MSS850: BUILDING A SHARED MENTAL MODEL OF THE CRITICAL VIEW OF SAFETY: A PROSPECTIVE EDUCATIONAL QUALITY-IMPROVEMENT INITIATIVE
Melissa Burns, MD1; Megan Breckheimer, MD1; Lily Johnson2; Joseph Aryankalayil, MD1; Christopher Dyke, MD, FASMBS1; 1Walter Reed National Military Medical Center; 2Uniformed Services University of the Health Sciences
Objective: The Critical View of Safety (CVS) is essential for safe laparoscopic cholecystectomy, yet variability in how trainees conceptualize and assess the CVS has not been studied. This project aims to (1) improve the accuracy and consistency of trainee knowledge of the CVS across postgraduate levels and (2) standardize evaluation of CVS images so that all residents develop a shared mental model of an adequate CVS. The ultimate goal is to align operative expectations across the program and promote safer surgery.
Methods: This is a prospective educational quality-improvement initiative within a single academic military medical center. Data collection began in July 2025. Weekly academic sessions integrate conceptual and applied learning through QR code–based surveys. For the conceptual component, a QR code links to a free-text prompt: “What is the Critical View of Safety?” Anonymized responses are scored by two independent raters according to whether 1, 2, or all 3 elements of the CVS are accurately described with a third rater who adjudicates disagreements. For the applied component, a second QR code presents a video of the intraoperative CVS from that week’s cases. Respondents (Medical students, general surgery residents, staff) answer yes/no questions on whether each CVS element is achieved. Responses are analyzed for variability across postgraduate year levels.
Results: Sixty-three responses were collected using the free-text prompt to describe the components of a CVS. There was greatest variability in describing the clearance of fibrofatty tissue from the hepatocystic triangle. Amongst the resident classes, the variability on correctly describing clearance of the hepatocystic triangle ranged from 0% to 80% without correlation with higher training level (spearman rank correlation 0.61, p=0.15). Even amongst staff two of nine respondents (22.2%) correctly stated the hepatocystic triangle must be cleared of fatty and fibrous tissue. Regarding the applied component involving rating of CVS images, ninety-three responses were collected. When staff noted an appropriate CVS, the scoring was homogenous between residents and staff. When staff were more critical of the CVS, medical student and resident interpretation showed more variability (Figure 1).
Conclusion: While CVS criteria are well defined, knowledge gaps exist at all levels of training. This leads to varying interpretations of the CVS especially when it is not obviously obtained. Data will be collected longitudinally using the methods described above to determine if resident scoring becomes more homogenous and closer to staff scoring over time indicating a shared mental picture of what makes up the CVS.
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