March 27, 2019
3 min read

STS News, Spring 2019 — One of the first concepts that a newly minted cardiothoracic surgeon learns from experience is that excellent patient care in our field is a “team sport”. In this installment of STS News, Dr. Walter Merrill nicely outlines how we can lead by example to improve the function of our patient care teams.

Frank L. Fazzalari, MD, MBA, Chair, Workforce on Practice Management

Walter H. Merrill, MD
Senior Associate Chief of Staff, Vanderbilt University Hospital, Nashville, Tenn.

Good surgical skills combined with a high level of team performance are key to achieving low mortality rates. In order to achieve that high performance, you need to take a systems approach—optimizing the working environment, paying attention to equipment design and function, understanding the subtleties of decision-making in a dynamic and often fluid situation, and enhancing team communication.


The typical approach to health care safety focuses almost exclusively on ensuring that individuals do not make mistakes. This places most, if not all, of the blame for a less-than-perfect result on an individual; however, the latent conditions for failure reside in the work environment. Thus, the burden of responsibility ultimately lies within the entire system—not on the individual practitioner.

Our current system of fragmented care and gaps in continuity cannot be overcome simply by working harder. We must introduce systems of care that align and coordinate the efforts of everyone involved, doing so in such a manner that facilitates the personal aspects of patient care rather than separating us from them.


Most busy surgeons do not have sufficient discretionary time that can be devoted to major systems design in their hospitals. We can, however, “lead from behind” by setting an example in our own practices and sharing what we learn with others.

The strategies that I have learned to incorporate include:

  • Identifying and correcting all errors, even the near-misses.
  • Using task reminders or checklists for routine, repetitive procedures. Team training and checklist usage decrease delayed starts, case length, and turnaround times.
  • Insisting on formal sign-outs of patients at shift changes.
  • Including and improving upon formal briefings and debriefings for every operation. Preoperative
  • briefings have been shown to increase job satisfaction.
  • Encouraging “stop the line” communication in which every member of the team is empowered to speak up if they see something that appears out of the ordinary. This is one of the most effective tools that I have learned to incorporate.

These steps help to ensure that team members are confident about what is expected of them. In addition, surgeons who encourage communication in the operating room and elsewhere can gain knowledge and experience unique vantage points, which are critical for good decision-making.

I encourage you to start implementing these systems-based strategies today for better results in the near future.

To view previous practice management columns, visit