SAFE SURGERY CHECKLIST: TOOLS TO SUPPORT COMPLIANCE WITH THE NEW CMS

REPORTING REQUIREMENT

February 23, 2012

ASC Knowledge Share

2012 WEBINAR SERIES

Welcome

• ASC Knowledge Share is a new webinar series designed to address infection prevention related topics of interest to Oregon ASCs

• Each webinar will have 20 to 30 minutes of educational content presented by various speakers, followed by time for questions and answers

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Networking

• The remaining 10 to 15 minutes of the webinar will be available for participants to network with each other by asking questions or addressing concerns on any infection prevention related topic

• The goal of the webinar is to share knowledge and experience with other ASCs

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Webinar Speakers

Oregon Patient Safety Commission (Host)

• Valerie Van Buren, MPH, Patient Safety Consultant

Northwest Ambulatory Surgery Center, LLC

• Kecia Rardin, RN, CNOR, CASC, Administrator, Director of Nursing

• Debbie Spain, RN, BSN, CNOR, Clinical Director

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Webinar Speakers (cont.)

Oregon Eye Surgery Center

• Cheri Van Bebber, RN, BSN, Operating Room Manager

Oregon Patient Safety Commission

• Leslie Ray, PhD, RN, Patient Safety Consultant

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SAFE SURGICAL CHECKLIST: THE NEW ASC MEASURE & HOW IT CAN IMPACT PATIENT OUTCOMES

Valerie Van Buren, MPH, Patient Safety Consultant

Oregon Patient Safety Commission

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ASC Quality Reporting Program

Five quality measures:

1. Patient burn

2. Patient fall

3. Wrong site, side, patient, procedure, implant

4. Hospital admission/transfer

5. Prophylactic IV antibiotic timing

Two structural measures:

1. Safe surgery checklist use in 2012

2. Volume of certain procedures in 2012

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Safe Surgery Checklist Structural Measure

Measure Measurement

Period Reporting

Period Payment Affected

Safe Surgery Checklist Use

CY 2012* July 1 – Aug 15, 2013 CY 2015*

*CY: calendar year

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Annual Global Statistics

234 million operations

Known surgical complications → 3-16%

Known death rates → 0.4-0.8%

One operation for every 25 human beings

At least seven million disabling complications

About one million deaths

World Health Organization: http://www.who.int/en/

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Eight Checklist Pilot Sites

Manila, Philippines

London, UK

Amman, Jordan

Toronto, Canada

New Delhi, India

Ifakara, Tanzania

Seattle, USA

Auckland, New Zealand

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Checklist Pilot Results

• Reduced rate of postoperative complications and death by more than one-third

• Similar effect in high and low/middle income country sites

William Berry. Harvard School of Public Health. December 7, 2009. Oregon IHI Network Webinar. Haynes, et al. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 360:491-9.

Income Level Change in Complications Change in Death

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

Low/Middle 11.7% -> 6.8%* 2.1% -> 1.0%*

* p<0.05

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A recent study showed…

…when a safe surgical checklist was used:

• Surgical complications reduced by one-third

• Mortality reduced by nearly half

De Vries, E.N., Prins, H.A., Crolla, RM, et al. (2010). Effect of a comprehensive surgical safety system on patient outcomes. New England Journal of Medicine. 363: 1938-37.

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Three Crucial Phases

1. Before induction of anesthesia

2. Before skin incision

3. Before the patient leaves the operating room

The WHO Surgical Safety Checklist: Adaptation Guide http://www.safesurg.org/uploads/1/0/9/0/1090835/who_checklist_adaptation_guide.pdf

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World Health Organization: http://www.who.int/en/

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Correct Patient, Operation & Operative Site

Before induction of anesthesia:

Before skin incision:

Before patient leaves operating room:

• 1500-2500 wrong site surgery incidents every year in the US¹

• 1050 hand surgeons surveyed, 21% reported performing at least one wrong-site surgery in career²

¹ Seiden. Archives of Surgery. 2006. ² Joint Commission. Sentinel Event Statistics. 2006.

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Safe Anesthesia and Resuscitation

Before skin incision:

Before induction of anesthesia:

Study in Australia:

Of 1256 general anesthesia incidents, pulse oximetry on its own would have detected 82% of them Webb. Anaesthesia and Intensive Care. 1993.

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Infection Risk Reduction

• Antibiotics within one hour before incision reduces risk of surgical site infection by 50%

• At pilot sites, failure to give antibiotics on time occurred in almost half of patients who would benefit from timely administration

Before skin incision:

Bratzler. The American Journal of Surgery. 2005. Classen. New England Journal of Medicine. 1992.

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Effective Teamwork

Communication

• A root cause of ≈70% of events reported to the Joint Commission (1995-2005)1

Preoperative team briefing

• Enhanced prophylactic antibiotic choice and timing

• Appropriate maintenance of intraoperative temperature and glycemia2,3

Before skin incision:

Before patient leaves operating room:

¹ Joint Commission. Sentinel Event Statistics. 2006.

² Makary. Joint Commission Journal on Quality and Patient Safety. 2006.

³ Altpeter. Journal of the American College of Surgeons. 2007.

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Survey: Attitudes Among Clinicians

Attitudes About Checklist Use Among Clinicians N = 229

The checklist was easy to use 78.6%

The checklist improved operating room safety 79.0%

Communication was improved through checklist use 84.3%

The checklist took a long time to complete 18.3%

The checklist helped prevent errors in the operating room 78.2%

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

92.6%

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Information & Resources

• Safesurg.org www.safesurg.org

• (Book) The Checklist Manifesto: How to Get Things Right, Atul Gawande

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ASC EXPERIENCE

Kecia Rardin, RN, CNOR, CASC, Administrator, Director of Nursing

Debbie Spain, RN, BSN, CNOR, Clinical Director

Northwest Ambulatory Surgery Center, LLC

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Northwest Ambulatory Surgery Center

Multi-specialty surgery center established in 2005

• Located in northwest Portland

• 3,100 procedures per year: Orthopedics, ENT, Podiatry, Hand Surgery, Gynecology and Pain Management

• Joint venture with 17 surgeons, USPI and Legacy Health Systems

• 35 employees

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Surgery Checklist Implementation

• This current checklist was developed by USPI Corporate and replaced our original Surgical Site Verification Checklist

• Our staff was presented with this new form at our monthly staff meeting

• The new form is more user-friendly making its implementation seamless

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Key Successes

• The new checklist is an evolution of our original checklist which primarily focused on preventing a wrong site surgery

• The previous form involved multiple departments tracking the patient from scheduling until the OR Time Out looking for any discrepancies specifically related to wrong site prevention

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Key Successes (continued)

• The previous form also included many of the required elements, but lacked the three distinct critical points: prior to administering anesthesia, prior to skin incision, and prior to patient leaving the operating room

• The updated form includes these areas and a few additional RED Alert areas our center felt were beneficial

• At our center we are particularly concerned about pain procedures and anesthesia blocks so those became RED Alert areas for us

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Key Challenges

• The key to staff participation is understanding how it applies to them; through the use of our original form, it became apparent how frequently cases were scheduled incorrectly; wrong site surgeries can occur anywhere

• The staff wasn’t thrilled about more paperwork, but understood that mistakes happen everyday and the checklist is a safety mechanism to protect the patient

• The new form is more efficient and easier to use; it’s important that the staff realizes you are trying to make their jobs easier

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Key Learnings

• Even experienced staff make mistakes

• Checklists are only effective if they are actually read thoroughly and followed; we had several cases in which staff members completed the checklist, but the information wasn’t actually in the chart

• We have to learn from our mistakes

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ASC EXPERIENCE

Cheri Van Bebber, RN, BSN, Operating Room Manager

Oregon Eye Surgery Center

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Oregon Eye Surgery Center

We are an Ophthalmic Physician-owned ASC, opened in 1988

• Located in Eugene, Oregon

• 2,000 to 2,500 surgeries per year

• Procedures include: cataracts, cornea, retina, plastics, glaucoma, lasers, and Lasik

• 12 MDs, 3 operating rooms, no general anesthesia

• 25 employees

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• Started with WHO’s “Implementation Manual for the Surgical Safety Checklist”

• Sources: WHO, AORN, National Patient Safety Agency, SCOAP, current Time Out

• Input from the people who would use list

• Considered what is useful/relevant to our setting

• Emphasized that it is a “No pressure” worksheet meant to help not hinder care

Developing the Checklist

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Key Successes

• Found that it is a good communication tool

• We caught missing or inconsistent information

• More complete/thorough patient care

• Promotes MD marking surgical site

• Slows work flow down, yet does create efficiency

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Key Challenges

• More work, another piece of paper, duplication, slows down the flow, staff resistance, hard getting it done

• How we’ve dealt with challenges:

• It’s the law!

• It is a helpful communication tool

• In our EMR world, serves as a quick visual

• Assigned personnel to check for list completion

• More effective “chart” organization makes easier

• Listen to feedback and stay positive

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Key Learnings

• We’ve caught missing and inconsistent information

• Why didn’t we do this sooner-like pilots?

• It is a consistent approach

• Feels like better patient care; patients like seeing their doctor before surgery

• Expands time out: reception through post-op care

gpecora@oregoneyeassociates.com

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MAKING CHECKLISTS EFFECTIVE

Leslie Ray, PhD, RN, Patient Safety Consultant

Oregon Patient Safety Commission

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The checklist is a tool to help you provide the best possible care

An Effective Safe Surgery Checklist

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• Use the right checklist the right way

• Start small and modify

• Clinician support and practice changes

• Policy revisions

Lessons Learned

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3 Phases

Team Participation

Critical Elements

Right Checklist/Right Way

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Consider each use a trial

Incorporate recommended changes

Re-try on smaller scale

Start Small & Modify

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Checklist focus

Respond to concerns

Give it time

Clinician Support & Practice Changes

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Last step

Avoid too much detail

Build in revisions

Policy Revisions

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• Have the checklist reflect reliable

processes, not personal preferences

• Avoid multiple checklists

• Team focus is on the checklist during

each pause – other tasks stop

• Include only the most critical elements

• Post a big, laminated checklist in each OR

• Check off items as reviewed, then erase at end

• Notice and share “good catches”

Helpful Tips

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SAVE THE DATE

Next ASC Knowledge Share

Date: Thursday, April 19, 2012, 2:00-3:00p.m. PST

Topic: Biological Indicator Failures:

Updated Processes

Speaker: Joseph F. LeBouef, RST, CST, CRCST, CHL Regional Sterile Processing Educator Kaiser Foundation Health Plan of the Northwest

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