safe surgery 2015: sc

Rick Foster, MDFebruary 17,2011

I do not have any relevant financial relationships with any commercial

interests related to the content of this activity to disclose.

“we're good at making sure we do most of these things most of the time, but we're not good at doing all of them all of the time.”

-Atul Gawande, MD

“…because each slip represents an opportunity for harm to your love ones,”

-Alex Haynes, MD Harvard School of Public Health

three central problems in surgical safety

unrecognized as a public health issue

lack of data on surgery and outcomes

failure to use existing safety know-how

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 Surgery

1. 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 Surgery

6. 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?

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%

Stanford University, United StatesStanford University, United States

• E/O Mortality declined from .88 to .80

• Reported Patient Safety Never Events (PSN) rose from 559 to 637

• Reported events due to errors/complications decreased from 35.2% to 24.3%

• Mean OR start to incision time was shorter

• There was improvement in the belief (SAQ) that all personnel take responsibility for patient safety

Tsai Thomas, Boussard Tinna, Welton, Mark, Morton, John. Does a surgical safety checklist improve patient safety culture and outcomes? [Abstract]. In: American College of Surgeons Annual Clinical Congress. 2010 October 3-7; Washington D.C. Journal of American College of Surgeons.

(N=12,247)

SURPASS Checklist, The Netherlands

• 100 item checklist implemented in 6 high performing hospitals

• Compared to controls the test hospitals had a greater than one-third reduction in complications and achieved an almost 50% reduction in deaths (from 1.5% to 0.8%)

(N=7,580)

de Vries EN, et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363:1928-1937

Veterans Health Affairs, United States

• Implemented a surgical team training program incorporating a modified version of a surgical checklist in the operating theatres of 74 facilities

• Experienced a mortality reduction of 18%

Neily J, Mills PD, et al. Association Between Implementation of a Medical Team Training Program. JAMA. 2010 Oct 20;304(15):1693-700

The Use of the WHO Surgical Safety Checklist and Cost Savings

• The use of the Checklist can generate cost savings for hospitals.

• The use of the Checklist decreased complications by more than 1/3rd in the original study published in the NEJM.1

• Cost savings from the use of the Checklist has the potential to save hospitals >$8,000 per surgical complication.2

1. Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.

2. Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood) 2010 Sep;29(9):1593-9.

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

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

• Create an organizational culture of safety with engaged leadership

• Actively improve the quality & outcomes of evidence-based care for key patient populations

• Eliminate preventable serious adverse events and unintended patient harm

• Establish a patient-centered environment of care with open and transparent communication

• Built on a strong mission and strategic foundation

• Collaboration and shared accountability among key stakeholders- “seat at the table for everyone”

• Active communication and knowledge sharing

• Effective use of QI tools and methodologies

• Education built around active learning model

• Focus on measurable process and outcomes performance indicators

• Environment that encourages innovation

partners dr. atul gawande and the safe surgery 2015 team from harvard school of public health

pht services, ltd.

health sciences south carolina

blue cross blue shield of SC

almost 900,000 surgery cases in one year

364,000 inpatient surgery cases

523,764 outpatient surgery cases

Estimated 8,500 surgical related deaths per year!

2,893 patients’ lives could be saved!

FACT: Doctors can avoid complications if they use the surgical checklist.

if the checklist could reduce mortality by one-third in south

carolina …

visionEvery surgical patient in South Carolina will receive the highest quality and safest care in all surgical settings.

purposeDevelop an integrated system for hospital surgical teams that focuses on process improvement, establishing a just culture of open communication, learning and team work and reducing near misses and adverse events by providing the highest quality of care and the safest environment using evidence based medicine in the surgical setting.

safe surgery 2015: scsafe surgery 2015: sc

Establish a statewide multidisciplinary leadership team to guide and direct Safe Surgery 2015

Establish surgical safety teams in every hospital in SC

Provide a Team Training Program that can be accessed by any SC hospital or other surgical care provider

Implement a common set of standards/guidelines for team based surgical care built around the WHO checklist

Create a common statewide data base of key surgical safety process and outcomes measures/indicators

improvement aims

goalBy 2014 a modified version of the WHO Surgical Safety Checklist with team based communication will be used in every operating room for every surgical patient every time a surgical procedure is performed in the state of South Carolina.

100% of hospitals committed To date, all SC acute care hospitals with surgical suites have fully committed to implementing the surgical checklist.

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 You Use the ChecklistWhen You Use the Checklist:

Surgical point of contact completed the surveyOver 90% of hospitals responded that they implemented the WHO (modified) Surgical Safety Checklist  in 81-100% of their hospital based OR roomsNeed to drill down further to determine if implementation of checklist processes are consistent in and among all SC hospitalsNeed more surgeons to be on board with the checklist75% of the hospitals feel that SURGEONS are the best group to help implement the checklistOver 60% said team training would help100% think the checklist has improved safety and 100% would want the checklist used on them

baseline assessment of hospitals

cardiac surgery

ambulatory surgery centers

safe surgery subgroups

inpatient mortality rates

unplanned return to operating room within 48 hours

surgical site infectionsHarvard team to determine clinical data definitions of these three data components

Ask South Carolina Hospitals to track identified data components

Use SSI data reported through CDC NHSN system (HIDA program)

Explore data using administrative claims from Office of Research and Statistics (ORS)

key surgical outcome indicators

data subgroup

recommend hospitals track data measures for “unintended” consequences using existing state and national level data measures

data measures include:Surgical Care Improvement Project (SCIP): CMSSurgical AHRQ indicators: ORSHIDA infection measures: DHEC/NHSN

implementation effectiveness

• Safety culture assessment by all surgical team members

• checklist implementation/utilization assessment by OR managers and directors

• assessment of checklist application and team-based communication in each OR by circulating nurses

Will be distributed within 2011 with re-measurement

Use survey questions from the Safety Attitudes Questionnaire (OR Version)

Conduct survey to better understand attitudes and opinions regarding surgical safety

Distribute to participants of the Operating Room Team

Anonymous and confidential

culture of safety survey

South Carolina teams will conduct on site visits to evaluate implementation effectiveness of the surgical checklistEffectiveness tools developed by research team from Harvard School of Public HealthOutcomes will be assessed using multiple data metricsIdentify Team Training as a critical component of the implementation process and imbed in the overall educational componentExploring a TeamSTEPPS Training Course that is customized for the OREncourage customization while maintaining the basic components in the surgical checklist that need to be included in the checklist

shaping the path in safe surgery 2015:sc

Currently surgical teams do most of the right things, on most patients, most of the time.

The checklist helps us do all the right things, on all the patients, all of the time.

safe surgery reality check

contact information

lorri gibbons, rn, bsn, cphqVice President, Quality Improvement and Patient Safetylgibbons@scha.org

learn more about scha’s partnership with dr. atul gawande and his safe surgery 2015 team by visiting our website http://www.scha.org/newsroom/681-sc-hospitals-partner-with-dr-atul-gawande