During the fall 2018 in-person meeting of AAOS’ Patient Safety Committee (PSC), members discussed methods for creating a culture of safety and enjoyment in orthopaedic surgery. David C. Ring, MD, PhD, chair; and committee members Michael R. Marks, MD, MBA; Michael T. Archdeacon, MD; Todd Soung Kim, MD; Dwight W. Burney III, MD; and AAOS Medical Director William O. Shaffer, MD, addressed the value of feedback and coaching to enhance individual and team performance as well as contentment and fulfillment at work.

Dr. Marks: You’d be a fan of 360s.

Dr. Ring: I’m a fan of requesting numerical ratings and verbatim feedback from people you work with who have less, similar, and greater status than yourself (typically referred to as 360-degree feedback surveys). I’ve personally benefited greatly from them. We have found that 360s correlate with patient ratings, because our colleagues see situations similar to how patients do. Feedback surveys are an opportunity for ongoing self-awareness, humility, curiosity, openness, and a growth mindset. Automated 360 feedback surveys run through computers using email lists and are relatively inexpensive. The coaching based on the feedback received can be costlier. In my opinion, effective organizations set up measurement strategies that identify opportunities for growth and improvement at the individual, team, and organizational levels.

Dr. Archdeacon: For the past four years, we’ve invested in 360s. We pick four individuals a year and provide them with a professional training program. It involves 360 evaluation, fatigue assessment, self-awareness, and coaching—a whole program. A question from a business perspective is, “What’s the return on that investment?” It’s pretty hard to objectively measure this. Subjectively, four years in, we see fewer behavioral issues. We’ve had fewer mistakes in the operating room and fewer sentinel events in the department. We’ve been able to standardize more care across the department because we are focused on the big picture.

Dr. Ring: How do you choose the four people?

Dr. Archdeacon: We start with the leadership, then we go down the line.

Dr. Ring: That’s the way to do it.

Dr. Archdeacon: We ask people if they’re interested.

Dr. Ring: Start with leaders and early adopters.

Dr. Kim: An incentive for a group might foster a team approach rather than me trying to dump off the hard patients on my colleague. In my setting, our primary care physicians were burned out from spending so much time with their online messaging. It was helpful for them to set up some financial acknowledgement of that time.

Dr. Burney: All of this we’re talking about requires work. It is emotional labor. It requires time to do this well. How can we move this to the forefront of priorities?

Dr. Ring: And the technical part of what we do becomes easy, at least for the common things. We distract ourselves and get into the minutiae that may not matter like, “Should I use the high flex knee? Should I use the new scope or the laser?” That probably doesn’t matter very much. The nontechnical skills may merit more of our attention.

Dr. Shaffer: One of the things I’m hearing is that there are epiphanies—events and moments when we become more self-aware. It is different for each of us. We usually become self-aware by getting through a difficult time.

Dr. Ring: That’s where the 360s come in. It can be a wake-up call or call to action—without the challenging life event. Lawsuits and specific quality events can prompt self-awareness and growth. Other safe opportunities for feedback to enhance awareness and identify opportunities for coaching include patient surveys.

And those events can’t be about, “We’ll sweep it under the rug,” or “One more time and you’re out.” It has to be, “How are you doing? What’s going on in your life? How can we help? We want you to succeed.”

Dr. Burney: I think what we’re talking about with those epiphanies is something that’s there—that we’ve been managing to compartmentalize—but all of sudden, we have to face. It is like tripping over the obvious.

Curiosity and humility about our nontechnical skills can lead to invigorating opportunities. Devoting time to such skills can lead to more rewarding and effective work. The resulting culture of growth and teamwork can reduce adverse outcomes and make work more enjoyable.

David C. Ring, MD, PhD, is chair of the AAOS PSC.