LEADING THE MAKING GREAT CARE CHALLENGE AFFORDABLE Checklists and Simulation Training Jason Cheng, DO; Paul Preston MD NATIONAL QUALITY CONFERENCE: April 29 –– May 1, 2014 LEADING THE MAKING GREAT CARE CHALLENGE AFFORDABLE

Speakers  Jason Cheng, D.O.  Simulation Physician Champion  Kaiser Permanente Southern California, Downey Medical Center  L&D Perinatal CETT; Periop HRT, MedSurg Inpatient, Interventional Radiology;  Southern California Regional Simulation Human Factors Committee National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Learning Objectives  Understand the frequency of errors when managing emergencies  Define the measured improvements when checklists are used  Understand the 5 A’s to checklist success  Look at a successful implementation in one KP facility  Consider how these can best be used to break down interdisciplinary barriers to communication and action National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Critical Events in Your OR/PACU  More or Less Frequent?  Organized or Chaotic?  We are building more reliable systems and need to systematically address our emergency skills National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Where We Are Now  Reliance on memory for Critical Steps  Show of hands – who is ACLS certified?  What are all the Hs and Ts?  “Gee, haven’t seen this in awhile…” National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

W. Wayne Babcock, M.D

“If a response is not instantly obtained by simple measures, a fixed emergency routine, posted on the walls of every operating room and drilled into every member of the staff, should be enforced.”

Failure of Adherence to Critical Steps (%) P<0.001 With Checklists Without Checklists 75% Reduction in Failure to Adhere to Life Saving Processes of Care National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Delivering optimal care to our patients from memory alone? “The frequency of cognitive aid use correlated significantly with the MH treatment score….” National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015 Latent knowledge activation? Prospective memory cue?

What we can learn from aviation… National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

PILOTS TRAIN TO FLY THE PLANE AND DEAL WITH EMERGENCIES National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Pilots Train In…  CRM – Communication – Teamwork  How to use checklists National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

5 A’s of Checklist Success  AWARENESS—did you know they exist?  ACCESSIBILITY---can you get to them…easily???  ACTION—read it, write on it, hold it…if you don’t use it, you lose it!  ASSESS—simulation, in service, test it to see how it works for you  ACCOUNTABILITY—helps engage team members to stay on the same page National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Access in OR  Consistent location  Easy to see and reach when needed  Does not block daily workflow National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

L&D, Operating Rooms Easily accessible by entrance Located next to that other emergency equipment! Easily visible National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Lights, Camera…Simulation! National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Periop Use of Checklists: BiMonthly Simulation  OR/Periop—OR, PACU – 8 Main ORs, 2 PACUs, 1 MOB/Procedural Sedation Center – Hemorrhage  Cardiac Arrest – Malignant Hyperthermia  Cardiac Arrest – Fire/Airway Fire – LAST  Difficult Airway  Cardiac Arrest – Difficult Airway  Hypoxia  Cardiac Arrest – Anaphylaxis  Cardiac Arrest National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Simulation – L&D CETT  Monthly  Involves OB, nursing team, NICU team, anesthesiologists  Checklist scenarios used: – Massive Hemorrhage  Cardiac Arrest – Failed Airway  Hypoxia  Cardiac Arrest – Fire National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

What have we learned?  Knowing what you didn’t’ know before!  I thought, you thought, she thought…we all “assumed”…  Roles may need to be more clearly defined!  We’re not set up for this sort of thing! (system improvements needed)  What goes where? Who does what? National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Roles not clear, too many cooks in the kitchen! National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Roles defined, everybody knows where to go! National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Checklist helps redefine roles more clearly  Role of Circulating RN (or primary RN on floor)  Role of Charge RN  Who are the immediate first reponders to circulator and anesthesia?  Who gets the checklist, and who reads it?  What are the responsibilities dictated on the checklist—rehearsing the roles!  Is anesthesia or surgeon the best person to be the “leader”?  What system improvements need to be made based on the checklists? (emergency drugs, emergency equipment, communication protocols, etc) National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

Fire Simulation improvements Gas valves labeled for specific OR National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

LOCAL ANESTHETIC TOXICITY SIMULATION Emergency resuscitative medication from local anesthetic toxicity best kept inside regional anesthesia and nerve block carts National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

L&D CARDIAC ARREST/MASSIVE HEMORRHAGE Original OR room small, poor access to emergency resuscitative equipment, especially with neonatal staff during muiltiple births Emergency access limited during crash c-section sometimes 10 staff members in room National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

L&D Simulations Entire wall knocked out and moved back further for greater access; OR monitors relocated to make more room for neonatal staff; National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

When and How NOT to Use  NOT when immediate action is required  NOT preventing additional clinical actions  NOT as a replacement for appropriate training  NOT as a replacement for clinical judgment  NOT instead of calling for appropriate help  NOT selecting incorrect cognitive aid  NOT distracting leader October 25, National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. 28

More Observations  Read these out loud!  Some checklists (MH) work really well to guide the emergency management – Read/Do  Some checklists (Airway) will work best before you get into the emergency – Preflight briefing  Some checklists (Hypotension, hemorrhage) may often be used early by an individual to double check themselves  A lot of the time the first few steps will have been done before the checklist is deployed- use as a quick review! National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

The Implementation Journey  Learn to manage OR emergencies using checklists – They work – There is a lot of science in how to design them – They will evolve over time – They do disrupt our learned patterns – Training is essential  Give us input on: – Usability of the checklists – Implementation and training – Ongoing checklist refinement and automation October 25, National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. 30

The team that trains together makes music together! National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015