Disclosure StatementDisclosure Statement

“I have no financial disclosures to report but I am employed by the

South Carolina Hospital Association.”

Transforming Surgical Care through Transforming Surgical Care through Team-based CommunicationTeam-based Communication

Palmetto Health System PresentationPalmetto Health System Presentation

August 12, 2010August 12, 2010

Redesigning Health SystemsRedesigning Health Systems

“The American healthcare delivery system is in need of fundamental change….Healthcare

today too frequently harms and routinely fails to deliver its potential benefit…. Between the

healthcare we have and the care we should receive lies not just a gap, but a chasm”

If 99.9% Were Good Enough…If 99.9% Were Good Enough…

• IRS lost documents 2 million per year

• Major plane crashes 3 per day

• Lost items in mail 16,000 per hour

• ATM errors 37,000 per hour

• Pacemaker incorrectly installed 291 per year

• Babies given to wrong parent 12 per day

• Erroneous medical procedures 107 per day

IOM ReportIOM Report• Deaths due to medical errors exceed the number

attributable to 8th leading cause of death.

• More people die in given year as result of medical errors than from motor vehicle accidents, breast cancer or AIDS

• Medication errors alone estimated to account for over 7,000 deaths annually

• Up to 100,000 deaths due to healthcare-associated infections- vast majority are preventable

• Total national costs of preventable adverse events are estimated to be between $17 - $29 billion

IOM Six AimsIOM Six Aims for Improvementfor Improvement• Patient care that is:

• Safe- avoidance of unintended pt. harm• Effective- evidence-based• Patient-centered- focused on needs and

rights of the individual patient• Timely- avoidance of delays & barriers to

patient care flow• Efficient- elimination of waste• Equitable- fair access to comparable

health care services for all

““My Mom” Quality/Safety StandardMy Mom” Quality/Safety Standard

How would you want your Mom treated at your hospital?

Every patient in your hospital expects and deserves that same high level of care/safety

Now we have to prove how well we’re performing under this “My Mom” standard

Vision:Vision: That all SC hospitals and providers deliver safe, high quality healthcare in a caring and compassionate manner to

each patient, every time

Mission:Mission: To establish a culture of continuous improvement in the quality, efficacy and safety

of patient care across all healthcare organizations and

providers statewide

Redefining Performance ExcellenceRedefining Performance Excellence

What is the ultimate we believe our hospitals can and should accomplish to

dramatically improve the safety and quality of the care and the health of the

patients they serve?

“Rather than uncoordinated, episodic care, we need to offer care that is well organized, coordinated, integrated, characterized by effective communication,

and based on continuous healing relationships” -Eric Larson

Creating a Culture of SafetyCreating a Culture of Safety

• Acknowledgement of the high-risk, error-prone nature of an organization’s activities

• Blame-free environment where individuals are able to report errors and close calls without punishment

• Expectation of collaboration across ranks to seek solutions to vulnerabilities

• Willingness on the part of the organization to direct resources to address safety concerns.

Communication and EducationCommunication and Education

• Create an environment of mutual trust, respect and psychological safety

• Actively support open communication and courageous dialogue system-wide

• Establish a Leadership orientation/training program to ensure “quality literacy/competency”

• Promote an active learning process for all clinical staff including physicians (including access to simulation training)

Why Communication ?

* The overwhelming majority of medical errors involve communication failure

* Wrong site surgery - somebody knows there’s a problem but can’t get everyone in the same movie – often it’s hard to speak up

* The clinical environment has evolved beyond the limitations of individual human performance

Crew Resource ManagementCrew Resource Management

Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making

Non-punitive reporting of near misses, 500,000 reports over 15 years

Very open culture with regard to error and safety

The Safe Surgery Saves Lives The Safe Surgery Saves Lives ProgramProgram

The ProblemThe Problem

The 3 Central Problems in Surgical Safety The 3 Central Problems in Surgical Safety Throughout the WorldThroughout the World

• Unrecognized as public health issue

• Lack of data on surgery and outcomes

• We know what to do, but we don’t do it consistently

Four Categories for Surgical Four Categories for Surgical Standards:Standards:

CONTROL OF INFECTION AND

CONTAMINATION

ANESTHESIA AND PATIENT

MONITORING

SURGICAL OPERATOR QUALITY ASSURANCE

WHO’s 10 Objectives for Safe SurgeryWHO’s 10 Objectives for Safe Surgery1. The team will operate on the correct patient at the correct site.

2. The team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain.

3. The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function.

4. The team will recognize and effectively prepare for risk of high blood loss.

5. The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

WHO’s 10 Objectives for Safe SurgeryWHO’s 10 Objectives for Safe Surgery6. The team will consistently use methods known to minimize the

risk for surgical site infection.

7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds.

8. The team will secure and accurately identify all surgical specimens.

9. The team will effectively communicate and exchange critical information for the safe conduct of the operation.

10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.

Why a Checklist?

Pilot Study

London, UK EURO EMRO

WPRO I

SEARO

AFRO

PAHO I

Amman, JordanToronto, Canada

New Delhi, India

Manila, Philippines

Ifakara, Tanzania

WPRO II

Auckland, NZ

PAHO II

Seattle, USA

International Pilot Study 8 Evaluation Sites - Nearly 8,000 Patients

Site CasesInpatient

ComplicationInpatient Death

1 524 11.6% 1.0%

2 357 7.8% 1.1%

3 497 13.5% 0.8%

4 520 7.5% 1.0%

5 370 21.4% 1.4%

6 496 10.1% 3.6%

7 525 12.4% 2.1%

8 444 6.1% 1.4%

Total 3733 11.0% 1.5%

Outcomes at BaselineOutcomes at Baseline

Results - Process Measures Results - Process Measures Baseline Checklist P-value

Objective Airway Evaluation 64.0% 77.2% <0.001

Abx at 0-60 Mins Except Dirty Cases

56.1% 82.6% <0.001

Verbal Pt/Site Confirmation 54.4% 92.3% <0.001

Two IVs /Central Line if EBL≥500

58.1% 63.2% 0.32

Pulse Oximeter 93.6% 96.8% <0.001Sponge Count 84.6% 94.6% <0.001All Six Safety Indicators Done

34.2% 56.7% <0.001

Results – All SitesResults – All SitesBaseline Checklist P value

Cases 3733 3955 -

Death 1.5% 0.8% 0.003

Any Complication 11.0% 7.0% <0.001

SSI 6.2% 3.4% <0.001

Unplanned Reoperation 2.4% 1.8% 0.047

Change in Death and Complications Change in Death and Complications by Income ClassificationIncome Classification

Change in Complications

Change in Death

High Income 10.3% -> 7.1%* 0.9% -> 0.6%

Low and Middle Income

11.7% -> 6.8%* 2.1% -> 1.0%** p<0.05

Survey of Attitudes to Checklist Use Survey of Attitudes to Checklist Use Among Clinicians at Study Site Among Clinicians at Study Site (n=229)

The checklist was easy to use 78.6%

The checklist improved operating room safety

79.0%

The checklist took a long time to complete 18.3%

Communication was improved through use of the checklist

84.3%

The checklist helped prevent errors in the operating room

78.2%

If I were having an operation, I would want the checklist to be used

92.6%

Where is the Checklist Today

Participating Hospitals: 3,865

Actively Using the Checklist: 1,657

IHI Sprint

Challenged every hospital in the U.S. to trial the Checklist with one surgical team-

80% of SC Hospitals

Notable Endorsing OrganizationsNotable Endorsing Organizations

• American College of Surgeons• American Society of Anesthesiologists• Association of Perioperative Registered Nurses

(AORN)• American Academy of Otolaryngology-Head & Neck

surgery• American Orthopedic Association• Anesthesia Patient Safety Foundation• Blue Cross Blue Shield Association

What key steps have other hospitals followed that have enabled them to successfully

implement the Checklist?

What Can Make a DifferenceWhat Can Make a Difference

• Find a “champion” in each discipline (anesthesia, nursing, and surgery)

• Buy-in from clinical and hospital leadership

• Modify the Checklist and trial it

• Measurement/Local Evidence– Reinforce Change

– Show Progress

Checklist Modification BasicsChecklist Modification Basics

• One size doesn’t fit all

• Need to have full team buy-in

• Don’t remove teamwork items

– Introduction of team members by name and role

– Review of specific patient concerns

– Discussion of key concerns before patient leaves the OR

• Does the entire team stop all activity at the three critical points in care?

• Does the team verbally confirm each item on the Checklist?

• Are the items verified without reliance on memory?

• Does the Checklist promote communication?

When We Use the ChecklistWhen We Use the Checklist:

Virginia Mason Hospital- SeattleVirginia Mason Hospital- Seattle

• In order for the Checklist to work well it has to be used “right”- requires behavioral change

• Improving communication between all OR team members is critical to successful implementation.

2010 Annual Meeting of the American Society Anesthesiologists

Operation: Safe SurgeryOperation: Safe SurgeryVision/PurposeVision/Purpose

• Vision: That every patient in South Carolina willreceive surgical care in a safe environment

• Purpose: To create a statewide system of surgical safety that is built on teamwork and open communication

• All SC acute care hospitals will evaluate the WHO surgical safety checklist with at least one surgical team

• Surgical teams statewide will be provideddirect access to a focused crew/team resource management training program

Operation: Safe SurgeryOperation: Safe SurgeryInitial GoalsInitial Goals

• 100% SC hospitals will commit to checklist use and CRM-based communication in all ORs

• All SC hospitals and surgical teams will have direct access to a broad range of surgical safety educational resources and consultative services

• A unified data management system established to track and analyze key surgical care process and outcomes indicators within and across hospitals

Operation: Safe SurgeryOperation: Safe SurgeryMajor GoalsMajor Goals

Operation: Safe SurgeryOperation: Safe SurgeryKey ChallengesKey Challenges

• Attaining senior leadership/medical staff buy-in

• Integration of WHO checklist with TJC universal protocol requirements

• Spreading use of checklist from one to multiple surgical teams in each hospital

• Providing access to CRM training statewide

• Creating a user friendly system for tracking impact of program on patient outcomes

Operation: Safe SurgeryOperation: Safe SurgeryPhase 1 ResultsPhase 1 Results

• 55% of SC hospitals evaluated checklist with at least one surgical team by April 1, 2009

• 25% of SC hospitals committed to evaluating after Sprint deadline

• 80% total commitment from SC hospitals compared to 25% national rate

Operation: Safe SurgeryOperation: Safe SurgeryPhase 2Phase 2

• CRM training program for lead surgical teams in regional sites across the state

• Training sessions available to all SC hospitals

• Collection and analysis of predefined surgical safety process and outcomes measures

• Spread checklist/training to other procedural areas

Operation: Safe SurgeryOperation: Safe SurgeryPhase 3Phase 3

• Achieve goal of 100% SC hospitals actively using checklist/CRM-based communication in all ORs

• Create statewide surgical safety leadership team

• Establish standard surgical safety performance dashboard w/ key process and outcomes indicators

• Develop a menu of onsite CRM training and consultative services available to every SC hospital

• Serve as lead state for WHO surgical safety program (Dr. Gawande)

“To every person there comes in life that special moment when one is tapped on the

shoulder and offered the chance to do a very special thing. What a tragedy if that

moment finds you unprepared or unqualified for the work which would be

your finest hour.”

Sir Winston Churchill (1874-1965)

Institute for Healthcare ImprovementShort Movie Clip

http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm