Communication in overlapping procedures: a checklist to support compliance

A proactive and well-designed communication and consent process will help lessen the chance of litigation should a patient experience an adverse outcome during or following an overlapping surgery, says Aaron Fink, professor emeritus of surgery at Emory University School of Medicine.

The August 2016 Boston Globe series about overlapping and concurrent surgeries further focused the attention of risk managers and the general public on such situations. In addition, the series emphasized the need to inform patients of their physicians’ involvement in such surgeries. Growing consumer awareness is but one reason why risk management and compliance professionals must stay up to date with relevant definitions and guidelines from the American College of Surgeons (ACS), while also ensuring appropriate informed consent processes.

In brief, so-called “concurrent” surgeries occur when a physician is responsible for key components of two operations that are occurring at the same time. The ACS indicates that except in extremely rare circumstances, the primary attending surgeon’s simultaneous involvement in the critical portions of two different patient cases in two different rooms is “not appropriate.”

On the other hand, “overlapping” surgeries happen when the primary surgeon completes the key elements of the first operation before starting another surgery in a second room. In these instances, the ACS states that the surgeon’s involvement in both procedures is acceptable as long as a qualified practitioner performs the non-critical parts of the first surgery. In addition, the primary surgeon must assign responsibility for the first procedure to another attending surgeon who is either present or immediately available if required.

“Disclosing that a surgeon is involved in overlapping surgeries is not enough; patients need to understand what the practice involves and how it applies to their particular surgical case.”

The Boston Globe series focused on a malpractice suit filed by a patient who became paralyzed following an overlapping surgery at Boston’s Massachusetts General Hospital. The Globe reported that the patient was not informed that during the course of his procedure his primary surgeon would periodically leave the operating room to operate on a second patient in a different room. The hospital stated that in their subsequent investigation they found no difference in complication rates for overlapping and non-overlapping surgeries. Healthcare Risk Management also recently cited a review by AHC Media of data demonstrating “no indication of a correlation” between multiple surgeries and malpractice cases.

Nevertheless, Massachusetts General still had to contend with the lawsuit as well as the publicity precipitated by the Boston Globe article. In response, the hospital released an unusually detailed statement on its website. Seeking to support their position, this statement was accompanied by specific content about concurrent and overlapping surgeries. This information-laden response exemplifies the potential benefits that risk managers may achieve by proactively monitoring surgical team procedures and consent processes related to overlapping surgeries.

Help patients understand process, benefits

Overlapping procedures are performed routinely, especially in academic medical centers and trauma centers. They do have certain benefits including affording patients improved access to highly sought-after surgeons—a factor that can be very important in complex cases where unique medical expertise is required. These surgeries also provide increased learning opportunities for surgical residents. Additionally, patients tend to experience shorter wait times on the day of their procedures, which in turn may enhance overall patient satisfaction.

However, patients should be made aware of whether a provider other than their primary surgeon will be involved in parts of their surgery, as well as whether the case might be part of an overlapping schedule. With an eye towards patient safety, healthcare providers and risk managers should develop a strong communication process that clearly informs patients about:

• Their specific procedures; 
• The surgical process that will be followed during their procedures; and 
• The medical staff involved in their care.

Checklist for improved compliance

Given the explosion of media coverage and online content about medical errors and healthcare malpractice suits, patients are clearly more cognizant of the complexities of major surgeries. In fact, when informed that their surgeon might be scheduled for overlapping procedures, without appropriate context and background information, some patients might opt to forego their procedure or even select another provider.

Failing to inform patients about the role of the attending physician ignores guidance provided in the Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines. In addition, this shortfall may also place providers and organizations at risk if a patient’s expectations about her or his surgeon’s role don’t align with the realities of surgical suite scheduling.
The following seven-step checklist can help risk managers review their organizations’ communication and consent processes regarding such situations:

Have a policy. Facilities may have slightly different definitions of overlapping surgery due to the types of operations commonly performed at each organization. Thus, every facility should clearly define pertinent definitions and policies based on institutional factors such as facility conditions, patient populations, ancillary services and training/teaching roles.
Particular attention should be paid to details such as defining the critical and non-critical parts of each operation as well as outlining what “immediately available” constitutes within the surgical setting. At the same time, limits should be defined as to who can do multiple surgeries and how much they can overlap.

Educate the patient. Disclosing that a surgeon is involved in overlapping surgeries is not enough; patients need to understand what the practice involves and how it applies to their particular surgical case. Some organizations use a patient education tool that explains the role of various providers and how some surgical cases may run sequentially. In many cases, technology such as automated consent tools can ensure that the provision of this type of patient education material is documented in the patient’s record within the EHR.

Check informed consent language. Simply appending exhaustive legal boilerplate language to all consents to cover all scenarios is both confusing to patients and potentially harmful to the organization. Instead, informed consents should include language about alternative providers involved in overlapping surgery only when such a situation is certain or likely. Automated informed consent tools can support this goal by selectively populating such information on the consent form only when appropriate.

Discuss before signing. The informed consent process must not be viewed merely as a collection of signatures on a form; instead, the process must include a discussion of the items critical to the patient’s understanding about the planned intervention. Clearly the roles of various care providers should be a central part of such a discussion.

Gain consent early. Waiting until the day of surgery to have the informed consent discussion and acquire the patient’s signature puts the patient and physician in a precarious situation. Patients may not comprehend the facts about overlapping surgery or have adequate time to formulate any questions and have those questions answered to their satisfaction.

Assign an OR communications leader. Communication among providers also is key to knowing who is doing what and who bears ultimate responsibility for the patient at any particular time in the surgical suite. Identifying a team leader to coordinate communication helps optimize scheduling of overlapping procedures while ensuring that such scheduling does “not negatively impact the seamless and timely flow of either procedure.” Further, a team leader can help ensure an institution’s adherence to the ACS standards.

Document OR details. The ACS guidelines are designed to anticipate multiple different circumstances. However, each institution should define the requirements and oversee the documentation process. For example, consider documenting which activities are being performed by whom in the OR, when people enter and leave the OR, the portions of the procedure where the surgeon was present, and surgical outcomes (including any adverse outcomes). It’s also important to have a means of verifying compliance with these requirements.

Improve communication to reduce risk

The Bulletin of the American College of Surgeons recently reported on informed consent inadequacies and some of the benefits of an automated approach toward gaining consent. It notes that electronic applications can help guide the consent conversation and ensure that all applicable items are covered when discussing a procedure with the patient—including instances when the surgeon might be involved in overlapping procedures.

An automated approach can simplify and streamline the informed consent process while also improving communication, documentation and compliance. With a proactive and well-designed communication and consent process in place, healthcare organizations may help lessen the chance of litigation—and any resultant public relations fallout—should a patient experience a less-than-satisfactory outcome during or following an overlapping surgery.

Aaron Fink, MD, FACS, is professor emeritus of surgery, Emory University School of Medicine.