What is the OR Black Box?

On airplanes, black boxes record detailed information about flights. Now, a technology with the same name is being used in some hospitals to record information in the OR during surgeries.

The OR Black Box system, which was developed by Surgical Safety Technologies, consists of sensors and software that record video, audio, patient vital signs, and data from surgical devices. All personal information is immediately anonymized, blurring faces and bodies, and data is erased after 30 days.

The system provides multiple perspectives on an operation rather than just relying on team members' memories. It analyzes data and creates graphs, comments, timelines, videos, and audio clips for hospital personnel. Hospitals can use this data to view OR performance over time or analyze certain operations more closely.

"It's providing this treasure trove of data," said Jeff Salvon-Harman, VP of safety at the Institute for Healthcare Improvement. "It's giving us vast new insights into the quality of procedures and the quality of performance."

More hospitals are testing out black boxes

Currently, over two dozen hospitals in the United States and Canada have installed OR black boxes, and more are interested in implementing the technology.

For example, Duke Health originally added black box technology in two of its ORs four years ago. After implementing the technology, the health system discovered that OR staff was not following precise steps to prepare patients' skin before an incision — an issue that was quickly addressed.

"It's the simple things that we thought we were doing well," said Christopher Mantyh, professor of surgery and vice chair of clinical operations at the Duke University School of Medicine. "We looked at it – 'yeah, we're not doing this right.'"

"You're learning from your mistakes," he added. "The flip side of it is you're learning from your successes." This year, Duke plans to add five more black boxes, with four in ORs and one in the trauma bay.

The University of Texas Southwestern Medical Center has also used OR black box technology for a few years now, first introducing it in 2020. After reassuring team members about "how data would be collected and used, it quickly became an accepted part of the hospital's culture," said William Daniel, UT Southwestern's chief quality officer.

"The ability to watch ourselves is extremely powerful in education and our training as teams," Daniel added.

In Boston, two hospitals, Boston Children's Hospital and Brigham & Women's Faulkner Hospital, are currently testing out OR black box technology.

At Boston Children's Hospital, doctors are testing the technology in a simulated OR. According to Peter Weinstock, executive program director of the hospital's simulation center, the simulated OR is a "wonderful place to give people exposure [to the technology] in a professionally low-risk environment."

Faulkner Hospital is currently piloting the technology in two of its 16 ORs, and if successful, the technology could be adopted by the broader Mass General Brigham health system.

"The operating room has traditionally been a secretive place where we're not open to sharing things that happen there," said Douglas Smink, Faulkner's chief of surgery. Although Smink understands that the idea of being recorded is "uncomfortable," he noted that "it's in our best interest."

Concerns about black box technology

As interest in OR black box technology grows, some OR personnel have expressed concerns about patient privacy, liability, and whether data from the system could be used to discipline workers.

Although all information collected by black box technology is immediately de-identified, some workers say that it would not be hard to figure out who did what in a situation if the system is only running in certain ORs.

"Living in the age of technology, we all know that nothing that is recorded ever truly goes away," said Janet Donovan, an OR nurse at Faulkner and secretary of the Massachusetts Nurses Association's bargaining committee.

For his part, Smink said the hospital's intention is not to single out any individual person for mistakes. "It's about the system, and the team," he said. "Any one human could make a mistake. That doesn't mean they're a bad person, or they did poorly. … We want to identify common behaviors in our system, so that we can all benefit."

"The barrier [to implementing OR black boxes] is culture," said Teodor Grantcharov, inventor of the OR Black Box and a professor of surgery at Stanford University. "The operating room is one of the most secretive environments in modern society and changing that is not easy."

According to Advisory Board's director of international research Paul Trigonoplos, one way to gain clinician buy-in and trust with black box technology is to customize the system to match what surgeons and other clinicians are comfortable with.

For example, in Brazil, doctors were averse to having microphones in the OR but were more comfortable with cameras since CCTV is widely used in the country. Because of this, hospitals testing the black box technology implemented a camera-only version.

In general, black box technology is advanced enough to identify potential patterns or correlations in behaviors with any combination of tracking equipment, whether it's audio or video, so organizations don't need to go with the full capabilities if their staff isn't comfortable with that, Trigonoplos said.  (Freyer, The Boston Globe, 1/13)

Advisory Board has conducted research to better understand what role technology should (or shouldn't) play in supporting clinical staff. Read on to learn three key things about clinical workforce technology that we've found so far.