Anonymous observations by team members in order to improve compliance to safety procedures.

Anonymous observations by team members might improve compliance to specific safety procedures, but they can undermine trust within teams, which on itself is a safety risk. In this light the question is whether they can be used.

In our hospital, which is a medium-sized community hospital, we have a strong focus on quality and safety. We were one of the first hospitals in Belgium to become accredited by JCI (the international branch of Joint Commission) and we introduced the Time-out procedure years before it became common practice in the country. This was only possible because some people of the quality department, as well as some leading physicians, are really committed to safety.

In the week of the second module of MHCD though, our deputy CMO saw one of the residents, who would later on not join the surgery, performing the time-out procedure and putting an arrow on the patient to mark the site of surgery. Of course this is not according to our policy, which clearly states that the time-out procedure should be performed by the surgeon doing the surgery and as we say ‘The one who holds the knife, is the one who puts the arrow’. The situation observed was obviously  a safety risk.

My colleague immediately sent an email to all surgeons, anesthesiologists and OR-nurses, reminding them of the correct Time-out and site-marking procedure and of the risks of non-compliance.

Later on, the incident was discussed in the quality committee. We realized that, although many physicians and nurses really believe the procedures make sense, although we train new physicians and residents and although people of the quality department regularly do observations and on paper everything looks fine, compliance to the time-out procedure in practice is not perfect in all cases.

One of the solutions proposed, was anonymous observations of the time-out procedure. Since it’s obvious that observations are being performed when people of the quality department enter the OR room and since this might influence the practice of the time-out procedure, it was suggested to ask three surgeons and three anesthesiologists to anonymously observe their colleagues performing the time-out procedure and systematically report to the leadership about the performance of the individual surgeons, anesthesiologists and nurses.

I do believe in coaching by peers to use group pressure to improve compliance to the safety procedures. But I’m very reluctant to introduce or even propose our surgeons and anesthesiologists the above mentioned anonymous observations by peers. Even though compliance to the time-out procedure might improve this way, it would probably still not become perfect. But more importantly, even if it would be possible to become the best time-out hospital in the world, we would institutionalize distrust in our surgical teams. And a lack of trust between the members of our teams, undoubtedly constitutes another safety risk for our patients.

I’d like to ask whether the members of our group have the same opinion or whether, on the other hand, some might have good experiences whit this type of anonymous observations by team members.


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Participant comments on Anonymous observations by team members in order to improve compliance to safety procedures.

  1. Dear Belgium friend,
    We faced the same scenario before.
    Asking peer reviewers to submit anonymous review of their colleague was a no-no. Even to the present time here in the USA, you hear little bad mouthing of doctors concerning other doctor, but very few end up in written complaint.
    the way we approached was drastic as usual, we mentioned that any reported time out violation will end up in doctor temporary suspension even it was done once. The compliance was overwhelming.
    So, sometimes you need to take drastic measures to correct a safety behavior. And remember this measure not only protect the patient but protect the doctor also from being sued and to keep his reputation as good as possible.

  2. Dear JR,
    I believe that surgeons and anaesthesiologists watching over their own colleagues is not a good idea as it will foster a sense of mistrust among team members.They may also under-report or skip taking note of “You watch my back I will watch yours”.
    Some penalty for non observance of protocol can be instituted but that also may not be sometimes enough.
    ” Education ” of doctors regarding the IMPORTANCE of Time-out is very important. The various incidences which have lead to the disasters due to non compliance of the same , should be REPEATEDLY informed/educated to all.
    Doing the TIME-OUT under camera /cctv can help so as to make people realise that they are being watched (But ensuring at the same time that the privacy of the patient is protected by not including the painted and draped part in camera”s vision )

  3. Making colleagues watching and reporting on each other, will create hostile and not trusting work environment.
    Rules should be in place and parties involved need to be educated, CCTV or designated people should keep the whole team accountable.
    For crucial patient safety matters, Zero-tolerance policy should be implemented.
    For teams following the rules without incidents on a quarterly basis rewards and incentives could be helpful.

  4. Dear belgian colleague 😉
    I agree with MLR, I wouldn’t go for the anonymous reporting system. It’s against the ‘no shame no blame’ principle of incident reporting.
    I definitively don’t like the anonymous way of proceeding.
    You have 2 options: or you start that process but with a clear mention who’s is reporting and doing a strong communication/communication on why and who this will happen. Trust building will be key, but I knowing the OR environment it will be a difficult one. Or you simple fo gor the ‘zero tolerance’ Policy. While being deputy CMO I fight a lot for that approach, not an easy one, but at least people knew the rules not to encompass.
    We can discuss further next week !

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