Domain 3: Colleagues, culture and safety
'Domain 3: Colleagues, culture and safety' is the third domain of Good Surgical Practice, which sets standards for surgeons and members of the surgical team. Good Surgical Practice uses the same headings that appear in Good Medical Practice and is the surgical companion to these General Medical Council (GMC) standards.
3.1. Contributing to a positive working and training environment
3.3. Training, teaching and supervising
3.4. Continuity and coordination of care
3.5. Record your work clearly, accurately and legibly
3.6. Respond to risks to safety
3.7. Protect patients and colleagues from any risk posed by your health
The provision of high-quality surgical services requires effective teamworking in and between teams. Good practice rests upon collegiality, a culture of openness, supportive discussion and accountability to offer safe and effective care to patients. Employers have a responsibility to build a culture in which all staff can work in an environment that is free from fear of intimidating behaviour. Surgeons also have a duty to work with management to promote a working environment that is positive, fair, free from discrimination and intimidation, and where everyone is respected and valued as an individual. Constructive teamworking enhances the performance of surgical teams and results in good outcomes for patients. Surgeons should comply with the codes of conduct of their respective surgical college and surgical specialty association.
3.1. Contributing to a positive working and training environment
In meeting the standards of Good Medical Practice, you should:
- Be aware of the impact of your own behaviour on the people around you, and particularly on resident doctors and trainees.
- Be mindful that your behaviour serves as a role model to more junior members of the team and set an example to other colleagues in your team by behaving professionally and respectfully towards all team members.
- Communicate respectfully with colleagues and refrain from dismissive or intimidating behaviour and inappropriate, offensive or pejorative language, including swearing.
- Be accessible and approachable to colleagues.
- Not abuse your position in any way, including by making any form of sexual advance towards students or trainees, pressurising them into intimate relationships, or through any form of sexual harassment, coercive/controlling or predatory behaviour.
- Support colleagues who have problems with performance, conduct or health.
- Challenge counterproductive behaviour in colleagues constructively, objectively and proportionately.
- Be mindful of and support colleagues against unwanted conduct of a sexual or hostile nature that violates their dignity and creates an intimidating, degrading, humiliating or offensive environment.
3.2. Teamworking
- Attend multidisciplinary team meetings and morbidity and mortality meetings, and engage in systematic review and audit of the standards and performance of the team.
- Work effectively and amicably with colleagues in the multidisciplinary team, arrive at meetings on time, share decision making, develop common management protocols where possible and discuss problems with colleagues.
- Engage in and encourage reflection and learning from the activity of the multidisciplinary team and take appropriate action in response.
- In addition to patient feedback (see 1.1.15), ensure that you undertake at least one full multisource feedback exercise in each revalidation cycle, using your colleagues’ feedback on your clinical performance and professional behaviour as a basis for reflection, self-evaluation and discussion at appraisal.
- Understand and respect the roles and views of other members in the team. You should promote well-structured and inclusive processes that encourage contributions of all members and ensure that the views of new and junior members are taken into account.
- Encourage a culture of safety, candour and constructive challenge in your team, in which difficulties and problems that may cause harm to the patient can surface and be openly discussed and mitigated.
- Ensure that each member of your team understands their own and each other’s role and responsibilities.
- Ensure that new members of the team, including locum surgeons, are not isolated.
- Ensure that members are fully conversant with the routines and practices of the team and know from whom to seek advice on clinical or managerial matters.
- Be mindful of the risks of diffusion of responsibility in the multidisciplinary team setting and the wider hospital setting, and ensure that shared and corporate responsibility does not interfere with or diminish your own professional responsibility to your patient.
- Always respond to calls for help from trainees, colleagues and other members in the surgical team. If unexpected circumstances require staff to act beyond their practised competencies, you should provide support for colleagues in making the care of the patient the first concern.
- Encourage and be open to feedback from colleagues, including junior colleagues, and be willing to reflect on feedback about your own performance and behaviour and acknowledge any mistakes.
- Willingly and openly participate in regular appraisal of yourself, resident surgeons and other staff.
- Take responsibility to act as a mentor to less-experienced colleagues. You should also take responsibility to seek a mentor to reflect on your practice and improve your own skills at any point in your career and particularly when taking on a new role.
3.3. Training, teaching and supervising
Surgeons often take an active role in teaching other surgeons, resident doctors and other members of the surgical care team. Surgeons should maintain and develop their skills as supervisors, trainers and educators, in line with their roles and responsibilities, and strive to create a learning environment suitable for teaching, training and supervising. When providing an assessment, a surgeon must include only accurate and verifiable information, ensuring that all feedback is respectful and timely. Surgical educators and trainers should ensure there is a balance between teaching surgical knowledge and training practical skills.
In meeting the standards of Good Medical Practice, you should:
- Support those under your supervision to carry out learning and development activities identified by appraisals or performance systems.
- Ensure that you provide appropriate supervision that minimises risks to patients and maintains responsibility for patient welfare, whether through close personal supervision or through a managed system with clear reporting structures.
- Be satisfied that those under your supervision have the necessary knowledge, skills and training to carry out their roles.
- In accordance with your educational role, take responsibility for the teaching and training of future surgeons, resident doctors, medical students and other members of the surgical team. This should include appropriate emphasis on the practical skills of surgery, alongside general surgical knowledge.
- Give honest and respectful feedback on progress and performance and assist in a remediation programme when asked to do so.
- Participate in surgical audit, self-assessment and reflection through established processes to maintain competence as a teacher, trainer and supervisor.
- Ensure that those under your supervision are safe in the workplace, addressing issues that may impact on their physical, psychological and emotional health.
- Encourage your students, trainees and supervisees to attend courses and workshops when this does not compromise patient care or service delivery.
- Do not discriminate against, bully, undermine or sexually harass a student, resident doctor or any member of the surgical care team.
- Do not make prejudicial decisions or judgements that are influenced by a resident doctor’s age, gender, marital status, ethnicity, religion, lifestyle, sexual orientation, gender identity, culture or disability.
- Be honest, factual and objective when providing an assessment.
- Participate in the assessment process and communicate assessment results in a constructive and supportive manner.
- Provide a satisfactory assessment only when this is justified.
3.4. Continuity and coordination of care
Effective continuity of care is vital in protecting patient safety. It is the duty of every surgeon to convey appropriate clinical information to oncoming healthcare professionals to allow the safe transfer of responsibility for patients.
In meeting the standards of Good Medical Practice, you should:
- Ensure that the patient knows the name of the person responsible for their care. If the responsible person changes, this should be promptly communicated to the patient.
- Where this is appropriate, ensure that only one team is responsible for the patient’s care at any one time. If the patient’s care is shared with other specialty teams, one of those teams should be coordinating the patient’s care across all teams.
- Ensure that sufficient protected time within working hours is set aside for handover.
- Ensure that there is a formal and explicit handover for the assessment, treatment and continuing care of patients for whom you are responsible to another named colleague following periods of duty or when you are unavailable for any reason.
- When transferring care to an oncoming team, ensure that team members have access to all necessary clinical information about the patient. The patient’s notes should be clear and sufficiently detailed, taking into account the level of knowledge of the oncoming team members. All notes should be traceable to the referring surgeon.
- Be prepared to take responsibility for patients under the care of an absent colleague even if formal arrangements have not been made.
3.5. Record your work clearly, accurately and legibly
Surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained of all their interactions with patients.
In meeting the standards of Good Medical Practice, you should:
- Ensure that all medical records are accurate, clear, legible, comprehensive and contemporaneous, and have the patient’s identification details on them.
- Ensure that all records make use of or are compatible with local electronic health record systems so that they can be shared securely with colleagues and patients and reused safely in an electronic environment.
- Take part in the mandatory training on information governance offered by your organisation, including training on data protection and access to health records. All use and storage of patient data should comply with the guidelines of the Data Protection Act 2018.
- Ensure that when members of the surgical team make case note entries these are legibly signed and show the date, and in cases in which the clinical condition is changing, the correct time.
- Ensure that a record is made of the name of the most senior surgeon seeing the patient at each visit.
- Ensure that a record is made by a member of the surgical team of important events and communications with the patient or supporter (eg prognosis or potential complication). Any change in the treatment plan should be recorded.
- Ensure that there are clear (preferably typed) operative notes for every procedure. The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. The notes should include:
- date and time
- elective/non-elective procedure (see 1.3 for classification of non-elective surgery)
- names of the operating surgeon and assistant
- name of the theatre anaesthetist
- operative procedure carried out
- incision
- operative diagnosis
- operative findings
- any problems/complications
- any extra procedure performed and the reason why it was performed
- details of tissue removed, added or altered
- identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials
- details of closure technique
- estimated blood loss
- antibiotic prophylaxis (where applicable)
- deep vein thrombosis prophylaxis (where applicable)
- detailed postoperative care instructions
- signature (handwritten or electronic).
3.6. Respond to risks to safety
Every surgeon, regardless of seniority or grade, must put the care and safety of patients above all other considerations and take action or speak up through the appropriate channels when concerns arise.
In meeting the standards of Good Medical Practice, you should:
- Recognise that your primary accountability is to the patient and support a culture of openness, honesty and objectivity in which concerns can be raised safely by all staff members.
- Act promptly to rectify, or notify those responsible for rectifying, any incidents of poor quality of care or shortfalls in resources that might compromise safe care, including suitable facilities, equipment and support services.
- Raise concerns at the earliest opportunity when you have reasonable belief that the care and wellbeing of patients or colleagues may be put in jeopardy for any reason. Such a reason may include the conduct, performance or health of a colleague, as well as inadequate resources, systems and policies. You should not assume that someone else will take action. If you have concerns about patient safety, it is your responsibility to establish whether action is already being taken.
- Use local policies and resources for raising concerns in the first instance. Normally, you should raise your concerns to your immediate superior, followed by the medical director and the chief executive, as appropriate.
- Escalate your concern to the appropriate regulator if you have not been satisfied that your concern has been adequately addressed through local channels. Concerns around the organisational standards of quality and safety should be escalated to the Care Quality Commission (for England), the Care Inspectorate (for Scotland), or the Regulation and Quality Improvement Authority (in Northern Ireland). Concerns about the fitness to practise of colleagues should be raised with the GMC or other appropriate regulator (eg the Nursing and Midwifery Council).
- As a final recourse, if neither local nor regulatory processes have appropriately addressed your concern, bring your concern to the attention of the general public. You should seek advice before going public with your concern as outlined in the GMC guidance Raising and Acting on Concerns about Patient Safety.
- Support others who are taking steps to raise valid concerns on patient safety. You must ensure that your own knowledge, understanding and any evidence of wrongdoing available to you is put at the service of the person leading the response to a concern.
- Keep a dated and verifiable record of how you have raised your concerns, including notes of any supporting evidence, taking into account patient confidentiality.
- Not conflate a legitimate concern around patient safety with a personal grievance.
- If you have both a concern around care quality and a personal employment grievance, you should pursue these separately
- Be familiar with local processes and agreed thresholds for recording adverse incidents and keep a record of incidents in which you have been directly involved. You should report such incidents to those responsible in your hospital and, where relevant, to a local audit meeting.
- Make full use of local electronic systems for reporting incidents and adverse events. You should reflect on adverse incidents in which you have been directly involved and present them for discussion at appraisal.
3.7. Protect patients and colleagues from any risk posed by your health
Surgeons have a duty to maintain safe care at all times and not to work in any health state that might impair judgement and/or jeopardise patient safety. You should:
- Not work when your health is adversely influenced by fatigue, illness, disease, drugs or alcohol.
- Recognise when your health state might impair your judgement or jeopardise patient safety. You should promptly seek independent medical advice and devolve clinical responsibility to an appropriately qualified colleague.
- Take precautions against the transmission of blood-borne viruses by following established guidelines when operating on high-risk patients or in the event of a needlestick injury.
- Exercise a duty of care in terms of reporting serious communicable disease or health states in yourself or colleagues that might jeopardise safe patient care.
- Be aware of health and safety regulations with respect to your practice and follow relevant guidelines, including local vaccination and immunisation requirements.
3.8. Sustainable operating
Sustainability is a challenging aspect of surgical practice, but with the rise of greenhouse gases as one of the biggest current global health threats and the heavy environmental impact of operating theatres, surgeons and surgical teams can play a part in improving the sustainability of the operating theatre by adopting small sustainable practices that maintain patient care and support environmental health.
Surgeons should follow the recommendations of RCS England’s guidance on Sustainability in the Operating Theatre as follows:
- Reduce solid waste by correct waste segregation, optimising the contents of surgical kits, reusing products and instruments where appropriate and as indicated by the World Health Organization, and recycling clean plastic, paper and other materials.
- Support environmentally preferable purchasing in your hospital by working with managers of surgical units to incorporate environmental sustainability into purchasing decisions.
- Encourage energy-efficient electricity usage initiatives such as motion-sensitive lighting in public areas and ‘power-down’ initiatives in which specific teams take responsibility for switching off computers, lights, equipment and other electrical devices on weekdays and weekends at set times designated as ‘power-down’ times.
- Make a conscious effort to conserve water.
- Engage in quality improvement initiatives relating to sustainability