Part B: Surgical Safety Checklist How-To Implementation Guide

Transcription

1 Part B: Surgical Safety Checklist How-To Implementation Guide

2 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide Surgical Safety Checklist How-To Implementation Guide This section sets out a step-by-step approach hospitals can use to implement the Surgical Safety Checklist in their operating rooms. Hospitals are encouraged to use this approach because it focuses on improving compliance via improved teamwork, communications, and use of evidence-based practices. For more information about the background, evidence, and rationale for surgical safety checklists, refer to the Part A: Primer in this toolkit. 02

3 Table of Contents This pull-out guide describes the What you need to do to implement a surgical safety checklist program within your hospital. Setting the Stage Outlines important steps to engage all hospital leaders and stakeholders to introduce a checklist program. The importance of preparing and encouraging all clinicians to own the checklist - including using local evidence to create a case for use of the checklist. 1. Build Ownership and Buy-in Assess Current Practices and Risk of Complications from Surgery Getting Started Steps to assist the checklist program leader with formation of pilot teams, raising awareness and launching a checklist program, modification of the CPSI checklist, recommendations to consider when running through the checklist, and overcoming common barriers to program implementation. 3. Form the Pilot Team(s) Public Reporting and the Surgical Safety Checklist The CPSI Checklist and Detailed Explanation of Checklist Items Consider Customizing the Checklist (includes modifications and compliance to public reporting) Run the Checklist Overcoming Barriers to Using the Checklist Moving to Full Implementation Provides strategies to spread the checklist across your organization, including sharing successes, full scale roll out, and sustainability ideas. 9. Spread the Checklist Across the Organization/ Share the Checklist s Success Sustain the New Practices Address the Evidence-Based Practices Contained in the Checklist Identify Additional Opportunities for Quality Improvement Checklists are designed to help team members exchange information, reduce communication failures, and improve safety by: Providing structured memory prompts to ensure that team members do not omit critical steps or established safety practices. 1,2,3 Identifying opportunities to share information about a patient that may not be known by all members of the team. Improving team building and communications between professionals and thereby increasing the team s ability to act as a safety net for the patient. 6,7 4,5 03

4 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide The steps involved in implementing the Surgical Safety Checklist include: Setting the Stage Getting Started Moving to Full Implementation 1. Build Ownership and Buy-in 2. Assess Current Practices and Risk of Complications from Surgery 3. Form the Pilot Team(s) 4. Public Reporting and the Surgical Safety Checklist 5. The CPSI Checklist 6. Consider Customizing the Checklist (includes modification compliance to public reporting) 7. Run the Checklist 8. Barriers to Using the Checklist 9. Spread the Checklist Across the Organization 10. Sustain the New Practices 11. Address Evidence Based Practice Contained in the Checklist 12. Identify Additional Opportunities for Quality Improvement As the diagram illustrates, some of the steps occur in sequence while others should happen simultaneously. For example, identifying opportunities for improvement in evidence based practices and developing new processes to meet them can occur while test teams are being formed and the checklist is being customized and run. 04

5 Setting the Stage 1. Build Ownership and Buy-In While ultimate and final accountability for the checklist program resides with the CEO and the Board of Directors, the direct responsibility for actual delivery of the program lies with the Peri-operative Services Advisory Committee. To achieve the goals of the Safe Surgery Saves Lives Initiative and the Surgical Safety Checklist, all members of the OR team must be fully engaged and own the checklist. Ownership and buy-in requires the formal support and endorsement of administrative and clinical/physician leaders. Clinician support is critical. Any significant change to the design, process, practice, or delivery of medical or surgical care can be challenging to implement without strong engagement and acceptance. 8 Establishing Clinician Ownership: Physicians need to be involved at the outset in any decisions making that concerns the delivery of care to patients, since they carry a powerful sense of personal responsibility for the quality of care that they provide, as well as the outcomes of their care*. Reinforce that the checklist is a patient safety initiative, and that much of the value in the tool pertains to common sense (i.e., every patient case is discussed by the team, and all necessary preparations are made to ensure patients receive any and all interventions that will lead to the best possible outcome). Encourage clinicians to mentor and influence their peer group. Reinforce the systems perspective of patient safety and focus on the team*. Consider harnessing the logical negative of those clinicians who historically have been the most vocal or critical about changes and new programs. Seek their active participation and keep an open mind to discover any previously unreported problems with implementing new changes*. This will help produce a realistic change plan well suited to the needs of individual organizations. * Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institutive for Healthcare Improvement; (Available at 05

6 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide To obtain optimal buy-in, adoption and spread of the checklist among clinical staff, consider the following: 1. Identify senior leadership lead(s). Ensure that senior administrative (e.g., corporate and clinical) leadership actively supports this initiative and considers it a patient safety priority. Clinical staff will be more likely to buy in when they believe their physician leaders are serious about improving the quality of care of their patients. The Role of Senior Leadership: Support the use of the checklist as a communications tool to facilitate teamwork and communication, not as another piece of documentation to be completed for the chart. Support the time and effort teams will need to implement the checklist program. Encourage pilot teams to test, modify and adapt the checklist to setting and type of surgery (and not by individual preference). Be visible and address concerns as teams pilot the checklist. People will be more apt to adopt a tool if their concerns are addressed and they receive positive feedback on how they are doing. Encourage teams to collect proof that the checklist is working to improve patient safety. Support a highly visible, ongoing tracking record of the uptake and implementation of the checklist across the organization. This may take the form of a weekly (or daily) chart of accomplishments posted in a prominent location in the OR. Celebrate the work of champions and spread the news throughout the organization via newsletters, banners, s, notice boards, or lunch and learn sessions. Make this an ongoing success story for your hospital. Remember that clinicians are driven to change practice by local evidence of improvements due to their change in practice. Measuring success will help spread adoption of the checklist throughout the organization. 06

7 Champions are usually highly-respected clinicians who are not necessarily the administrative leaders in an organization. If they are not in leadership roles, it is important that they have the full endorsement of senior leadership. They have gained respect from their colleagues and are often early adopters of emerging evidence-based practice. They generally have good social skills and may be able to counteract other staff resistance.* * Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institutive for Healthcare Improvement; (Available at 2. Formally engage the Perioperative Advisory Committee (or equivalent) to formally endorse the checklist program in practice as well as principle. 3. Appoint a program lead or co-leads. These individuals will help coordinate implementation of the checklist and provide instant feedback as teams become more familiar with it. 4. Engage other stakeholders in the process. Consider leaders in Patient Safety, Quality, Risk Management, Pharmacy, Central Processing Department, Information Technology, Decision Support, Blood Bank, Infection Prevention and Control, Medicine, and others. 5. Read this toolkit in its entirety. Ensure the checklist lead(s) and the hospital s Perioperative Services Advisory Committee read this toolkit. Encourage them to also read other resources such as the CPSI s Implementation Kit for the Surgical Safety Checklist 9, and the WHO Guidelines for Safe Surgery Establish physician, anesthesiologist, and nurse champion teams for every surgical service if possible. Identify champions in various clinical groups, such as professional practice leaders, team leaders, OR educators, and clinical nurse specialists. 7. Communicate and inform OR teams and other services in the organization about what you are doing. The key messages located in appendix 11 - A40 may help with messaging. It is essential that consistent internal messages and memos are shared with all internal stakeholders and consistently come from the list below: Senior Administrators CEO Board of Directors VP of Clinical Services VP of Patient Services Clinical Chiefs Chief of Surgery Surgical Division Chiefs Chief of Anesthesia Chief Nursing Officer Perioperative Services Advisory Committee Medical Advisory Committee Director/Manager Director of Peri-operative Services Director of Surgery OR Manager Director of Risk Management Director of Quality and Patient Safety 07

8 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 2. Assess Current Practices and Risk of Complications from Surgery To obtain ownership, buy-in, and a passion for change, it is highly recommended to collect and share some local hospital data about risk of complications from surgery in your hospital. This can be consolidated and presented back to leadership and clinical teams, and will help to create a platform for launch and implementation of the surgical safety checklist. While collecting the evidence, it is important to ascertain the current state of the operating room - including policies, processes, practices, safety and teamwork cultures, and communication patterns. Statistics around adverse events and rates of certain preventable complications (such as VTE) are also useful. Approach your clinicians and identify how a surgical safety checklist could improve issues and outcomes. Appendix 5 - A27 of this toolkit includes a self-assessment audit tool that hospitals may find helpful to assess their current OR practices. To evaluate programs and assess for current practice and risk, consider the following: 1. Work with the hospital s patient safety, quality, or risk lead. They may have access and knowledge of information and quantitative data necessary to prioritize some areas for improvement within the checklist program. 2. Determine the hospital s current state. Assess processes and practices in the operating room. Use the Surgical Safety Checklist Self-Assessment Audit Tool (see appendix 5 - A27). It includes questions about culture, communications and teamwork, processes and practices around select evidence based practices contained in the checklist. Compare results with those reported in the OHA s June 2009 survey (see appendix 5 - A29) for benchmarking purposes. Identify gaps in processes or evidence-based interventions. 08

9 Determine the impact of culture, communication, and teamwork in the OR. Teams that practice good communication and teamwork are more likely to provide safe care. 11 Consider completing a culture and teamwork survey, such as the Safety Attitudes Questionnaire (for ORs). Note: there is a cost to use the questionnaire. For an article about the original SAQ questionnaire, see content/pdf/ pdf Create a gap analysis chart. This will help determine current state of practice for each item or phase of the checklist, and define a program s strengths or areas for improvement. Add additional items or practices that would constitute full wide-spread compliance with the intervention (e.g., SSI, VTE). Example of a Gap Analysis Chart (using the Surgical Safety Checklist) Checklist item/phase Full compliance Partial compliance No compliance Rating Comment Anesthesia safety check completed prior to every surgery strength Site, side and level marked Improvement needed Practice varies by surgeon/ anesthesiologist. Need to develop policy/ guidelines for marking. SSI: Antibiotic prophylaxis for major general surgery Improvement needed Timing is late when administered on patient unit 09

10 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 4. Collect key quantitative information if available Analyze reported incidents using your patient information or event tracking system (either electronic or paper-based) and claims information. Analyze the easier to find incidents which may relate to surgical error (such as wrong site, wrong side, wrong patient, wrong procedure, or unintended retained foreign objects). Look at data from the past five years to get an idea of an organization s rates and trends. Determine the more difficult to capture incidents, such as mislabeled specimens, medication errors, unsuitable or delayed equipment or supplies. Keep in mind that the number of reported errors will be directly proportional to the type of safety and reporting culture at a hospital. Determine the number of cases (or rates) of both VTE and SSIs. These two preventable complications from surgery can be difficult to track and may require the involvement of decision support and infection control practitioners to extract and examine the data. It is essential to capture both in-hospital and post-discharge events - using readmission rates and/or imaging results because a high proportion of post-operative VTE and SSI occur after the initial surgical admission. Consider doing a more thorough search of data related to surgical complications. Some of the items in the box can be used as a list of search terms for a clinical audit. For other potential complications related to surgery, see the indicators listed in the Institute for Healthcare Improvement s Surgical Trigger Toolkit, 13 including change in procedure, transfer to higher level of care, and re-intubation in the Post-Anesthesia Care Unit. 10

11 Easier to Find Incidents (search terms): Wrong site Wrong side Wrong patient Wrong procedure Foreign body in patient Procedure not ordered Consent missing or inadequate Count incomplete or not performed Count incorrect Surgical site infection Deep vein thrombosis (DVT) Pulmonary embolism (PE) Other Search Terms: Procedure not completed Procedure cancelled or not performed) Break in sterile technique Unanticipated insertion of arterial or central venous line during surgery Unplanned return to OR Unplanned intubation 5. Rank probability and impact of the risk. This will help you determine the areas of greatest priority for targeted quality improvement. For more information on how to rank probability and impact of risk, see appendix 10 - A Summarize and present this data to senior administration, the Perioperative Services Advisory Committee, and OR teams. The numbers and trends of surgical complications may help build buy-in for using the checklist. Consider telling a story about a previous preventable adverse event that occurred in the hospital, as well as any examples of when a potential event was averted (i.e., a good catch ). However, if a case is under review, consult with legal councel before sharing any facts with staff. Getting Started 3. Form the Pilot Team(s) 1. Start with the enthusiastic. In any new initiative, it is much easier to start with the willing. Find people passionate about patient safety who are willing to assist in laying the groundwork for implementing the checklist in the OR. Try to include clinical champions from all professions (surgery, anesthesiology, and nursing) as well as those in administrative roles. Work with teams who already have high compliance to the present time out. 2. Assemble materials and raise awareness. Use information from the Part A: Primer of the Surgical Safety Checklist Implementation Toolkit to present evidence that the Surgical Safety Checklist is an effective way to build teamwork and improve patient safety. Provide copies of the checklist and various articles referenced in appendix 4 - A26. Tell staff that the checklist is a tool that can improve process, and communication and is not intended to be a documentation form. Explain that the checklist is only an extension of the surgical pause or time out that they are already doing. 11

12 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 3. Choose a forum to introduce the Surgical Safety Checklist. It is important to have a well planned communications strategy. Communication about this program must reach all the stakeholders who will be affected by this new process. Having a key champion present the same information at all venues to all disciplines will ensure consistency in messaging. Provide several different venues and opportunities for OR personnel to attend and learn about the checklist and decide on a venue that will be well received but that is also practical for the OR team. Hold lunch and learns if teams are already keen to get started, or dedicate a week of early morning coffee and muffin sessions whereby staff could visit a safe surgery information booth. For maximum exposure, use a large multi-disciplinary forum, such as Grand Rounds, to share information about the initiative. The goal is to ensure that everyone involved understands that the checklist is the new expected standard of care. It s important to reinforce that all items in the checklist will contribute to improved patient safety through better teamwork and communication. 4. Invite a local guest speaker. Take advantage of clinician champions who have already started using the checklist in their hospital. Invite local and/or well respected guest speaker(s) who have used the checklist and have them share their success stories. 5. Form a test team and pilot the checklist. Once you have enough people who are on board with this initiative, form the initial testing team to provide feedback and modifications to the checklist, and decide where, how and who should be testing it. 12

13 The core team(s) will need to trial the modified checklist and ensure that it fits with the setting and types of surgeries it will be used for. Start small in one OR suite or with one case per day. Have a week of practice runs before committing to using the checklist for every patient. Ensure all test team members have ample time to try the checklist, provide input on what process is best to run the checklist, and suggest any additional modifications that may be needed. Work out any potential problems and make adjustments to your checklist before you go live. Once the core team(s) is satisfied that the checklist can work for one service or division, it will be well positioned for use throughout the entire division. 6. Determine the best format for the checklist. 1. An oversized laminated checklist. Posted on the back of the operating theatre door and then taken down and led by the designated checklist coordinator. This ensures the checklist remains a conversation and not a written tick box exercise. If you use this option, you will need separate documentation that indicates the checklist was completed. 2. A paper form that resides on the patient s chart. Read and marked by the individual who leads the conversation. Note that this option could lead to mindless box ticking, in which case the inherent value of the conversation is lost. The upside is the real time documentation that each item is discussed. 13

14 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 4. Public Reporting and the Surgical Safety Checklist Compliance to the Surgical Safety Checklist and Public Reporting For the purposes of public reporting to the Ontario government, the case definition is the percentage of surgeries in which a three-phased checklist based on the CPSI checklist was performed. The most basic reporting requirements of the surgical safety checklist will entail a simple check of yes or no to a field prompt in the present Surgical Efficiencies Target Program (SETp) ministry wait times electronic reporting Operating Room Benchmark Collaborative (ORBC) system. It will replace the surgical pause yes or no prompt that is presently in place. Hospitals that are not wait times funded, will have to collect data (either as an electronic record or in a paper-based method), and report it through the Government of Ontario s Web-Enabled Reporting (WERS) system. To check yes implies the OR team complies with completing a three-phased surgical safety checklist for each individual surgical procedure and there was no collapsing of the phases of the checklist (from three phases to two). Compliance assumes the briefing was carried out while the patient was still awake, and every phase had representation from the entire surgical team. Compliance with the checklist process includes principles of interprofessional teamwork and communication with all relevant interventions for a surgical procedure being discussed, as appropriate. This also includes taking steps to address the evidence based practices that are contained in the checklist. To ensure the best possible quality data, hospitals are encouraged to take steps to ensure reliability of their process so that the data they submit is accurate (see appendix 10 - A39). 14

15 5. The CPSI Checklist and Detailed Explanation of Checklist items The CPSI Surgical Safety Checklist is a one-page list of 26 important patient safety processes/items that surgical teams should discuss at three critical points in surgery with all team members present: 1) The preoperative evaluation of the conscious patient prior to induction of anesthesia or Briefing. 2) The time out immediately prior to incision or Time Out. 3) The preparations for appropriate postoperative care prior to the patient leaving the operating room or Debriefing. The Briefing and Time Out phases of the checklist should be viewed as an extended surgical pause during which team members verbally confirm the identity of the patient, the operative site, and the procedure to be performed. Also in these phases, team members should ensure that evidence-based interventions are provided (e.g., prophylaxis against infection). The Debriefing section of the checklist is a key opportunity to discuss future ideas for quality improvement and learning. The final question -- Could anything have been done to make this case safer or more efficient? -- will allow every member of the team to provide their thoughts and plans to address these issues. These kinds of conversations may not otherwise occur once the team has left the operating room. Used in this manner, the Surgical Safety Checklist should take no more than one minute per section. The following checklist and explanation of checklist items has been reprinted with the permission of the Canadian Patient Safety Institute, as presented in their Detailed Explanation of the Surgical Safety Checklist Items manual ( 15

16 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 16

17 17

18 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 18

19 19

20 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 20

21 21

22 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 22

23 23

24 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 24

25 25

26 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 26

27 27

28 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 28

29 The Surgical Safety Checklist is available in an electronic Word format, making it easily customizable. For example, hospitals can add their logos and add or remove items within a section as required by each unique surgical setting. 6. Consider Customizing the Checklist The CPSI Surgical Safety Checklist is the provincial standard. It aligns with other Canadian initiatives such as SSI prevention and VTE prophylaxis, supported by Safer Healthcare Now! However, the full Surgical Safety Checklist may not be appropriate for all surgeries. If customizing the checklist, hospitals should proceed with caution and consider the following: 1. The Perioperative Services Advisory Committee should work with the pilot team during the customization process and approves any modifications. 2. Changes should be driven by best practices for improved patient safety. Modifications to the checklist should be driven by surgery type rather than by individual preference. For example, the items to verify patient, site, side, procedure, and allergies are highly relevant for both minor procedures and major operations. However, the items on blood loss and VTE prophylaxis are not relevant for cataract surgery. It is important to not remove safety items from the checklist simply because they cannot accomplished*. Some items on the checklist, such as antibiotic prophylaxis and medications, may require OR teams to make process changes to the delivery of care. *Implementation Kit For the Surgical Safety Checklist; Canadian Patient Safety Institute, May www. patientsafetyinstitute.ca For additional information regarding the rationale for the 19 essential items on the original WHO checklist, see the detailed Guidelines for Safe Surgery manual on WHO s website How to handle interventions on the checklist that are only in a developmental stage. Even if your hospital has not yet fully implemented SSI or VTE prevention, keep these items on the checklist. Make a definitive plan to implement these practices, and ask teams to address them when running the checklist by stating something to the effect of: We can t do this today, but we are in the process of implementing VTE as a standard part of patient care, and we will do this as soon as we can. 4. OR teams and other professionals need to be included in modification processes. Encourage OR teams to discuss and test modifications to the checklist and provide feedback and recommendations to the Perioperative Services Advisory Committee. There may also be other clinical specialties that can provide valuable input such as pharmacy, perfusionists, blood bank, respiratory therapists, and medicine. 29

30 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 5. What will work best to promote teamwork and a patient safety culture? Some hospitals have opted to separate items within the phases of the checklist by role (e.g., nursing, anesthesiology, surgery) to ensure all disciplines have an opportunity to speak. See examples of these types of communication modifications in appendix Limit the number of checklists used within the organization. Some hospitals may decide to use one comprehensive checklist for all surgeries, with minor surgery teams agreeing to review relevant information only, stating not applicable to items that are not pertinent to that type of surgery. Other hospitals may choose to have several checklists, for example a shorter high-volume checklist for minor surgeries and a longer standard version. Some exceptions may apply for certain specialties, such as cataract surgery and caesarean section. Multi-site hospitals using separate site checklists could cause confusion and/or frustration for team members travelling and working between sites. 7. Resist the temptation to add many new items to the checklist or to combine it with other checklists. One long checklist could become cumbersome for your teams. Always keep in mind that the checklist is a communication improvement tool and not a documentation form. For more guidance related to checklist modifications see appendix 9, the CPSI has available a Human Factors Guidelines for Redesigning the Checklist and the WHO has created a Surgical Safety Checklist Adaptation Guide. Additional examples of modified checklists are also available in appendix 1 of this toolkit. 8. Pilot test the customized checklist for functionality. Initial piloting should be done in only a few operating rooms or services. Give ample time for test teams to try modifications to the checklist before the Perioperative Services Advisory Committee makes final decisions. A quality improvement methodology approach -- including Plan Do Study Act (PDSA) cycles - may work well for some teams (see appendix 10 - A39). 30

31 Invite those who have tested the modified checklist to a quick meeting at the end of the week or, for immediate feedback, write down what worked well and what didn t in a log book outside the pilot OR. This may allow the more quiet members of the team to share their opinions freely. Prompt teams with questions such as how many minutes it took to run the checklist or how the role of Checklist Coordinator is going. The core team can take this information, plan next steps and test the appropriate changes the following week. Keep the same questions to see if there are any positive changes. Teams may take several months and make 10 or more modifications to the checklist as improvement cycles continue. This is common. Once final modifications are made to the checklist, it can be formally rolled out to the rest of the organization. For examples of high volume and standard checklists, see appendix 1. Customizing for Pediatric Populations Populations such as pediatric patients may present unique challenges that may not currently permit a full Briefing phase to be completed before the induction of anesthesia, distinct from the pre-incision Time Out phase. Nevertheless, as a patient safety initiative, the goal remains to prevent incorrect Briefing elements from occurring prior to the induction of anesthesia, especially if they would have precluded or altered the plan for proceeding with the anesthetic. In addition, some checklist elements may not be as applicable on a routine basis in the pediatric population (e.g., VTE prophylaxis), while other elements not on the CPSI checklist template (e.g., Sickle Cell Disease testing) may need to be added. 31

32 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide Customization of the Checklist and Public Reporting To ensure compliance with public reporting, adhere to three distinct phases when modifying and carrying out the Surgical Safety Checklist. For the purposes of public reporting to the Ministry of Health and Long-Term Care, this indicator will only be reported as one check (overall as yes or no compliance), but includes: Briefing (before induction of anesthesia) Time out (after induction, before initial incision) Debriefing (during or after closure) Do not collapse the checklist into two phases. Collapsing the checklist involves removing an entire phase or combining Briefing and Timeout into one phase. A representative from each professional discipline is expected to be present at each phase: this participation is essential to ensure interdisciplinary teamwork, communication and optimal patient safety. Print these steps and include them on the back of a laminated copy of the checklist. 7. Run the Checklist Here are the steps to running the checklist. 1. Who should be present? All members and/or representatives of the surgical team (surgeon or resident, anesthesiology, nursing) should be present for every phase. Although getting everyone together just before induction can be challenging, it is important, for optimal patient safety, that all members involved in the patient s surgery have access to the right information at the right time. 2. Who takes responsibility for running the checklist? The entire team is ultimately responsible for ensuring the checklist is completed. However, some organizations may assign this responsibility to a Checklist Coordinator, such as the surgeon, circulating or scrub nurse, or anesthesiologist. 32

33 3. Where and when to run the checklist? Run the checklist in the OR, or in the holding area. The Briefing should be done before induction, while the patient is awake, either with or without the patient in the room. 4. How will the patient react? The decision to run the checklist in front of the patient is up to each hospital. Many patients welcome and appreciate this approach, especially if it is explained ahead of time (i.e., either in the surgeon s office, pre-op clinic, or in a pre-admission package). Some OR teams may be concerned that patients will become alarmed by discussions of blood loss. Patients should already have been advised about surgical risks as part of their consent to the procedure. However, if clinicians do not wish to do the Briefing in front of patients, or patients do not wish to hear, the team should make appropriate alternative arrangements. The checklist should not be read to merely go through the motions. If experiencing regular difficulties from specific team members, seek to resolve the situation by consulting with the Perioperative Services Advisory Committee and senior leadership. 5. How to run through the checklist? There are several alternatives. One is to designate a Checklist Coordinator. Any profession can take this role. The coordinator leads the checklist by posing each item either as a question to the others (if an intervention has been done) or as a confirmation with details (if that item is applicable to their expertise). Someone on the team should confirm that each item or task has been completed and that there are no concerns. If there is no answer from either another team member or the Checklist Coordinator, the team should not continue with the next item until the necessary information is exchanged. Each team member will have discipline-specific information that should be shared. Another alternative is to discuss items by relevant role. Each profession is responsible for speaking to the items related to their knowledge of the patient/procedure. Or, one profession could ask another profession the questions that pertain to their role (e.g., anesthesiology asks items related to nursing). 6. Can work continue at the same time as running through the checklist? To fully realize its patient safety potential, the checklist should be regarded as an extended surgical pause or extended time out. It is strongly recommended that the team stop all individual task work during the Briefing and Time Out sections of the checklist. The entire team should fully concentrate and actively participate. 33

34 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 7. Ensure the team goes through all three phases. Completing the Debriefing phase will be a new process, and will have its own challenges. Some staff may have to leave to attend other duties, so the Debriefing may be discussed just prior to or while the case is closing. It presents the best time to discuss post-operative plans, and quality improvement plans for future cases. Think of ways to improve surgical team communication: Try to break up the checklist by profession, and have each profession be responsible for going through their most relevant section. Or, have each profession be responsible for asking the other profession a selection of questions on the checklist (for example, nursing asks anesthesiology about all anesthesia relevant interventions). 8. Overcoming Barriers to Using the Checklist Resistance or barriers may arise when implementing the Surgical Safety Checklist. Here are some common ones and ways to overcome them: The checklist involves a change in practice. Teams may need to change processes and practices to meet some of the evidence-based interventions in the checklist. This will require education and support and may involve the forming of separate working groups and the appointing of champions to help lead the changes (see appendix 7 and 8 for evidence based practice, and appendix 10 - A39). Respect and collaboration of all disciplines is key to process and practice change. 34

35 The checklist involves a change in culture. Surgical, anesthesia, nursing, and OR teams all have different cultures and hierarchies. Each profession must take part in the initiative for it to succeed. This may require a comprehensive effort on the part of the organization to help change the culture of the OR. The active participation of senior administration can help. Encourage administrators to meet with staff, listen to problems, and work with them to overcome barriers. Encourage open communication by having senior leadership perform OR walk-arounds. To build teams, frontline workers need to feel supported by senior leadership and have opportunities to communicate directly with them. Nurses and other team members also need to be empowered to speak up and stop the running of the checklist if it is not followed in an appropriate manner. There will be a new flow in the OR. Some team members may worry that the process will slow the flow through the OR. Initially the flow may be slower, as teams get used to the checklist. But, with time and experience, teams will find that it takes very little time (approximately one minute for each phase). Skeptical clinicians will be more likely to buy in if they see the checklist can save them time. Ask test teams to document any time savings (e.g., fewer work-arounds to get equipment and supplies) in written logs. Gathering the entire team for a Briefing is a change in routine. There will be some clinicians who may have to change their regular routines in order to attend the Briefing before patient induction. Reinforce that the goal of the Briefing is to improve team communication and patient safety, and highlight the benefits of having the entire team present with the patient still awake during the Briefing. The Briefing phase ensures all professions confirm adequate preparations for surgery have been made so that optimal patient safety can be achieved. The checklist is seen as an add-on task rather than an integral part of patient safety. Some members of the team may become antagonistic if they see the Checklist Coordinator as a policing role in the OR (rather than someone working within the team to improve patient safety). It is important to allow time to adapt to the new normal. If problems with the same individuals persist over time, it is important to have a strategy in place to address them. It may be easier to address the small number of resisters after the wider implementation of the Surgical Safety Checklist when the majority of clinicians are accepting and supportive of the initiative. 35

36 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide Moving to Full Implementation 9. Spread the Checklist Across the Organization/ Share the Checklist s Success To help create buy-in and readiness for using the Surgical Safety Checklist throughout the hospital, it is important to share information about the pilot tests with all OR teams. 1. Collect and share positive preliminary data. Collect early evidence that OR staff can easily see. Keep a log of good catches and post it in a common area. Write down success stories of saved time, improved flow, or improved teamwork to help raise awareness and improve team camaraderie. 2. Post the question: Would you want the Surgical Safety Checklist done for you if you were having surgery? Let teams write their answer below. 3. Ask patients pre- or post-operatively if they feel safer knowing the checklist is being used. Share their answers with the teams. Posters and bulletin boards work well to spread the news and make other staff in the OR aware that the checklist is being rolled out. 4. Spread the news and celebrate successes. Share the good work and successes of the teams who are testing and running the checklist. Encourage staff to speak out and to collaborate with their colleagues. They should be encouraged to plant the seeds of success and share their positive experiences. Celebrate the fact that many teams may become more sensitive to picking up potential sources of error and work proactively to become tighter safety nets for the patients. Ask teams to submit articles, stories and anecdotes about their pilot testing experience and print them in your internal messaging system, OR newsletters, or corporate newsletter. Include thank you notes from senior administration and other leaders to make people feel that their efforts are being noticed. 36

37 Full-Scale Rollout Once the new process has been tested and shown to make improvements, it should be more widely accepted, and changes can be implemented across the hospital, developing a new norm. Once the Perioperative Services Advisory Committee is satisfied that a checklist can be rolled out to the broader organization, the following strategies may be helpful to increase widespread use: 1. Introduce the checklist into a new service or OR every week (depending upon the size of the organization). 2. Make sure that all staff receive written communication and notice of the launch date and upcoming roll out schedule. Include endorsement letters from the Perioperative Services Advisory Committee, senior administration, and physician champions. Make all the materials that were provided to test teams, such as FAQs, evidence, and articles available to everyone. 3. Build in sufficient time to allow staff to attend scheduled education sessions, and include discussion of the checklist in morning huddles. 4. Provide day-to-day leadership support to help teams learn about and implement the Surgical Safety Checklist process. The constant physical presence of OR educators, mentoring clinicians from all professional disciplines, and leads and co-leads of the checklist program is important to prevent early frustration and resistance to the program. Consider creating a policy for the Surgical Safety Checklist once the tool and process for completion has been trialled, revised and agreed upon. This policy can then be used for teaching and to assist in the standardization in the Surgical Safety Checklist process. 5. Continue to congratulate and celebrate success of those participating, and share these messages across the hospital. 6. Engage late adopters. As much as possible, clinicians should be encouraged to influence their peers. Consider posting data comparing the rates of compliance in different teams. This may help sway clinicians who may not want to be seen to practice differently from their colleagues. However, some people may continue to resist the use of the checklist, even after the broad rollout of the initiative across the organization. As a last resort, it may be necessary to inform these individuals that the current practice is no longer an option, especially given the requirement for public reporting of compliance with the Surgical Safety Checklist. Plan who will deliver this message; it is advised that this be handled at the senior administrative level. 37

38 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 10. Sustain the New Practices It will take time for the Surgical Safety Checklist to take hold and spread throughout hospital ORs. It will also take ongoing effort to sustain its momentum. Over time, teams may lose some of the initial enthusiasm of running the checklist. As time pressures and demands increase, teams may start rushing through in a tick and flick manner. Ongoing monitoring and support of this process including occasional direct audits -- is essential to ensure proper adherence. Monthly or quarterly compliance reports are useful to monitor sustainability (see appendix 10 - A39 for more information on monitoring). Follow these steps to maintain the use of the checklist, sustain the new practices, and meet reporting requirements: 1. Continue to support surgical teams. Provide education and support as required to help teams use the checklist and implement best practices effectively. 2. Audit practice. Periodic random sampling snapshot audits are a good way to ensure the process is working as intended. Collecting data on overall use of the checklist and possibly compliance with individual components or phases may help direct sustainability efforts, and focus on areas for continued improvement. When developing audit tools, consider examining current process for quality checks of data submitted to the Government of Ontario (e.g., SETp surgical pause indicator, or SSI on-time antibiotic prophylaxis). If a method to audit processes is in place, it may be helpful to revisit and use previous lessons learned to audit for the Surgical Safety Checklist. Consider in the audit, different operating room teams, surgical divisions, times of day, and OR suites; consider having an OR educator, OR manager, or trained student observing processes; or randomly interview professionals who have just completed surgery. 38

39 3. Communicate improvement data and keep teams motivated. Share information about reductions in surgical complications, good catches that were caught by teams, improvements in patient safety, patient satisfaction, teamwork, communication, and staff satisfaction to show how well the new process is working. It is ideal to show the data over time in an annotated run chart. Continue informing everyone affected by the change in practice about the progress being made, and focus on the overall aim 15 to improve patient safety. 4. Document results and ensure data quality: Ensure there is appropriate documentation identifying whether the checklist was actually done. How to document is best left to individual hospitals, however a clear policy and process should be established. For Wait Times-funded, Surgical Efficiencies Targets Program (SETp) hospitals, the absolute minimal documentation entails the entry of checklist completion into the ORBC system. However, for quality purposes, it is recommended that there be another documentation process for the patient s record. Some facilities have decided that compliance should be dictated or written into the surgeons operating room note (as part of ensuring ownership). Other hospitals have built a check for the checklist as a mandatory field of their electronic system (i.e., Meditech or PICIS) as one check (completed or not completed) or as three checks (one for Briefing, Time out, and Debriefing). Other hospitals are choosing to physically mark the checklist directly as phases are completed in surgery with the paper copy included the patient chart. 5. Assign accountability for documentation of surgical checklist completion by profession or role (e.g., surgeon, anesthesiologist, circulating nurse). 6. Consider documenting compliance to each phase separately to remind clinicians that they need to complete each phase and to target future quality improvement efforts. For example, if the Debriefing phase is seen to have the lowest compliance, a targeted effort can be made to improve compliance to this phase. 39

40 Part B: Surgical Safety Checklist How-To Implementation Guide Surgical Safety Checklist Implementation Guide 7. Some hospitals have moved ahead to request an incident report if the checklist or any phase has been omitted, which is another way to capture data about compliance in the OR. 11. Address the Evidence-Based Practices Contained in the Checklist A significant amount of research supports evidence based practices for the prevention of the following surgical complications: VTE, wrong site surgery, medication errors, and surgical site infections. Elements of the surgical safety checklist support prevention of these complications and are located on the CPSI checklist and are considered to be integral to hospitals efforts in providing safe, quality patient care. The OHA and the Government of Ontario strongly recommend that hospitals integrate these practices into their surgical checklist program and utilize practice guidelines available from Safer Healthcare Now! More information and references are located in appendix 7 and 8 of this toolkit. 40

41 Compliance with the VTE prophylaxis component of the Safe Surgery Checklist involves the following principles: VTE Prevention* Despite compelling evidence that thromboprophylaxis reduces the morbidity and mortality from VTE after surgery, consistent adherence to optimal practice remains low. In a national survey sent to all Canadian hospitals, 94% of hospitals reported that they routinely provided thromboprophylaxis to hip replacement patients, but only 33% reported routinely providing thromboprophylaxis to patients undergoing major general surgery. (See pages 34 and 35 of Part A: Primer) Preventative Actions* A proactive VTE prevention strategy means using evidence-based guidelines to assess patients and/or patient groups for risk of VTE and to consistently deliver an appropriate anticoagulant and/or mechanical method of thromboprophylaxis to all patients with sufficient risk. This best practice involves selecting an appropriate prophylaxis option, at the optimal dose, starting at the optimal time, and continuing for an appropriate duration of time. Assess all patients for their risk of VTE. In some surgical patients or patient groups, the VTE risk is too low to warrant the routine use of thromboprophylaxis. However, in all surgical patients, the need for thromboprophylaxis (or not) should be an active decision. Most inpatients undergoing major surgery warrant thromboprophylaxis. Assessment of VTE risk can be done at the group level (for example, all colorectal surgery patients or all hip arthroplasty patients have sufficient thromboembolic risk to warrant thromboprophylaxis, but most patients undergoing an uncomplicated inguinal hernia repair do not) or thromboembolic risk can be made at the individual patient level. See appendix 7 - A31 for recommended prophylaxis options for various patient groups. 41