from a shift at my practice and this was on the counter top andmy wife had left it for me. this was directed anonymously. he didn't know who was makinghis lunch. i was making his lunch. so it was aimed at me. i was making him sandwiches avoidingpeanut butter and jelly because i thought there was a peanut kid in his class. thoseof you with children know there are peanut kids and if you have a peanut kid in yourchildren's class you can't have any peanut related products or bad things happen. soi had been avoiding peanut butter and jelly. this was a business appointment to my i was corrected with this note. so the

message for you is i've made a sandwich foryou. i've put together a lecture and i think i know what you need to hear but rather thanwrite me a note raise your hand if i'm not giving you what you need. if you want peanutbutter and jelly raise your hand or find a crayon, leave a note, we'll pick it up later.i'm hoping by the end of this morning this presentation at least you'll have a prettygood appreciation for the benefits. a general overview hoe much to create standard operatingprocedures, how to use them and revise them because they're not static documents. theyneed revision, they need to be cared for and fed as it were. we're going to talk a littlebit about errors, adverse events, bad outcomes and some ways to counter that. what i do withstudents primarily is teach surgery in a very

high volume shelter, 32,000 intake, 22,000of that cats, about 10,000 dogs, philadelphia city animal control facility. we're in there3 days a week with students. we do a lot of surgery. we also do surgery in another facilityso process orientation and having a different group of students every week is a standard operating procedures and avoiding bad outcomes through attention to detail issomething that we try to live in our program. we're going to introduce the concept of situationalawareness just to give you a sense of who you should be looking for to be a team leaderor a surgical coordinator in the or or to be managing complex operational tasks so thatthere's somebody who's got a sense of the whole process who can be the team leader.then believe it or not we're going to take

a lesson from formula one. so this is a stringof benefits. these should be familiar for those of you who use standard operating proceduresin your shelters. by the way how many of you have a book or an online or a computer basedstandard operating procedure manual for the tasks in your shelter? got some hands goingup. okay. okay. the alternative to that will be on the next slide. but the benefits tousing standard operating procedures are consistency, improved patient care and process based qualityassurance. so the entire process has built into it methods for checking quality. improvedefficiency. how many of you wish you could do more surgeries, more vaccines in your shelter?if you have standardized processes it makes you more efficient than having random facilitates training and crosstraining.

how many shelters hire people because they'reshort staffed they hire the first person that can fog a mirror? they assign them to somebody'swho already overworked, over burdened, not particularly inclined to train somebody andthey say train this person to do x and the training consists of here's x. and that'stheir on the job training. turnover is often very high in shelters so training is critical,particularly when animals' lives depend on how well you do really simple tasks. cleaninga cage is really simple once you know how to clean a cage. using the right products,the right materials, how to dilute them, having the right supplies in the right place so youcan dilute them properly. these things seem really straight forward but it's all partof the standard operating procedure and the

introduction to those materials is made much,much easier by having them and having them handy, having them not in the chief operatingofficer's desk or sitting up there far away from where the action takes place but havingthem near the place where the task is executed. sop's facilitate leadership development. thisis perhaps an odd place to put this but if you allow your staff to participate in thedevelopment of these documents, you give them sort of incremental ability to show you whatthey know and they can synthesize and integrate. we do this in our student laboratory. we havea new program where our students run a weekend surgical opportunities laboratory primarilycats but crucial to that laboratory is a surgical team leader and this is a student who is qualifiedto do spays who is prohibited to do spays

for the day. that student has to manage thepeople on its 12 to 14 students she has to manage for that entire day. so she's qualifiedto do surgery but she's not allowed to because she has to stay not scrubbed in, she has tobe available to do all the troubleshooting a team leader must do in a 60 to 80 cat spaysurgical event. so leadership development is perhaps a little off the beaten path butsop's and participation in their development can help people become leaders. facilitatescontinuances improvement, adherence or deviation from your standard operating procedures canbe a basis for performance evaluation rather than the alternative which is a somewhat randomperformance evaluation. and of course it documents your processes. this is the flip side. inconsistency,patient neglect, no process for quality, inefficiency,

mythic training or on the job training, leadershipvacuum, stagnation of process, that is your processes remain static or in fact they decline.there's degradation or deviation from process if it's not documented and maintained. sothings start to slide if you don't have standard operating procedures. random performance reviews.very creative problem solving. i admit that sometimes creativity is a gift and it's agood thing but sometimes creative problem solving is not good for the animals in yourshelter. and i love the term tribal knowledge. tribal knowledge is the unwritten undocumentedway that information is conveyed in many circles but within your shelter it's the sense thatwe do it this way but i can't point to a document that says we ought to do it this way. buteverybody thinks we should so it's a tribal

knowledge basis. how to create them? whenyou can institute them from on high. you can just write them and hand them over but thatcan produce implementation challenges for years potentially. you have to involve yourteam and there's actually some literature on the human side that documents this particularlyin surgery. growing body of evidence that links teamwork and surgeon to improved outcomes,high functioning teams achieve significantly reduced rates of adverse events. so the teamproduces a better outcome and a high functioning team produces the best kind of outcome. that'sa disappointment to surgeons. because surgeons are kind of the center of the universe inan or in their own minds. you know? life in their hands kind of thing. but in fact it'sthe team that affects the outcome more than

the surgical technique or the surgeon in manycases. this is last year's pumpkin. i was proud of that but...�all team members mustwork with the draft versions of the standard operating procedures. so everybody whose lifeis touched by that task, everybody who has to implement that task or supervise that taskhas to be part of the development of the standard operating procedure or there won't be buyin. they won't do it. they'll resist, they'll complain. they might complain anyway but ifthey're not part of the development you may have very difficult time with adherence tothe protocol. we start with a goal. and there are high level goals, there are process goalsand there might be participant goals in the case of a teaching protocol. we have goalsfor our students. and this is an example from

a surgical opportunity program i mentionedearlier and so the highest level goal is that for the animals. so that animals are providedhigh quality surgical and medical procedures. that can be delivered at high volume due tothe commitment of a relatively large number of students. for the organization this isthe lab rating shelter on the weekends, that helps fulfill their mission and again a studentgoal at the bottom. after you establish the goals you need to sketch out the work flow.and work flow involves a lot of concepts. i've been to a lot of shelters and i've beensurprised when i go into a shelter, particularly a relatively high volume shelter and i'llask to see where intake occurs. and a lot of times i'm� the answer is well it canhappen here or it can happen over here or

it happens when aco brings them in, kind ofhappens in the garage bay and there's no dedicated space and no sense of consistent work flowfor something that's very important in a shelter. intake processing is perhaps one of the mostimportant steps for life saving in sheltering because that's the time that they get theseimportant vaccinations and they get at least a cursory assessment of their physical statuson the way in. and if the location and the process isn't established then it's probablynot happening with any consistency and that's an issue. so the work flow when you're developinga standard operating procedure the work flow ought to incorporate and include all of thosefeatures. provides an overview of the goals and process and it also introduces the teammembers that are executing the protocol. again

from our surgical opportunities program thisis an overview of work flow. so there's a goal within the work flow and that is thatno surgeon is ever waiting for a cat. that is there's always a cat ready to go as soonas the surgeon has finished the last cat. animals are never unattended. and also theanesthetic time is minimized for these patients. so those are goals that are built into thework flow description and you can see there are some other sort of travel related catsprogress from station to station, et cetera. this is part of the orientation materialsfor this same surgical laboratory and so the students during their orientation are introducedto these various team positions. the physical exam induction team, prep team, castrationstation, spay set up team, spay, recovery

team and then there's a debrief at the endof the surgical session. so at the beginning of the day there's an orientation or reorientationbecause in fact all of these students have gone through the orientation online beforethey come out for the day but it's reviewed very briefly the morning off. all of the studentsintroduce themselves even though they typical know each other reasonably well but they'rereoriented and their roles are clarified or identified then they go through the rest ofthe work flow description. then we get down to the task level descriptionsand tasks include location, again for intake processing that's an important part. if you'reasking somebody to prepare delusions of cleaning product that happens in a particular locationwith particular kinds of equipment as well.

and i'm adding to this or introducing theidea of check lists. we'll expand on that in just a little bit. again, this is an exampleof the task list for exam and induction stations. so physical exam, et cetera. all of thesethings have to happen and they happen in sequence and they happen in a particular location.this is the surgical facility that was developed to host our students. this particular organizationphiladelphia animal welfare society used to hold the animal control contract. they arereleased of the contract responsibilities and they repurposed themselves, became a rescuepartner to animal control, developed a surgical and wellness facility. they built it 2�milesfrom the veterinary school so that our students would have convenient access to it and theydeveloped as a very flexible multibay surgery

with beautiful tall windows. we have lotsof natural daylight. unfortunately the windows overlook the post office's parking lot andthe post office parking lot patrons are among the worst parkers in the world. so my carwas hit about 2 weeks ago despite being parked on a small berm. i thought 60�feet awayfrom the nearest car would be pretty safe but somebody backed into me about 2 weeksago. i usually get to see somebody get backed into at least twice a day from those windows.this is an example of a cleaning exam room cleaning protocol from my practice. my officemanager and staff have developed about 50 or 60 standard operating procedures or protocolsfor various tasks within my practice. i wish i could develop 50 or 60 protocols in my lifetimebut my office manager is very good at this

and this is a detailed description of allthe steps. i don't expect you to be able to read it but this is our current exam roomcleaning protocol along with the concentrations and also the renewal or refresh dates forthe product. many of these products have a finite shelf life or life in the bottle. thisis a peroxide based accelerated hydrogen peroxide based product and it has to be refreshed everyweek in your exam room. so this goes through that in some detail. finally, i'm sorry, aftertasks and detail the various rolls of the team members. so onsite surgical coordinatoror team leader in the case of a surgical program. there is a castration captain. the title forthat role was a variety of titles but they settled on castration captain. castrationcaptain actually has a sash that says castration

condition. serious about that. they have asash that they wear. and that's to identify them in a hurry. and that was inspired byjulie's program cat nip, the surgical coordinator onsite for cat nip wears an orange safetyvest because in a room full of 100 plus volunteers or 80 plus volunteers with a lot of chaosit's nice to be able to find that person now when you need them now. so the team captainor surgical coordinator and the castration captain are color coded so there's easy tofind in the or. it's not quite as big an operation as cat nip mind you and it's a smaller spacebut still when you're in a hurry you want to be able to find these people. we have spaycertified students, volunteer positions for the day. our spay participants and castrationcertified participants as well. the team leader

identification, documentation, sop's haveto be documented or they aren't real. they have to be documented and the documents haveto be in a place that is accessible when people need to review them but it also has to bekept by somebody who will maintain them so that not everybody in the organization canmodify them. you don't want people altering them willy-nilly. they will need to be revisedbut there should be a process and there should be a person or maybe a couple of people chargedwith revising them. this is an example of a poster that's by one of the work this goes through in brief the various steps for the feral cat prep station includinga depiction of a tipped ear. the positive results of the snap kits and all this is printodd a nice poster that's right at the work standard operating procedures for the process content, that is the steps, make surethe steps are still the ones that you're doing and if there's a problem, if people are complainingor people have suggestions for revising the process it can be revised. you can changeit. you don't have to keep the process exactly the same just because it started that way.accuracy, clarity, simplicity. sometimes there are ways to simplify the process and makeit easier for people. and also if the process is necessary, that's a fundamental we really have to do this? or does it have to happen here? that is maybe it doesn't haveto happen at this particular time. maybe it can happen at some other point in time andthat's something your staff can negotiate

with you. they may have a suggestion for wherea task would be better done at some other place and if it makes sense or if it's equivalentin the medical care from the medical care stand points that's something that can happen.for example in this particular laboratory they were doing vaccinations at the prep stationand prep station has a challenge keeping up with the surgical paper work so they suggestedthe vaccines move to recovery where they've got a little bit more time. there's a littlebit more time on the recovery station, a little less paper work excitement. so they movedvaccinations to the recovery side for this laboratory and that was negotiated. your teamleader, your chief operating officer, your veterinarian should observe for choke pointsin whatever that task is. in the case of a

surgical clinic what are the choke points?what are the points where everything jams up and you have people standing around waitingfor surgery? in a high volume cat clinic retrovirus screening is a big choke point and particularlywhen people ask for a retrovirus test but they don't give you the what if it's positiveoptions. which seems to me you�re either going to get a positive or a negative. it'spredictable. it's going to be positive or negative and if it's positive that seems tobe something the trapper or the owner or the shelter ought to have given some thought toand given you some direction on the front end of ordering the test. and it happens allthe time that you suddenly get this result and it's a complete surprise. it's a positive.and it just shuts everything down while you're

trying to chase down a human being to getsome 1 direction. that's predictable. that choke point is predictable, a positive testresult is inevitable at some point in your day if you're doing a high volume clinic andyou should have some direction when they're signing the cat in as to what to do with thatresult. so that choke point is predictable and somewhat solvable and yet if you don'tattend to that on the front end of admissions you can end up shutting down your surgeryor at least jamming up your surgery for 20 or 30 minutes and you may not even resolveit. you may call the cell phone, rolled over to voice mail, person is out of cell contactand they can't get back to you in time then you don't know what to do with the cat.not sure if this made it into your handout

but this is a little bit of a twist. anestheticprotocol alert. how many of you want a safer anesthetic protocol or are interested in that?okay. hoping i have somebody's attention in here. in this particular example perioperativedeath rate was 1 and a half percent. complication rate, complication is defined as these postop infection, pneumonia, unplanned return to the or, unplanned return to the or or death.11�percent. new protocol was introduced dropping the cumulative death rate to 8�percent,.8�percent, 46�percent reduction, complication rate dropped to 7�percent or 36�percentreduction. is it a new injectable drug cocktail, fancy new machine that goes ping, a more secureway of ligating the ovarian pedical in a fat dog spay? i was very excited to see the lecturecontent for north american veterinary conference

has mark bollinger from tennessee doing abig fat dog spay lecture. so that's worth a this new protocol is perhaps the least sexy thing i can show on a power point slide.check lists. that's right. check lists. introduction of a check list system in 6 globally distributedhuman surgical practices decreased perioperative death rate 46�percent, decreased complicationrates 36�percent. check lists. atul gawande is an author surgeon, has written a numberof books, complications, the check list manifesto. after this he was assigned to the world healthorganization's global study of implementation of check lists. so most human hospitals rightnow are beginning to or are well on their way to implementing a check list system forsurgical practice. and these are the check

list that is are recommended by world healthorganization as kind of a template or blueprint and they have various hard stops built intothem. that is the patient cannot proceed until the check list is addressed and it's a physicalcheck list. people in the or have to complete it and have to audibly acknowledge that theyhave completed the check list or the patient does not move. the patient doesn't move outof preop, the patient doesn't have an incision started, the patient doesn't leave the oruntil these things are addressed. now this is the concept. this is something that's rollingout right now. i met with the folks down the street at the hospital of the university ofpennsylvania the human hospital which has 40or's and they're fairly busy practice andthey're well into, well into this section.

they don't have the sign out phase completedyet. so they're not fully integrated into this blueprint and i'll tell you our program,our surgical program is not fully integrated into this. this is something to consider withvarious tasks that lend themselves to a check list system. this is developed from the avionicsindustry, airline industry where very complicated processes like flying an airplane are incrediblysafe and they're incredibly safe because there's a standardized way of getting started, there'sa standardized way of problem solving and then there's a mechanism for learning fromevents that happened. so there's a debrief or a post failure analysis that allows themto develop safer check lists going forward. this is some of the data from that study.again these were globally distributed hospitals.

each of the hospitals saw improvement thoughnot every hospital saw improvement in every category. that is some hospitals experiencedreductions in complications but did not experience improvements in perioperative death rate butcumulatively and individually each hospital saw improvement with the implementation ofthe check list. there were no other substantial differences in their anesthetic protocolsor their caseloads or the case demographics or signalment so everything else was relativelysimilar and this happened in a fairly short study period. so this happened within abouta 4 month period of time so it was fairly compressed in time. substantial improvementin outcome with implementation of the check list system. this is an example of the checklist that our students follow when we're in

animal control as we're getting our patientsready for and as we're getting our patients processed through a surgical. again theseare places where we have a hard stop built in. so with dogs exam patient confirm thepresence of testicles. that seems pretty straight forward but how many of you have sedated adog with nothing in the scrotum? that's unfortunate because that dog could have spared, you know,fairly expensive dose of anesthetic agent potentially and certainly the dog did notneed to have a 4 hour nap in order to have a microchip implanted if he didn't have amicrochip already. and again this is a detailed check list that our students follow as we'removing through the or. this is a list of all the surgical tasks that have to take placefrom the beginning of the day to the end of

the day with a patient. why is surgery inred? i'm sorry? somebody says it's the main goal. i can't tell you the number of students;they want to get faster in surgery. they want to get more efficient. and they imagine thatif they can only get faster, you know, they can do more surgeries a day but i'll tellyou that all of these other things around surgery eat up more time than most� nowstudents are somewhat slow. somewhat. but if you can get standardized processes aroundall of these other things and if you can become more efficient at those other things and ifyou can keep your surgeon busy all the time a surgeon who can do a 20 minute dog spaycan do an awful lot of surgery if every 20 minutes they're starting another dog. butif there's 10 or 15 minutes between every

patient no matter how fast they are they'renot going to get through a lot of surgeries. so i use this slide to emphasize that there'sa lot of other stuff that's happening other than the surgical procedure. and all of thatother stuff has process around it and needs to be standardized. this is a form, this isactually quite a nice form that our philadelphia animal welfare society uses as the work orderand surgical report for every one of their patients. when we're in their facility wework off of this sheet and the sheet has all of the menu options that are available forthat particular surgical center. so it has the vaccine list, it has the tests that areavailable, heart worm or retrovirus and we can walk through the work pretty easily becauseit's in a physical or visual format and we

can just check off the boxes and fill in theplanks as we work through the case. that's just a nice useful form to follow the patientaround the or. by the way my opening slide was a picture of operation cat nip from januaryof 2010. january's pretty cold in philadelphia so i thought it's 24�degrees in philadelphiai'll come down and visit julie and sinda and see operation cat nip for a sunday. so wescheduled this and i came down. 24�degrees in philadelphia was 22�degrees in gainesville.thank you. and it was a slow day. they did about 175 cats on a slow day. julie normallyit's 250 is kind of their, you know, we're feeling good about the day. 250 cats and you'reusually closing your last abdomen at? quarter till� 1:00�or 2:00�they're closing theirlast abdomen, 250 cats roughly half female.

so that's organization. that's some standardizedoperating procedures. this is an example of an exam station list. just a slide or twoabout surgical standards in veterinary medicine. this is a screen shot from the american animalhospital association organization, very near and dear to me. accredited practices adheredto roughly 900 standards and there are some specific standards for various parts and practice.there's a lot of standards around surgery, medical records and so forth. this is justan example of some of the standards around surgical practice. when you're developingstandard operating procedures you have to keep in mind that there is an emerging senseof standard of care. there are spay and high volume spay and neuter guidelines that havebeen published for a few years so there are

standards that are resources that you cango to to see if what you're doing is in conformity to those standards. it used to be that therewere local or prevailing standards of care in veterinary medicine so if you were farfrom the big city and you were in a somewhat rural area it used to be considered you wereheld to a different standard of care by veterinary boards, boards of veterinary medical examinersbecause you didn't have access to or ability to have the latest and greatest knowledgeor gadgets. i will tell you from talking to people who sit on boards, veterinarians andrepresentatives of the public that that sense of local standard is changing and it's nowone standard because knowledge is now easily available, conferences like this, other veterinarymedical conferences can easily distribute

information about the latest and greatestways to do things. the internet has made access. veterinarians have access to information thatused to take much longer time to distribute. so the sense today at boards of veterinarymedical examiners is that you should know this stuff. you should know about pain medsand you should know about appropriate surgical protocols because it's easily available there is this sense that there are emerging standards, those standards are going up, notdown. it is no longer the shelter held to a different standard than a practice. youdo need to keep that in mind as you're developing protocols because your protocols may comeunder some scrutiny either from a volunteer who doesn't like what you're doing who maytake a photocopy or take a screen shot of

your protocols and share that with other as you're developing, not that that's the only thing to consider when you're creatingprotocols but just keep that in mind. your protocols need to be sound medically. we'rehoping also that people are paying attention to the asv's guidelines for shelters. payattention to what your state boardsyou know, those of you who are in contact with peoplewho had experience with the state boards or if you have a publication from your stateboard, if you're a licensed veterinarian within your state they probably send out informationto you on a quarterly basis or a yearly basis. talk a little about errors, adverse eventsand bad outcomes. how good process and situational awareness can improve quality. medical misadventureshappen because of the following reasons. and

this is based on error analysis in human literature.there are entire journals in human medicine devoted to quality and quality's a very strong area of active study. obviously medical misadventures are a huge costly tragiccondition or circumstance so there's a lot of effort on the human side to try to mitigatethose and prevent those. we look at systems factors, break down and delivery function,productivity pressures. who is under pressure for productivity at their shelter? discontinuouscare or hand offs. that is patient care starts in one section or one function and then transfersto another function. and that can be from station to station. that can be from categoryto category or status to status. so it moves from adoption to some other part of the shelter.there's an opportunity for loss of information

or misinformation at each one of those handoffs. so hand offs are a weak link. weekly standardized processes or policies, or lackof processes and policies, poor communication systems and then lack of patient data. youjust didn't know the patient had this or that. sometimes that's because an owner doesn'ttell you, sometimes it's because it wasn't asked and sometimes it's because it was had it then you lost it, it got separated from the patient. those are all systems. everythingin blue is a systems or process problem. that is with better processes, with better systems;with better protocols you can mitigate or avoid errors in that category. on the bottomin black are individual operator errors that can happen. failed situational awareness,tunnel vision. you just didn't know it was

happening. you were so focused on the abdomenyou didn't notice your patient stopped breathing. those kinds of errors. following faulty rulesof thumb. that is if it comes in looking like this i do this. well sometimes it comes inlooking like that for a different reason than the treatment you're used to using. so sometimeswe fall to rules of thumb and sometimes rules of thumb don't work for us. biases, you maybe inclined to treat things a certain way because it's worked for you. but it may notwork in every case. mental states or affect. if you're in a terrible mood, if you're incrediblydistracted, if you're angry, the quality of your work, the quality of your thinking isdegraded. so that's an individual type of error that can occur. and then technical factors.surgical accidents, surgical misadventures,

those things can happen. they do happen. butthey probably have a lot less than these other categories when it comes to bad outcome contribution.situational awareness. how many of you have heard of this term? situational awareness.situational awareness is the ability to know in a complex environment to be able to kindof high level view of what's happening overall. it's what fighter pilots are tested for tofly very complicated equipment with a lot of distracting data streams coming out. they'vegot a lot of information coming at them. they're in a very expensive technologically advancedaircraft, they're 23 years old flying a 35�milliondollar airplane. they screen and test for very highlevels of situational awareness so they can keep track of all the stuff that's happeningoutside the plane and inside the cockpit.

and there are various levels that have beendescribed. again this is a field of research for a variety of reasons but with respectto surgery it's because situational awareness can prevent or can lead to errors. that islack of situational awareness. pit crew lessons. how many of you are motor sports fans in theroom? any motor sports fans? okay. so formula 1 pit crew we're in the south so that's anascar pit crew. now from this picture there's a lot of people. they do a pit stop in somethingunder 5 seconds typically, 4 tires, fuel. they can do some other things, make some adjustmentsin under 5 seconds in many cases. takes a lot of people to do it. the most importantperson in this is the fellow called the lollipop man. he's the fellow here. he's got a poleand on the pole is a go or stop. he flips

it around and the only thing the driver doesis watch that stop sign. and when the stop sign is flipped around he knows he can gunit, you can pull out. that's the only thing the driver has to do when he's in the pitstop and the lollipop man controls, he's the team leader for that entire event. doesn'tseem like a very hard job does it? hold the stick and flip it at the right time. but hehas to have a very high level of situational awareness and he has to know exactly everytask that every team member can do because he has the life of the driver, the life ofthe crew, the life of the driver and crew in front of him in his hands. he has to havethe highest level of situational awareness when they're in the pits. and in motor sportsraces are won and lost in the pits. cars are

going so fast, first and second place areseparated by fractions of a second in many cases and those fractions of a second areearned or lost during pit stops. i didn't invent this analogy. this is from the humanliterature. this is� they have looked at pit crews and they've had pit crews come intooperating rooms, they've had them come into surgical theaters and they've had them takea look at process and to reengineer some of their processes. nascar visited a human orthopedicsurgeon who was troubled by his inability to do more than about 4 or 5 total hip replacementsin his surge. so they looked at his surgical practices from start to finish. now they weren'tthere to recommend technique. they were there to look at the process and they reorientedhis process and made him have a consistent

team and they implemented more structure,the team was sharply defined into divided roles, they tightened up his processes, nothis techniques, they tightened up his processes. they became more organized with orientation,preevent briefing, they had an equivalent of a lollipop man. they had a team leader.they did after the day of surgery they did a debrief. they went through what went welland what didn't go well and they learned from it. so they did data analysis and they trainedand cross trained all the members of the team so they understood each other's roles andresponsibilities so they were a more effective high functioning team. and when they did thatthey were able to take him from 5 total hips a day to about 12 per day and if you're underproductivity pressure that's pretty good.

and so that was a good outcome and that wasfrom nascar and from a pit crew looking at process. standard operating procedures fundamentallyimprove your team's ability to organize, train, to function and to lead. check lists, morethan any new drug� i'm sorry for the anesthesia people in the room� more than any new surgicaltrick, sorry for the surgeons in the room, will decrease your perioperative death andcomplication rate. sop's will clarify and reinforce goals. this is from one of our firstyears in the shelter. this is one of my shelter medicine elective groups. this kitten, littleblack kitten covered in roofing tar was brought in by a roofer. they had been doing a roofin the summer and this kitten had somehow gotten up on the roof and drifted or wonderedthrough the tar and came into animal control

and it happened that we were in the buildingbecause the shelter would not have had 4 staffers to sit around with warmed mazola oil and spend3 hours taking roofing tar off this kitten. this student then took the kitten home andof course found it adoptive home for it so it was a good outcome for the cat and i thinka good outcome for our students as well. sop's will improve your productivity. thereforeyour efficiency. adherence or deviation will help with staff accountability and performancereviews. so you'll have a standard by which employee performance can be graded. are theydoing it the way they're supposed to? have they been trained to it and are they doingit the way they're supposed to? yes or no? it's much easier to tell if there's a standardagainst which they can be judged. check lists,

if you implement them it will reduce adverseevents, absolutely. it will reduce adverse events. and so in short standard operatingprocedures and checklists save kittens. [applause]

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