How do we know the surgical checklist is making a meaningful. impact in surgical care? Virginia Flintoft, MSc, BN Vancouver, BC March 9, 2010

Transcription

1 How do we know the surgical checklist is making a meaningful impact in surgical care? Virginia Flintoft, MSc, BN Vancouver, BC March 9,

2 Show Me the Evidence You simply have to MEASURE! 2

3 Why Measure? To assess current performance, identify priorities, build tension for change and overcome resistance To assess the impact of your tests of change to guide improvement and build momentum To improve your knowledge of the care process and to identify potential solutions To create a culture that supports safer patient care 3

4 Why Measure? To assess current performance, identify priorities, build tension for change and overcome resistance To assess the impact of your tests of change to guide improvement and build momentum To improve your knowledge of the care process and to identify potential solutions To create a culture that supports safer patient care 4

5 It 1010 is1101 not0001 acceptable for hospitals to make blanket statements about providing high-quality care without backing it up with proof. Dr. Jack Kitts, President & CEO The Ottawa Hospital Metrics for Healthcare: The Leader s Role. CMAJ, Feb

6 What kind of proof? Measure at different levels Individual/Team, Organization, Provincial/National Measure for different uses Improvement Accountability Research 6

7 The Goal The only realistic goal of safety management in complex healthcare organizations is resilience - to develop a maximum capability to catch, correct, and learn from surprises as they arise - to develop a kind of intrinsic resistance to operational hazards. (adapted from Carthey, de Leval, Reason, 2001) 7

8 Is Canada any different?... 8

9 From the CAES Patient waited over one year for elective surgery. After anaesthetic induction review of x-ray indicated significant progression of disease and patient was rebooked for different procedure. Briefing: Review final test results Confirm essential imaging displayed 9

10 From the CAES Mismanagement of post-op diabetic resulting in hypoglycemic episode requiring intravenous glucose due to unresponsiveness. Debriefing : Anaesthetist reviews with the entire team recovery plans (including postoperative glucose) What are the KEY concerns for this patient s recovery and management? 10

11 Do you or your hospital want to be Famous? 11

12 Land of Opportunity 12

13 How will we know we are making a difference?... 13

14 Anticipate Correct Cope 14

15 What should we measure?... What does research tell us?... 15

16 Measuring Impact of SCL From Research* Outcome AE in surgery Blood loss Cardio-pulmonary instability, RTS Pneumonia Shock Dialysis ALOS Infection Death Process Airway assessment pre anaesthetic Pulse induction 2 PIVs or CL if blood loss >500ml expected; Prophylactic abx w/i 60 mins of incision; Verbal confirmation of patient identity, operative site, planned procedure; Sponge count completed post-op *A. A. Gawande et al. NEJM January 29, A surgical safety checklist to reduce morbidity and mortality in a global population 16

17 0011 we needed an 0100 approach 1011 that would help across a much wider range of ways in which surgery can go wrong Then Richard Reznick, the chairman of surgery at the University of Toronto, spoke up [they had trialed] a 21 item surgical checklist A. Gwande, The Checklist Manifesto 17

18 Measuring Impact of SCL From research* Number of Communication Failures per surgery Communication happened too late Failed to achieve its purpose Excluded relevant team members Outcomes of failed communication Inefficiency; Team tension; Resource waste; Workaround; Delay; Patient inconvenience; Procedural errors Outcomes Perceptions of the care team regarding the checklist and briefing experience 18 question exit survey 18 *L. Lingard et al. Arch Surg 143 (1), Jan Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication

19 Measuring Impact of SCL From research* Number of Precursor Events Lead to adverse outcomes Timing of the precursor event Preop; during anaesthesia before incision; during surgery; post-op Severity of precursor event Minor, major Time required to compensate for event Was event discussed with other team members *D. R. Wong et al. European Journal of Cardio-thoracic Surgery 29 (2006) Prospective assessment of intraoperative precursor events during cardiac surgery 19

20 What should we measure?... What does WHO tell us?... 20

21 Measuring Impact of SCL-WHO Outcomes and Complications Surgical Site Infection Rate Unplanned Return to the OR. Surgical deaths Efficiency Case Length Length of OR day # times Circulating nurse goes for supplies Averted problems (define in advance) 21

22 Measuring Impact of SCL-WHO Quantitative measures Identify local problems and establish meaningful measures for your OR # of times no blood was available # times prophylactic abx not given # times surgeon not in OR for Briefing 22

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24 Sample Measurement Sheet* 24 *adapted from Susan Maknak

25 Measuring Impact of SCL-WHO Qualitative markers Culture Will the SCL change culture or will the culture change the SCL? Record and report good catches and near misses Staff attitudes survey Teamwork Improved teamwork and communication 25

26 What should we measure?... What does Ontario tell us?... 26

27 Measuring Impact of SCL in ON* Process measures MOHLTC required Percentage of all surgeries that a SCL was performed for all 3 phases Process measures OHA toolkit % of all eligible surgeries receiving timely abx prophylaxis % of all eligible surgical groups receiving post-op anticoagulants Balancing measures OHA toolkit # cases performed / day Staff satisfaction (also qualitative outcome measure) *Sudha Kutty and Dominique Taylor. Ontario Hospital Association Surgical Safety 27 Checklist Implementation Toolkit. 2010

28 Measuring Impact of SCL in ON* Outcomes measures - quantitative # unintentional retained foreign objects # wrong site surgery Surgical Site Infection and/or VTE Rate Outcomes measures - qualitative OR staff satisfaction Safety culture survey improvements *Sudha Kutty and Dominique Taylor. Ontario Hospital Association Surgical Safety 28 Checklist Implementation Toolkit. 2010

29 Measuring Impact - OR Culture Questions from UHN OR culture survey Do you think the use of the checklist has improved patient safety? Do you find it inconvenient to conduct the SCL? How much time does it take to conduct the SCL? If you were to undergo surgery would you want the SCL to be used? Are you comfortable reminding other members of the team to carry out the SCL? Do you think the use of the SCL generally has improved communication among members of the OR team? 29

30 Measuring Impact of SCL Survey questions from L.Lingard et al. The checklist gives me information about the patient and/or procedure that otherwise would not have been available to me. provides an opportunity for the team to identify and resolve problems and ambiguities provides an educational opportunity for students and residents has the potential to guard against mistakes in the OR strengthens the OR team Considering all of the positive and negative aspects of the checklist, are routine checklist discussions worthwhile? 30

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32 Measuring Impact - CPSI CPSI Objectives % of Canadian ORs using the checklist Goal = 60% Degree of Implementation Goal = All patients in all surgeries Impact on surgical outcomes Goal = reduce death and complications Impact on teamwork and OR culture Goal = improve efficiency, communication and staff satisfaction 32

33 CPSI Surgical Checklist National Survey 33

34 What is the ultimate goal?... A Mindful Operating Room in a A Mindful Organization 34

35 Mindfulness vs Mindlessness Mindfulness is about the quality of attention-updating and seeing details. Mindlessness is about following old recipes, acting rigidly, operating on automatic pilot, and mislabeling unfamiliar new contexts with familiar old ones. K. Sutcliffe, University of Michigan

36 Heedful Interrelating People understand: 1. The goals of their organization or work unit; 2. How their job fits together with other people s jobs to accomplish these goals; 3. And, they see their work as a contribution to the system, not as a stand-alone activity. 36 K. Sutcliffe, University of Michigan.2009

37 When an Organization or O.R. is Mindful its Members are 1. Spending time identifying what can go wrong and talking about mistakes and how to learn from them; 2. Pooling diverse perspectives to get a good picture of the situations they face; 3. Discussing alternatives as to how to go about everyday activities and problems; 4. Continually developing people s skills and abilities; 5. Taking advantage of the unique skills of one s colleagues even if the person is of lower status in the organization. K. Sutcliffe, University of Michigan

38 Pay Attention in a Different Way and look for the Proof