Reception to Honor FOCUS

On May 1, the SCA Foundation invites you to our annual reception recognizing the work of Bruce Spiess, M.D. and the FOCUS Committee in developing the FOCUS Initiative.

As part of the SCA Annual Meeting, the reception will be held at Vic’s on the River, 26 East Bay Street, in Savannah, GA from 6:00 pm – 8:00 pm.

We are excited to have in attendance our special guest, Paul H. O’Neill, former CEO of Alcoa Corporation, former U.S. Treasury Secretary, and SCA Annual Meeting Keynote Speaker. Mr. O’Neill transformed Alcoa Corporation in the 1990s by using Toyota Production System principles, making it the premier aluminum producer in the world. He then brought these same principles to the Pittsburgh Regional Healthcare Initiative to transform training of healthcare providers and delivery of healthcare. Mr O’Neill’s work has been highlighted in a recent article, by Culig et al (Improving patient care in cardiac surgery using Toyota Production system based methodology. Ann Thorac Surg 2011;91:394-400.)

The mission of FOCUS is to improve the care of patients undergoing cardiovascular procedures. FOCUS employs a rigorous social science and engineering methodology in order to develop and measure the effectiveness of our interventions on complex systems in the operating room and across the entire episode of care. Many of the FOCUS Initiative methods echo those of TPS, in rigorously identifying and removing defects in our delivery of cardiac surgical care.

On Sunday, May 1, you will have a unique opportunity to recognize this project and the work of the SCA Foundation. The $125 ticket price for the reception includes a donation to the SCA Foundation. In order to involve a newer member of your organization, consider sponsoring one of your fellows to attend the reception. Sponsored tables are also available to accommodate groups of 6 or more.

If you cannot join us in Savannah, we invite you to contribute to all the programs of the SCA Foundation or to honor this project by sending a donation. For more information, contact the SCA Foundation at or at 804-565-6324. You can also obtain information on our events online at the SCA Foundation website (

AHRQ Funds FOCUS Learning Collaborative

December 7, 2010 – Richmond, VA – The Agency for Healthcare Research and Quality (AHRQ) awarded a three year research grant of $4 million to the FOCUS initiative to improve teamwork to prevent infections in cardiac operations. This research is a joint collaboration of the Society of Cardiovascular Anesthesiologists (SCA) Foundation and the Quality and Safety Research Group (QSRG) at the Johns Hopkins School of Medicine.

Cardiac surgery is a high-risk procedure performed by a multidisciplinary team using complex tools and technologies. Efforts to improve patient safety and reduce human error for cardiac surgical patients have been ongoing for more than a decade, yet the literature provides little guidance regarding best practices for hazard identification and interventions to effectively reduce risk.

This three year study, led by Dr. Peter Pronovost, M.D., PhD, director of QSRG, uses the Comprehensive Unit Based Safety Program (CUSP) to improve teamwork and safety culture and technical interventions to prevent healthcare associated infections (surgical site infections, central line association bloodstream infections, and ventilator associated pneumonia).

“This study will examine whether a collaborative program to reduce infections and improve teamwork is more effective than the traditional passive method of sharing outcome data. This can positively impact cardiac surgery,” says Bruce Spiess, M.D., chair of the FOCUS initiative. Pronovost believes “For too long efforts to improve safety have been independent rather than interdependent, competitive rather than cooperative, and focused on efforts rather than results. In this project we will change this, working together, guided by science, informed by practice, we can reduce patient harm.”

Seventeen sites throughout the United States will participate in this study. The sites and primary investigators are:

Baystate Medical Center Springfield, MA

Anath Kashikar, M.D.

Bethesda North Hospital Cincinnati, OH

Elizabeth Burgess, M.D.

Duke University Durham, NC

Alina Nicora, M.D.

Lehigh Valley Hospital Allentown, PA

Nanette Schwann, M.D.

Liberty Hospital Liberty, MO

Mark Beltran, M.D.

Medical University of South Carolina Charleston, SC

James Abernathy, M.D.

New York University New York, NY

Marc Kanchuger, M.D.

San Francisco Veterans Affairs Medical Center San Francisco, CA

Martin London, M.D.

Shands Hospital at the University of Florida Gainesville, FL

Gregory Janelle, M.D.

Stanford University Stanford, CA

Christina Mora Mangano, M.D.

St. John’s Mercy St. Louis, MO

Christopher Young, M.D.

St. Lukes-Roosevelt Hospital Center New York NY

Zak Hillel, M.D.

University of Maryland Medical Center Baltimore, MD

Alina Grigore, M.D.

University of Miami/Jackson Memorial Hospital Miami, FL

Michael Barron, MD
University of Michigan Ann Arbor, MI

Wei Lau, M.D.

University of Pittsburgh Medical Center Presbyterian Hospital Pittsburgh, PA

Erin Sullivan, M.D.

University of Texas Southwestern Dallas, TX

Philip Greilich, M.D.

The FOCUS initiative is a multi-year, multi-center initiative, designed to examine the physical and cultural environment of the cardiac surgery operating rooms, and will seek to define processes by which the cardiovascular operative teams can reduce the occurrence of human error. Although every individual involved in cardiovascular operative patient care is dedicated to patient safety, the processes and communication patterns that exist frequently are inadequate to achieve the goal of absolute patient safety.

FOCUS takes pride in bringing together the key stakeholders in the operative cardiovascular surgery arena to not only study human error/patient safety but to take on the larger mission of changing patient care for the better. The FOCUS leadership has met with official representatives from four other academic societies: American Society of Extracorporeal Technology (AmSECT), Association of Operating Room Nurses (AORN), National Center for Human Factors Engineering in Healthcare (Medical HFE), the Society of Thoracic Surgeons (STS), and official collaboration of each society with the FOCUS project is currently being discussed.

The first step in the FOCUS initiative was an in-depth observation of the physical, interpersonal, and cultural environment in the cardiovascular operating rooms. The SCA Foundation funded the QSRG research team to conduct that baseline study. The results of that research helped inform the design of the new AHRQ funded grant.

The SCA Foundation, founded in October of 2007, is the philanthropic arm of the Society of Cardiovascular Anesthesiologists. The SCA Foundation advances cardiovascular patient safety and supports the continuous improvement of the cardiovascular anesthesiology profession.

The Society of Cardiovascular Anesthesiologists is an international organization of over 7,000 cardiac, thoracic, and vascular anesthesiologists that promotes excellence in clinical care, education, and research. Formed in 1977 to promote the specialty of cardiovascular anesthesia, it has grown rapidly with the expansion of cardiac, vascular and thoracic surgery. Over the past 30 years, the SCA has led the way in the training and certification of intra-operative echocardiographers, development of credentials for cardiovascular anesthesiology training (fellowship), and has collaborated with the wider medical community in setting guidelines for patient care.

Dr. Pronovost’s special interest is applying research methods that improve quality of health care and safety. In 2008, Dr. Pronovost was awarded a MacArthur Fellows Program grant. He is facilitating World Health Organization efforts to implement patient safety programs in several countries and is leading AHRQ funded efforts to replicate the Michigan program in every state in the U.S, the District of Columbia, and Puerto Rico.

FOCUS Update

Bruce D. Spiess, MD
Chair, FOCUS Committee

The FOCUS team, together with our research collaborators, the Quality and Safety Research Group at Johns Hopkins University, continue to forge ahead. The data collected during the literature review, analysis of the National Learning Reporting System, and observations at the five FOCUS sites, are being prepared for publication. Three publications, with joint authorship between SCA and QSRG members, have been submitted, with 5 additional manuscripts in preparation. The next phase of FOCUS is well underway, with QSRG developing tools to enhance teamwork and safety in cardiac surgery. FOCUS sites that indicated a primary interest in the Learning Collaborative are participating in the development of these tools, and will be pilot testing them in the near future.

The FOCUS team continues to seek participation and collaboration with the key societies involved in the cardiac operative setting. On Sept 16, a Society Summit was held in Boston, and was attended by the Presidents of the Society of Thoracic Surgery (Dr. Doug Mathisen), the American Society of Extra-corporeal Technology (Susan Englert), and the Society of Cardiovascular Anesthesiologists (Dr. Sol Aronson, President Elect). Dr. Bruce Spiess presented the history of FOCUS, and Dr. Elizabeth Martinez presented the work done to date, as well as the planned work. Although the FOCUS Steering Committee includes thoracic surgeons, perfusionists and nurses, participation and collaboration at the society level will enable the innovations and teamwork improvements of FOCUS to be disseminated and adopted more broadly

The FOCUS team attended the Lucian Leape/ National Patient Safety Foundation Forum in Boston on the afternoon and evening of September 16, 2010. A number of speakers reported on progress and recommendations from work groups within the Lucian Leape Institute. It was clear from listening to these reports that FOCUS is now and will be providing a vital research/interventional force to the movement to make medical care safer.

As a result of attendance at the Lucian Leape Forum, FOCUS has secured Paul O’Neill as the keynote speaker for the SCA Annual Meeting, in Savannah, Georgia, on May 2, 2011. Mr. O’Neill will talk on: “Leadership in High Reliability Organizations: Methods to Reduce Human Error. “ This keynote address will dove tail to the FOCUS session, held from 3:30 pm – 5:15 pm on May 2, 2011, where Mr. O’Neill will again appear on the panel to answer questions and provide discussion regarding FOCUS data and future programs.

Paul O’Neill has had an important career in private industry as well as public service. Mr. O’Neill served as the 72nd Secretary of the Treasury under George W. Bush (first term). Prior to this service, he had been CEO of Alcoa Corporation and the Rand Corporation. His experience from these leadership positions will form the basis for his address to the SCA and his participation in FOCUS. We hope as many members as possible will attend his address and hearing him speak is itself a reason to come to Savannah for the SCA Annual Meeting.

FOCUS Presentation at the ASA Meeting

By Bruce Spiess, M.D.

The FOCUS Initiative is a part of the program of the ASA Annual Meeting. Join us on Sunday, October 17 at 10:00 am -12:00 noon pacific time at the San Diego Convention Center, room Upper 1A for the presentation, “Patient Safety in the Complex Environment of the Cardiac Operating Room. “

Panelists for the presentation include Joyce A. Wahr, MD, Jeffrey Cooper, MD, Elizabeth A. Martinez, MD, Alan F. Merry, MD and Bruce D. Spiess, MD.

Pronovost Interviewed by New York Times

Dr. Peter J. Pronovost, 45, is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, which means he leads that institution’s quest for safer ways to care for its patients. He also travels the country, advising hospitals on innovative safety measures. The Hudson Street Press has just released his book, “Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out,” written with Eric Vohr. An edited version of a two-hour conversation follows.


John Melleky, SCA Foundation Executive Director

Anesthesia & Analgesia Spotlights the FOCUS Initiative

An introduction and update on the FOCUS initiative appears in two special articles, “Bring Your Life Into FOCUS “and “The Society of Cardiovascular Anesthesiologists’ FOCUS Initiative: Locating Errors Through Networked Surveillance (LENS) Project Vision” in the February 2010 issue of Anesthesia & Analgesia, the official journal of the International Anesthesia Research Society (IARS) and the SCA.

“Preventing humans from making mistakes may be nearly impossible, but the SCA FOCUS initiative is predicated on the strong belief that making an error-free medical environment can be achieved,” comments Dr. Steven L. Shafer of Columbia University, Editor-in-Chief of Anesthesia & Analgesia.

Read the full article in Anesthesia & Analgesia.

FOCUS Sets Priorities

By Bruce Spiess, M.D. and Joyce A. Wahr, M.D.

In 2009, the first year of the FOCUS research project, Dr. Peter Pronovost and the Quality and Safety Research Group (QSRG) at Johns Hopkins Hospital (JHU). completed an extensive review of the cardiac patient safety literature and reviewed the National Heath Service (United Kingdom) error reporting database, focusing on cardiac surgical errors. From this rich background, QSRG developed an in-depth, two-day observational process to research operating room factors that contribute to human errors. This observational process was conducted in cardiac operating rooms at five separate hospitals. At each of the five sites, surgeons, anesthesiologists, nurses, perfusionists, surgical technicians and hospital executive management personnel participated. Each individual completed extensive surveys on motivation and patient safety culture, and observations were conducted over several days at each site. The surveys and observations have been coded into a database and used to create a taxonomy of errors and to develop interventions. The data collected are both informative and distressing. For example, errors were made in nearly every skin preparation procedure, and in nearly every programming of the “smart” intravenous pumps. These errors were made despite the high level of motivation to provide flawless care by the OR staff who were surveyed. The data are currently being analyzed and will be presented in a series of publications over the next 6-12 months.

Although the full analysis of the observations will not be complete for some time, the FOCUS Steering Committee and QSRG have identified three priorities for interventions to improve patient safety.

1. Develop a learning collaborative within the cardiac surgical teams to enhance patient safety. This process will use the Michigan Keystone model developed by Dr. Pronovost and the QSRG team that has been so successful in eliminating catheter based infections in the ICU setting. The FOCUS learning collaborative will use reduction in wound infections as the metric that will inform us of how we are doing.

2. Develop a peer-to-peer assessment tool that can be used by operating room teams to assess their own safety performance, or be used by an invited visiting team to provide feedback regarding areas for improvement in safety. This non-judgmental, for-internal-use-only peer-to-peer assessment tool will be based on the highly successful WANO (World Association of Nuclear Operators) process that has made the nuclear industry a “highly reliable” industry.

3. Design the operating room of the future. Tackle the issues of equipment and OR design to improve the interfaces between humans and the machines they use to deliver patient care in the operating room.

The FOCUS committee is looking for more sites and individuals to get involved in the project, whether it is on a committee, on a workgroup of the three priorities above, or as a site for one of the workgroups. Committees that you can be involved in include Data, Fundraising/Grants, Public and Society Relations, Patient Safety Initiatives Liaison, Publications, Site Selection, Speaker’s Bureau, and Summit Planning. To get involved and for more details, contact the SCA Foundation at or call John Melleky, Executive Director at 804-565-6324.

A FOCUS Update

By Bruce Spiess, M.D.

The FOCUS Initiative is making strong progress through the summer months. At the SCA Annual Meeting in San Antonio, the curtains were pulled back for a slight peek into the initial data regarding human errors in the cardiac operating rooms. At that meeting the data was described as “robust”, meaning a number of problems had been uncovered. We are happy to report that since the Annual Meeting, the remainder of site visits and follow-up questionnaires have all been completed. The Johns Hopkins University Center for Innovation in Quality Patient Care (JHUIQPC) is now hard at work collating the data and inputting it into computers for analysis. That process is huge. As part of their analysis, JHUIQPC has undertaken a review of the data using the National Reporting and Learning System from the United Kingdom, which is the largest known error reporting system in the world.

FOCUS will convene a meeting in Baltimore at JHUIQPC on August 13, 2009 for an initial review of data. At this meeting a number or representatives from the FOCUS leadership, data management committee and consultants will be present as well as the JHUIQPC team. Importantly, leadership from the Society of Thoracic Surgeons and AORN are expected to attend. Enthusiasm from other associations is growing so that we can all work together to improve patient care. Letters and phone contacts have been completed to AMSECT and we hope to solicit their participation/sponsorship of FOCUS in the future.

The committees within the FOCUS Initiative have been formed and their charges have been given to them. Notably, the publications committee is moving forward with a written process with regards to authorship and participation in publications from FOCUS data. This process should be available to all for review through our FOCUS web site. Once our August meeting is complete, we will develop our next steps based on the data obtained at our initial sites. To become involved as a volunteer with FOCUS, you can contact the SCA Foundation via email at

FOCUS – Our Next Steps

By Dr. Bruce Spiess

FOCUS is very excited to announce that all the initial hospital sites have been visited and observed. The human factors research team employs a number of tools (called “LENS’) that have undergone validation and testing prior to being used as research tools in the present project. FOCUS is very proud to partner with the JHU Center on Quality Patient Care not only because of their and Dr. Pronovost’s international reputation, but also because it allowed both groups to further refine these human factors investigational tools. The tools employ survey instruments distributed prior to site visitation, extensive interviews with the entire operating room team (anesthesiology, surgery, perfusion and nursing) as well as the administration, on-site observation of cases, and post visitation surveys and interviews. The on-site team in a 2 day visit, examines communications, breaks in flow, ergonomics of equipment, and other systems constructs, all with a FOCUS upon how a team performs in a highly complex environment. The data from the various LENS’ are now being coded and collated. In discussions with the JHU team we are told: “The data is very rich, and full of possibilities for interventions that to improve patient safety – ones that can be done relatively easily and soon, and some that will take more earnest work”. What that means we cannot tell at this time, but suffice it to say that there will be directions and conclusions that can be drawn form this original first look inside the cardiac operating rooms.
What are the next steps?

Clearly we must finish what we have set out to accomplish, the first gathering of data and its analysis. As stated throughout the formation of FOCUS, this will be a scientific, data driven medical and sociological intervention. Until the data is analyzed, it is hard to say what interventions should proceed or in what order we should invoke changes. Although there is much data collected already, only five, albeit carefully selected and representative, sites have been studied. The FOCUS steering committee envisions that more sites should be studied (5-20 more), and that the beginning of a self-study program should be initiated. The form of the self-study tools will grow out of the data through a combined effort of the JHU human factors experts and the FOCUS Data Analysis Committee. It could well be that in the next 12 months we see the first recommendations from FOCUS come forward to be implemented and field tested at cardiac sites around the country. The on-going success of the FOCUS program itself is feeding back towards improving/reducing human error. By the existence and success of the initial site visits, national and even international curiosity is peaking. The FOCUS project is gaining exposure with reporting on the programs for educational meetings not only within the SCA but in other societies. The recent 14th Annual Update on Cardiopulmonary Bypass was held at Whistler, Canada March 14-20, 2009. At that meeting a session on patient safety was well received and the attendees asked for more and expanded sessions, workshops and team building training for future meetings all with the end goals of reducing human error in the cardiac operating rooms. So, in a small way the FOCUS program has already succeeded by creating buzz, discussion, and insight by the rank and file into how we go about delivering such complex care.

FOCUS has only begun – join us!