Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals.

OBJECTIVE: The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success. BACKGROUND: Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success. METHODS: We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time. RESULTS: Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives. CONCLUSION: We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

Human Factors and Ergonomics in Healthcare: Industry Demands and a Path Forward.

This article reviews three industry demands that will impact the future of Human Factors and Ergonomics in Healthcare settings. These demands include the growing population of older adults, the increasing use of telemedicine, and a focus on patient-centered care. Following, we discuss a path forward through improved medical teams, error management, and safety testing of medical devices and tools. Future challenges are discussed.

Demographic and technological factors influencing virtual seizure clinic visit satisfaction before and during the Covid-19 pandemic in rural Hawaii.

BACKGROUND: Telemedicine clinic visits traditionally originated from spoke clinic sites, but recent trends have favored home-based telemedicine, particularly in the time of Covid-19. Our study focused on identification of barriers and factors influencing perceptions of care with use of home-based telemedicine in patients with seizures living in rural Hawaii. We additionally compared characteristics of patients using telemedicine versus in-person clinic visits prior to the Covid-19 pandemic. METHODS: For the retrospective portion of our study, we queried charts of adult outpatients treated by the two full-time epileptologists at a Level 4 epilepsy center accredited by the National Association of Epilepsy Centers between November 2018 and December 2019. We included patients who live on the neighbor islands of Hawaii but not on Oahu, i.e., patients who would require air travel to see an epileptologist. There had been no set protocol at the epilepsy center for telemedicine referral; our practice had been to offer telemedicine visits to all neighbor island patients when felt to be appropriate. We collected demographic and clinic visit data. For the prospective portion we surveyed neighbor island patients or their caregivers, seen via home-based telemedicine between March 2020 and December 2020. We obtained verbal consent for study participation. Survey questions addressed satisfaction with clinical care, visit preferences, and potential barriers to care. RESULTS: In a 14-month period prior to the Covid-19 pandemic, 75 (61%) neighbor island patients were seen exclusively in-person in seizure clinic while 47 (39%) had at least one telemedicine visit. 39% of patients seen only in-person were female whereas 38% of patients seen by telemedicine were female. Patients seen in-person had an older median age (47.2 years) compared to those seen at least once by telemedicine (42.4 years). The no-show rate was 13% for in-person visits versus 4% for telemedicine visits. Among patients seen in person, 17% were Asian, 32% Native Hawaiian, and 47% White, whereas patients seen by telemedicine were 15% Asian, 23% Native Hawaiian, and 57% White. Patients who were seen in person lived in zip codes with median household income of $68,516 and patients who were seen by telemedicine lived in zip codes with median household income of $67,089. Patients who were seen in person lived in zip codes in which 78% of the population had access to broadband internet, whereas patients who were seen by telemedicine lived in zip codes in which 79% of the population had access to broadband internet. During the Covid-19 pandemic, we surveyed 47 consecutive patients seen by telemedicine, 45% female with median age of 33 years. Telemedicine connection was set up by the patient in 74% of cases, or by the patient's mother (15%), other family member (9%), or other caregiver (2 %). Median patient satisfaction score was 5 ("highly satisfied") on a 5-point Likert scale with mean score of 4.6. Telemedicine visit was done using a smartphone by 62% of patients, a computer by 36% of patients, and a tablet by 2% of patients. A home WiFi connection was used in 83% of patients. CONCLUSIONS: Home-based telemedicine visits provide a high-satisfaction method for seizure care delivery despite some obstacles. Demographic disparities may be an obstacle to telemedicine care and seem to relate to race and possibly age, rather than to sex/gender, household income, or access to broadband internet. Additionally, despite high satisfaction overall, more patients felt the physical exam was superior at in-person clinic visits and more patients expressed a preference for in-person visits. During the Covid-19 pandemic when there may be barriers to in-person clinic visits, home-based telemedicine is a feasible alternative.

Team Physiological Dynamics: A Critical Review.

OBJECTIVE: Review the use of physiological measurement in team settings and propose recommendations to improve the state of the science. BACKGROUND: New sensor and analytical capabilities enable exploration of relationships between team members' physiological dynamics. We conducted a review of physiological measures used in research on teams to understand (1) how these measures are theoretically and operationally related to team constructs and (2) what types of validity evidence exist for physiological measurement in team settings. METHOD: We identified 32 articles that investigated task-performing teams using physiological data. Articles were coded on several dimensions, including team characteristics. Study findings were categorized by relationships tested between team physiological dynamics (TPD) and team inputs, mediators/processes, outputs, or psychometric properties. RESULTS: TPD researchers overwhelmingly measure single physiological systems. Although there is research linking TPD to inputs and outputs, the research on processes is underdeveloped. CONCLUSION: We recommend several theoretical, methodological, and statistical themes to expand the growth of the TPD field. APPLICATION: Physiological measures, once established as reliable indicators of team functioning, might be used to diagnose suboptimal team states and cue interventions to ameliorate these states.

Managing creativity and compliance in the pursuit of patient safety.

BACKGROUND: Are creativity and compliance mutually exclusive? In clinical settings, this question is increasingly relevant. Hospitals and clinics seek the creative input of their employees to help solve persistent patient safety issues, such as the prevention of bloodstream infections, while simultaneously striving for greater adherence to evidence-based guidelines and protocols. Extant research provides few answers about how creativity works in such contexts. METHODS: Cross-sectional survey data were collected from employees in 24 different U.S.-based outpatient hemodialysis clinics. Linear mixed-effects models were utilized to test study hypotheses. Professional status, clinic climate variables, and interaction terms were modeled as fixed effects, with a random effect for clinic included in all models. RESULTS: Our results show that high status employees contributed more creative patient safety improvement ideas compared to low status employees. However, when high status employees were part of clinics with a stronger safety climate of compliance, they contributed fewer creative ideas compared to their counterparts working in clinics with a reduced compliance orientation. We also predicted low status employees working in less punitive clinics would contribute more creative ideas, but this hypothesis was not fully supported. CONCLUSIONS: This study suggests that in hospitals and clinics that rely on strict protocols and formal hierarchies to meet their goals, the factors that promote creativity may be distinctively context-dependent. Implications for theory, practice, as well as future directions for research examining creativity in healthcare and safety critical contexts are discussed.

Evaluation of a Measurement System to Assess ICU Team Performance.

OBJECTIVE: Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs. DESIGN: Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects. SETTING: A 15-bed surgical ICU at a large academic hospital. SUBJECTS: One hundred thirty-eight instances of teamwork were observed. Specifically, we observed 88 multidisciplinary rounds, 25 nurse-to-nurse handoffs, and 25 simulated code exercises. INTERVENTIONS: No intervention was conducted for this study. MEASUREMENTS AND MAIN RESULTS: Rater reliability for each overall task ranged from good to excellent correlation (intraclass correlation coefficient, 0.64-0.81), although there were seven cases where reliability was fair and one case where it was poor for specific competencies. Findings from generalizability studies provided evidence that the marker system dependably distinguished among teamwork competencies, providing evidence of construct validity. CONCLUSIONS: Teamwork in critical care is complex, thereby complicating the judgment of behaviors. The marker system exhibited great potential for differentiating competencies, but findings also revealed that more context specific guidance may be needed to improve rater reliability.

Epinephrine Auto-Injector Versus Drawn Up Epinephrine for Anaphylaxis Management: A Scoping Review.

OBJECTIVE: Anaphylaxis is a life-threatening event. Most clinical symptoms of anaphylaxis can be reversed by prompt intramuscular administration of epinephrine using an auto-injector or epinephrine drawn up in a syringe and delays and errors may be fatal. The aim of this scoping review is to identify and compare errors associated with use of epinephrine drawn up in a syringe versus epinephrine auto-injectors in order to assist hospitals as they choose which approach minimizes risk of adverse events for their patients. DATA SOURCES: PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library were searched using terms agreed to a priori. STUDY SELECTION: We reviewed human and simulation studies reporting errors associated with the use of epinephrine in anaphylaxis. There were multiple screening stages with evolving feedback. DATA EXTRACTION: Each study was independently assessed by two reviewers for eligibility. Data were extracted using an instrument modeled from the Zaza et al instrument and grouped into themes. DATA SYNTHESIS: Three main themes were noted: 1) ergonomics, 2) dosing errors, and 3) errors due to route of administration. Significant knowledge gaps in the operation of epinephrine auto-injectors among healthcare providers, patients, and caregivers were identified. For epinephrine in a syringe, there were more frequent reports of incorrect dosing and erroneous IV administration with associated adverse cardiac events. For the epinephrine auto-injector, unintentional administration to the digit was an error reported on multiple occasions. CONCLUSIONS: This scoping review highlights knowledge gaps and a diverse set of errors regardless of the approach to epinephrine preparation during management of anaphylaxis. There are more potentially life-threatening errors reported for epinephrine drawn up in a syringe than with the auto-injectors. The impact of these knowledge gaps and potentially fatal errors on patient outcomes, cost, and quality of care is worthy of further investigation.

Anesthesia Practice and Perioperative Outcomes at Two Tertiary Care Hospitals in Freetown, Sierra Leone.

BACKGROUND: Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone. METHODS: We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality. RESULTS: Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics. CONCLUSIONS: We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.

Leveraging Health Care Simulation Technology for Human Factors Research: Closing the Gap Between Lab and Bedside.

OBJECTIVE: We describe health care simulation, designed primarily for training, and provide examples of how human factors experts can collaborate with health care professionals and simulationists-experts in the design and implementation of simulation-to use contemporary simulation to improve health care delivery. BACKGROUND: The need-and the opportunity-to apply human factors expertise in efforts to achieve improved health outcomes has never been greater. Health care is a complex adaptive system, and simulation is an effective and flexible tool that can be used by human factors experts to better understand and improve individual, team, and system performance within health care. METHOD: Expert opinion is presented, based on a panel delivered during the 2014 Human Factors and Ergonomics Society Health Care Symposium. RESULTS: Diverse simulators, physically or virtually representing humans or human organs, and simulation applications in education, research, and systems analysis that may be of use to human factors experts are presented. Examples of simulation designed to improve individual, team, and system performance are provided, as are applications in computational modeling, research, and lifelong learning. CONCLUSION: The adoption or adaptation of current and future training and assessment simulation technologies and facilities provides opportunities for human factors research and engineering, with benefits for health care safety, quality, resilience, and efficiency. APPLICATION: Human factors experts, health care providers, and simulationists can use contemporary simulation equipment and techniques to study and improve health care delivery.

Comparatively Evaluating Medication Preparation Sequences for Treatment of Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized, Simulation-Based Study.

OBJECTIVES: To determine whether time to prepare IV medications for hyperkalemia varied by 1) drug, 2) patient weight, 3) calcium salt, and 4) whether these data support the Advanced Cardiac Life Support recommended sequence. DESIGN: Prospective randomized simulation-based study. SETTING: Single pediatric tertiary medical referral center. SUBJECTS: Pediatric nurses and adult or pediatric pharmacists. INTERVENTIONS: Subjects were randomized to prepare medication doses for one of four medication sequences and stratified by one of three weight categories representative of a neonate/infant, child, or adult-sized adolescent: 4, 20, and 50 kg. Using provided supplies and dosing references, subjects prepared doses of calcium chloride, calcium gluconate, sodium bicarbonate, and regular insulin with dextrose. Because insulin and dextrose are traditionally prepared and delivered together, they were analyzed as one drug. Subjects preparing medications were video-recorded for the purpose of extracting timing data. MEASUREMENTS AND MAIN RESULTS: A total of 12 nurses and 12 pharmacists were enrolled. The median (interquartile range) total preparation time for the three drugs was 9.5 minutes (6.4-13.7 min). Drugs were prepared significantly faster for larger children (50 kg, 6.8 min [5.6-9.1 min] vs 20 kg, 9.5 min [8.6-13.0 min] vs 4 kg, 16.3 min [12.7-18.9 min]; p = 0.001). Insulin with dextrose took significantly longer to prepare than the other medications, and there was no difference between the calcium salts: (sodium bicarbonate, 1.9 [0.8-2.6] vs calcium chloride, 2.1 [1.2-3.1] vs calcium gluconate, 2.4 [2.1-3.0] vs insulin with dextrose, 5.1 min [3.7-7.7 min], respectively; p < 0.001). Forty-two percent of subjects (10/24) made at least one dosing error. CONCLUSIONS: Medication preparation for hyperkalemia takes significantly longer for smaller children and preparation of insulin with dextrose takes the longest. This study supports Pediatric Advanced Life Support guidelines to treat hyperkalemia during pediatric cardiac arrest similar to those recommended per Advanced Cardiac Life Support (i.e., first, calcium; second, sodium bicarbonate; and third, insulin with dextrose).

Engaging staff to improve quality and safety in an austere medical environment: a case-control study in two Sierra Leonean hospitals.

QUALITY PROBLEM OR ISSUE: Inadequate observance of basic processes in patient care such as patient monitoring and documentation practices are potential impediments to the timely diagnoses and management of patients. These gaps exist in low resource settings such as Sierra Leone and can be attributed to a myriad of factors such as workforce and technology deficiencies. INITIAL ASSESSMENT: In the study site, only 12.4% of four critical vital signs were documented in the pre-intervention period. CHOICE OF SOLUTION: Implement a failure mode and effects analysis (FMEA) to improve documentation of four patient vital signs: temperature, blood pressure, pulse rate and respiratory rate. IMPLEMENTATION: FMEA was implemented among a subpopulation of health workers who are involved in monitoring and documenting patient vital signs. Pre- and post-FMEA monitoring and documentation practice were compared with a control site. EVALUATION: Participants identified a four-step process to monitoring and documenting vital signs, three categories of failure modes and four potential solutions. Based on 2100 patient days of documentation compliance data from 147 patients between July and November 2012, staff members at the study site were 1.79 times more likely to document all four patient vital signs in the post-implementation period (95% CI [1.35, 2.38]). LESSONS LEARNED: FMEA is a feasible and effective strategy for improving quality and safety in an austere medical environment. Documentation compliance improved at the intervention facility. To evaluate the scalability and sustainability of this approach, programs targeting the development of these types of process improvement skills in local staff should be evaluated.

Failure mode and effects analysis applied to the maintenance and repair of anesthetic equipment in an austere medical environment.

OBJECTIVE: Medical technology designed for Western settings frequently does not function adequately or as intended when placed in an austere clinical environment because of issues such as the instability of the electrical grid, environmental conditions, access to replacement parts, level of provider training and general absence of biomedical engineering support. The purpose of this study was to demonstrate the feasibility of applying failure mode and effects analysis as part of an implementation strategy for medical devices in austere medical settings. DESIGN: Observational case-study. SETTING/PARTICIPANTS/INTERVENTION: We conducted failure mode and effects analysis sessions with 16 biomedical engineering technicians at two tertiary-care hospitals in Freetown, Sierra Leone. The sessions focused on maintenance and repair processes for the Universal Anaesthesia Machine. Participating biomedical engineers detailed local maintenance and repair processes and failure modes, including resource availability, communication challenges, use errors and physical access to the machine. MAIN OUTCOME MEASURE(S): Qualitative descriptive themes in barriers perceived and solutions generated by biomedical engineers. RESULTS: Solutions generated involved redesigned work processes to increase the efficiency of identifying machine malfunctions, clinician engagement strategies, a formal plan for acquiring spare parts and plans for improving access to the machine. Follow-up interviews indicated solutions generated were implemented and perceived to be effective. CONCLUSIONS: This study demonstrates the feasibility of using the failure mode and effects analysis approach to improve implementation of technology in austere medical environments.

Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care.

OBJECTIVES: Enhanced recovery pathways (ERPs) are evidence-based approaches to improving perioperative surgical care. However, the role of electronic health records (EHRs) in their implementation is unclear. We examine how EHRs facilitate or hinder ERP implementation. MATERIALS AND METHODS: We conducted interviews with informaticians and clinicians from US hospitals participating in an ERP implementation collaborative. We used inductive thematic analysis to analyze transcripts and categorized hospitals into 3 groups based on process measure adherence. High performers exhibited a minimum 80% adherence to 6 of 9 metrics, high improvers demonstrated significantly better adherence over 12 months, and strivers included all others. We mapped interrelationships between themes using causal loop diagrams. RESULTS: We interviewed 168 participants from 8 hospitals and found 3 thematic clusters: (1) "EHR difficulties" with the technology itself and contextual factors related to (2) "EHR enablers," and (3) "EHR barriers" in ERP implementation. Although all hospitals experienced issues, high performers and improvers successfully integrated ERPs into EHRs through a dedicated multidisciplinary team with informatics expertise. Strivers, while enacting some fixes, were unable to overcome individual resistance to EHR-supported ERPs. DISCUSSION AND CONCLUSION: We add to the literature describing the limitations of EHRs' technological capabilities to facilitate clinical workflows. We illustrate how organizational strategies around engaging motivated clinical teams with informatics training and resources, especially with dedicated technical support, moderate the extent of EHRs' support to ERP implementation, causing downstream effects for hospitals to transform technological challenges into care-improving opportunities. Early and consistent involvement of informatics expertise with frontline EHR clinician users benefited the efficiency and effectiveness of ERP implementation and sustainability.

The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation.

INTRODUCTION: One in three patients is affected by diagnosis-related communication failures. Only a few valid and reliable instruments that measure teamwork and communication exist, and none of those focus on improving diagnosis. The authors developed, refined, and psychometrically evaluated the TeamSTEPPSⓇ for Improving Diagnosis Team Assessment Tool (TAT), which assesses diagnostic teamwork and communication in five critical teamwork domains and can be used to identify strengths and opportunities for improvement and monitor performance. METHODS: The TAT was administered as a cross-sectional survey to 360 health professionals across nine diverse US health systems. Content and construct validity were evaluated through pilot implementation and subject matter expert review. Reliability and internal consistency were assessed with Cronbach's alpha. To understand sources of variation in TAT scores and assess the tool's consistency across diverse health care organizations, generalizability theory (G-theory) was used. Best practices in screening for careless responding identified participants with random or nonvarying responses. RESULTS: Analyses indicated strong support for the tool. Content validity findings indicated that the TAT encompassed relevant diagnostic improvement teamwork and communication content. Construct validity, evaluated through pilot implementations, demonstrated the tool's effectiveness in assessing teamwork categories. Reliability analyses confirmed the TAT's internal consistency, with an overall Cronbach's alpha of 0.97. Each dimension of the TAT exhibited good reliability coefficients, ranging from 0.83 to 0.95. G-theory analysis showed that variations in TAT scores were primarily attributed to respondents (28.0%) and scale dimensions (59.6%); both are desirable facets of variation. Further, examination of careless respondents ensured the accuracy and quality of the results, enhancing the TAT's credibility as a valuable diagnostic improvement tool. CONCLUSION: Psychometric evaluation demonstrated that the TAT is a reliable and valid instrument for assessing teamwork and communication among and across diagnostic teams. The TAT adds a novel, evidence-based, psychometrically sound measurement tool to help advance diagnostic teamwork and communication to improve patient care and outcomes.

Multi-Team Shared Expectations Tool (MT-SET): An Exercise to Improve Teamwork Across Health Care Teams.

Care transitions among high-intensity units caring for patients with complex needs are a critical yet undeveloped area of patient safety research. In addition, effective communication and coordination across disciplines remain elusive. This study introduces and tests the Multi-Team Shared Expectations Tool (MT-SET), an exercise that aims to engage health care teams in eliciting needs and establishing agreed-upon expectations teams and individuals within a multi-team system have of one another. We piloted the exercise within hospital-based workflows for oncology inpatients and later adopted it to elicit data on mutual needs and expectations of teams across units involved in patient transitions in two patient safety projects. Our studies demonstrated that the exercise identified common cross-unit coordination problems of delays in care, unwanted variations in care, and lack of standardized communication among units. It also revealed mismatched prioritization of each of these problems between specific unit types. The participants reported that the MT-SET helped establish positive relationships for building better cross-unit and cross-disciplinary teamwork and coordination. There is a need for systematic approaches to understand and facilitate cross-unit communication and coordination in care delivery and transitions. Future studies should broaden the application of the exercise to additional types of multi-unit and multidisciplinary teams and observe intervention ideas generated from the exercise, as well as their implementation.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process.

OBJECTIVES: Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions. METHODS: We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model. RESULTS: We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions). CONCLUSIONS: Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Critical Behaviors for Perioperative Improvement Teams.

Effectively leading perioperative safety and quality improvement requires a multidisciplinary team approach. However, leaders are often left without clear guidance on how to assemble and manage teams in these settings. We employ a Delphi process to prioritize specific behavioral strategies surgical safety and quality leaders can use to improve their chances of success implementing improvement efforts. We present the panel's consensus practical guidance on designing, managing, sustaining, training their teams as well as managing team boundaries and the organizational context.