Promoting a Culture of Safety: Nurses and the Making of LiveData OR-Dashboard™

By Jeffrey Robbins

CEO, LiveData, Inc.

March 6, 2007

I recently came across a Gallup poll that asked people to rate the honesty and ethical standards of various professionals; results indicated that nurses outranked doctors, teachers, and the clergy—by far. I thought this would be a good opening for a presentation to group of nurses at an East Coast hospital where we are installing LiveData OR-Dashboard.

I was told not to bother with the introduction. Nurses knew patients and their families tended to trust them most in the hospital; they lived it. They were interested in learning how we could facilitate their work—taking care of patients. If we could help, they were interested; if not, forget it.

This rang a bell. When I first presented my card to the director of perioperative nursing at a major hospital in New York, she literally threw it back at me. As it stands, this nurse was one of the best collaborators we’ve ever encountered.

The ultimate success of a LiveData solution depends upon our collaboration with the providers who are slated to use it. LiveData OR-Dashboard™ is designed to reinforce patient safety and improve the flow of surgery by promoting increased situational awareness in the operating room. A good dashboard automatically provides the entire team with essential information on the status of the patient and operation, helping nurses, in particular, better anticipate events and respond to emerging needs as the case progresses.

Exactly what is “essential” information?

Responses proved to be an eye-opener when building our first dashboard in the Operating Room of the Future (ORF) at Massachusetts General Hospital (MGH). Many “cards” were thrown back—by nurses. They pointed out some basic pieces of information that had been overlooked, such as names, that of the patient and those of the staff in the room. ORs are often dark, particularly in minimally invasive suites such as that of the ORF; clinicians enter the room, with masks, not recognizing the people with whom they are working. A continually updated staff list was subsequently deemed “essential”; any member of the team could look up at a given moment and know whom to address when making a request.

Collaboration with every player in the OR is necessary in the development of LiveData OR-Dashboard; each has an impact on patient safety and a well-synchronized team effort. Nurses, however, are best equipped to provide a bird’s eye view of the perioperative process as well as the overall well-being of the patient. As one nurse phrased it, “During surgery, nurses become the eyes and ears for the sedated and helpless patient.”

Over the course of the MGH rollout, it became increasingly clear that the active participation and support of nurses was critical for identifying what information was essential to promoting patient safety as well as efficient workflow. They had extensive understanding of “life in the OR,” the high level information needs of different members of the clinical team, how surgery flowed, and what procedures were required. Nurses made it clear that their work in the OR was too demanding and fast-paced to allow for interaction with the dashboard; it had to function automatically. Nurses informed us that latex should be first on the list of allergies, and in bold, as this affected setting up the entire OR. Because their focus is always on the patient in a holistic sense, nurses were also instrumental in targeting essential information beyond the OR—family contacts, for example.

Since the MGH installation, LiveData has adopted Participatory Design as an integral part of the process of developing LiveData OR-Dashboard™ for all hospitals. This ensures collaboration of the entire OR team. With Participatory Design, we look to nurses for help in determining the content, presentation, and aesthetics of LiveData OR-Dashboard.

Content: Nurses typically help us identify the temporal sequence in which the content of LiveData OR-Dashboard should be presented. For example, at Memorial Sloan-Kettering Cancer Center (MSKCC), nurses informed us that PACU information is not valuable until the later part of the perioperative case—in the Closing panel. They also pointed out that presenting information about trays, equipment, and medical products was extremely valuable, but only at the onset—in the Setup panel. And it was the nurses who told us that once the incision was made, LiveData OR-Dashboard should focus on presenting information about patient status rather than equipment and setup information.

Presentation: Nurses help layout the information on the dashboard as well as select appropriate terminology. For example, for urine output, nurses at MSKCC informed us that change over time was more critical than absolute value; urine output is therefore presented in a graphical form, as a series of bars, on the MSKCC dashboard. The nurses pointed out that EBL information, on the other hand, should be presented as exact amounts.

Aesthetics: Personal taste is important. But in the case of LiveData OR-Dashboard, it is more than an expression of individuality; it is an expression of what is acceptable in the operating room, what makes for a pleasant environment in a highly stressful unit. Nurses at MSKCC stressed how crucial it was that the dashboard be attractive and radiate a sense of calm. Loud colors, high contrasts, animations, and auditory alerts could potentially push a clinical team “over the edge,” and most likely result in a request that the “thing” be turned off.

In sum, nurses have played and will continue to play a pivotal role in shaping and refining any installation of LiveData OR-Dashboard.

And yes—that nurse finally did accept my card.