1. A Few Notes About This Presentation
This presentation is designed to be given to an inter-disciplinary group of clinicians.
We recommend that you hold this type of meeting after you have had a chance to have one-on-one conversations with some of your colleagues that might be skeptical.
We have provided descriptions and some notes that might be helpful to you in the notes section of this presentation.
We recommend that this presentation is divided among the members of the implementation team.

2. Safe Surgery 2015: South Carolina
Insert Your Hospital’s Logo Here
Safe Surgery 2015: South Carolina
Presentation – Inter-Disciplinary Group
[ Insert Implementation Team Member Names]
[ Insert Hospital Name]
Insert your hospitals logo, names of people on the checklist implementation team, and your hospital’s name.

3. Our Hospital’s Implementation Team
[insert picture of your checklist implementation team]
Show a picture of your hospital’s implementation team - especially if there are members of the team that cannot attend the meeting.

4. Could This Happen Here?
We recommend that you open the presentation by telling a story of something that the checklist could have prevented. We provided a story that you can use, but you can also use one of the stories that you have heard. If you tell your own story, make sure that it cannot be identified with anybody from your hospital.

5. The Case 45 year old with breast cancer. Elective mastectomy.
Patient wants immediate reconstruction by plastic surgeon.
General surgeon does mastectomy.
Preference card is lost so instrument set not standard.
Very small room.
Scrub tech leaves because of family emergency.
Circulator becomes scrub nurse.

6. More Facts Circulating nurse is now covering two OR’s.
Plastic surgeon comes into room “early”.
Wants to begin reconstruction before general surgeons is finished.
Plastic surgeon “disruptive” saying procedure going “too slow”.
General surgeon insists on completing the mastectomy first.

7. What Happened Here The breast specimen was lost.
Surgeons had never worked together before and did not talk before procedure.
No “plan” for how surgery was to take place.
Nursing staff very stressed by surgeons and level of workload.
Complete system breakdown in processing specimens.

8. What Could Have Helped?
Discussion among the surgical team, where the following things were discussed prior to skin incision:
Surgeon shares the operative plan where s/he discusses anything that the team should be aware of.
Team discusses the equipment that is needed for the case.
Discussion at the end of the case where surgical teams confirms specimen labeling.

9. Does anybody want to share something that has happened to them?
Many hospitals have asked people in the audience to share a story of something that happened to them. We recommend that you identify somebody that will be attending the meeting beforehand and ask them to share their story. In general, people will talk if one person starts.

10. Safe Surgery 2015: South Carolina
To use of the South Carolina Surgical Safety Checklist in every operating room for every patient in our state.
To customize the checklist for our hospital’s unique needs.
To be part of a larger goal in partnership with the South Carolina Hospital Association and Safe Surgery 2015 [Directed by Dr. Atul Gawande at the Harvard School of Public Health].
Our state will become the model for improving surgical safety throughout the United States.
This slide is a summary of the Safe Surgery 2015: South Carolina Initiative.

11. What is the Evidence? Crude mortality decreased from 3.13%  2.85%.
Type of implementation
Scope of implementation
Impact of implementation
WHO Surgical Safety Checklist in OR
8 diverse global hospitals
In-hospital mortality rate1: %  0.8%
Post-op complication rate1: %  7.0%
Team training and use of briefing/ debriefing/checklists in OR
74 VA hospitals
18% decline in annual rate of mortality vs. 7% decline in control group of hospitals
Comprehensive set of surgery-related checklists in hospital including during surgery
6 'high-quality' Dutch hospitals
In-hospital mortality rate: 1.5%  0.8%
Post-op complication rate: %  10.6%
A Customized Version of the WHO Surgical Safety Checklist
Tertiary University Medical Center in the Netherlands
Crude mortality decreased from 3.13%  2.85%.
Measured checklist compliance and found that mortality was significantly lower in patients with completed checklists.
This slide summarizes the studies that have been published on using a surgical safety checklist. To access these articles or short descriptions of these articles, please go to:
1. For 4 pilot sites located in developed countries (USA, Canada, UK, New Zealand), results were a decline in the in-hospital mortality rate from 0.9% to 0.6% and a statistically significant decline in post-op complication rate from 10.3% to 7.1%
Source: Haynes, AB, et al, N Engl J Med 360:491-9, 29 Jan 2009; de Vries, EN, et al,N Engl J Med 363: , 11 Nov 2010; Neily, J, et al, J Amer Med Assn 304: , 20 Oct 2010; van Klei WA et al. Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality. Annals of Surgery Jan 1; 255(1):44-9.

12. Virginia Mason Hospital, Seattle
In order for the Checklist to work well it has to be used “right”.
Improving communication between all members of the OR team is critical to successful implementation.
Virginia Mason Hospital was one of the earliest adopters of the Checklist, and what they found was it’s not Checklist that changes patient care, it’s how people use it.
2010 Annual Meeting of the American Society Anesthesiologists

13. South Carolina Checklist Template
The South Carolina Checklist Template was developed specifically for South Carolina Hospitals. In particular, the briefing and debriefing sections have been expanded. This checklist was created through the consensus of the Safe Surgery 2015: South Carolina Leadership Team.

14. Our Hospital’s Checklist
[Insert your hospitals checklist]
We recommend that you show your hospitals customized checklist.

15. How Did We Customize Our Checklist?
Summarize items that you customized for your hospital.
Summarize what items you changed on the checklist and how they fit the culture and needs of your hospital. We also recommend that you briefly talk about how you tested the checklist with multiple surgical teams to ensure that it met the needs of your ORs.

16. Don’t We Already Do All of This?
It is more than the time out and our usual safety checks.
This is our chance to build on the time out and make it contribute significantly to every case.
Encouraging a conversation at the beginning and end of surgery to improve communication.
Providing structure and consistency so that every patient gets what they need every time.
“Don’t we already do all of this?” is the most common question that people ask when somebody first learns about the checklist. We have provided some helpful responses in this slide.

17. Show Checklist Demonstration Video
[Insert your hospital’s demonstration video or another video that you would like to show]
If you do not have a video many hospitals have role-played using the checklist.
If you have created a checklist demonstration video, we recommend that you show it on this slide. If you are still working on this or prefer to use another video you can find videos of surgical teams using the checklist at the following website:
Instead of using a video some hospitals role-play using the checklist at this meeting.

18. We are very good at what we do…. We can be even BETTER
This is a chance to remind everyone that although we are all very, very good at what we do, all of us can be better. Just like professional athletes and politicians who are at the top of their respected fields, everybody can be better at what they do, too.

19. We Are Not as Good as We Think
You can also use the results from your hospitals culture survey if you would like to present local evidence.
We’re not quite as good as we think. There’s a discrepancy between what different team members think about the communication in the OR. This slide shows that you get very different results when you ask surgeons and OR Nurses to rate each other’s communication and teamwork abilities. 87% of the time the surgeons think the nurses are good teammates. But when you ask the nurses if they think the surgeons are good teammates, you get a very different picture. It’s this gap that we’d like to close. We’d like both of those bars to sit up near the top of the chart so that the surgeons and the people around them are in agreement that the teamwork on our ORs is really, really good.
Makary et al., J Am Coll Surg 2006; 202:

20. How Can the Checklist Help Us Be Better?
It makes sure that we do the things that our surgical patients need every time.
It improves communication, teamwork and the culture of safety in our hospital.
Can make surgical teams more efficient – It has been known to save time.
“How Can the Checklist Help Us Be Better?” summarizes some of the benefits that we have seen in hospitals throughout the world when they effectively use the checklist.

21. Physician Acceptance is the Critical Factor in Successful and Meaningful Use of the Checklist
The most critical factor in the successful and meaningful use of something like the Checklist is its acceptance by the physician community, and by anesthesiologists and by surgeons in particular. If any member of the OR team is not fully engaged, the Checklist cannot do all of the things we know the Checklist is capable of doing. This is one project that cannot be done by the nurses alone. Nurses have carried the burden on safety for a long time. It is now time for us to get involved in this project and have them own the checklist.

22. HOW YOU ACT DURING THE TIME OUT/CHECKLIST MATTERS
The Team is looking to you for leadership.
You are setting the tone for the rest of the operation.
Others will follow your patterns of communication.
This is an opportunity to make your plan clear, answer questions, demonstrate openness and professionalism.
We often forget that how we act during the Time Out or during the Checklist really matters. Many times the Time Out is met with disengagement, eye rolling, or other kinds of body language that’s suggestive of a lack of respect for what the Joint Commission is trying to stop.

23. How Do Surgeons Feel in the OR
Stressed
Focused
“It’s time to do the CHECKLIST”
“I don’t want to do it – I never did this before – it makes me feel weird.”
“I am already safe - I don’t need to do it”
“Maybe the surgeon in the next room needs it”
Use this slide to discuss the ways surgeons feel when they are asked to do the checklist.

24. How Do Anesthesiologists/CRNA’s Feel in the OR
Stressed and focused
“I don’t want to do it – I never did this before – it makes me feel weird – it messes up the way I work”
“I am already safe - I don’t need to do it”
“Maybe the team in the next room needs it”
"Don't these other guys know what they're doing?"
"Didn't we all just check this stuff? Or did they?”
"If everyone had the attention to detail that I do, this would not be necessary”
"Don't make me do another G*% D&#$ piece of paper!!”
"If it doesn't take long, and we have to, well OK”
"This really doesn't take that long, and if it keeps us all out of courtrooms. . ."
How do other member of our team feel in the OR? Anesthesiologists and CRNA’s often feel the same thing we do.

25. How Nurses Feel in the OR
“Before going into the OR I need to prepare my approach depending on surgeon or team.”
“I know when there will be a battle and I need to prepare my response.”
“Try to stay positive during the surgical case, no matter what happens.”
“We carry the load to ensure that the safety checks are completed.”
“I don’t want to be the enforcer but sometimes need to be for patient safety.”
“I am not the right person to convince a surgeon who refuses to do this.”
“I feel shut down when there is not open communication.”
Let’s see how nurses tend to feel in the OR.

26. How Do Scrub Techs Feel in the OR
“I am part of the team and am responsible for patient safety as much as everyone else.”
“I don’t want to waste time fighting about this- I wish we could just do it!”
“ I am ready to change my approach, depending on who I am working with in the OR.”
“The majority of the team will listen and participate, but I may need to help remind the surgeons to follow policies.”
“Willing to back up circulator and to take on equal responsibility to ensure that this is completed for my patient.”
“I think that it is the right thing to do.”
“If I were the patient I would want it done for me.”
Finally, we asked circulating nurses how they feel.

27. The “Scrub Sink Trance”
The Scrub Sink Trance is a period of time that happens for surgeons as they scrub in when they actually begin to do the surgery in their minds. As they’re scrubbing, they’re beginning to review the first critical steps of an operation, or maybe the most critical steps of the operation they’re about to perform. One of the most common criticisms of the Joint Commission Universal Protocol is that it breaks up this trance.
All experts have their own versions of the Scrub Sink Trance. People who ski, people who bike, people who speak, people who do surgery all have this period of intense focus before they begin. The downside of this trance is that when you’re in it, you’re partially disengaged and you are much more vulnerable to forget things that you really mean to do. This is why the Checklist is so important – because the Checklist makes you stop, come out of your trance, and make sure you get all of the critical steps done. This quick switch from a state of intense focus to a state that is not nearly intense is just what baseball players do when they step in and out of the batters box, and it’s something that surgeons need to learn how to do.

28. “Reverence for Induction”
Our Anesthesiologist and CRNA colleagues have a period of intense focus like we do. I like to call it the reverence for induction. When they are putting someone to sleep at the beginning of the case they have a period of intense focus. We should all be mindful of this time and try to respect it.

29. “Respect for the Counts”
The counts at the end of the case is a period of intense focus for nurses. This is a period of time that should be respected in the OR and the checklist should never interfere. All experts have their own versions of this. People who ski, people who bike, people who speak, people who do surgery all have this period of intense focus before they begin. Every member of the OR team has a similar period of intense focus.

30. Surgeons Can Make A Difference
It is our responsibility to work to improve the safety and outcomes of our patients.
We are not powerless to make change.
We are part of a surgical team and often in the position of leading that team – that is a privilege and an opportunity to make a difference.
We can make a difference, and our plea to all you is that we have an obligation to make a difference. It’s our responsibility to work to improve the safety and outcomes of our patients. The system can’t do it without us. Even though we may feel like it, we are not powerless to change things for the positive.

31. Teamwork Communication Coordination
Team performance valued over individual performance
Wise use of resources
Leadership
The Checklist is the surgical community’s chance to improve the teamwork that is in their operating rooms. It can make the patients’ outcomes better, and it can make our life better because people will work together better. It’s all about communication and coordination, about a place where the performance of the team is valued over our individual performance, where we use resources wisely, and where we take opportunity to exert the leadership that we know is part of who we are as surgeons.

32. What Can You Do? Activate people by using their names.
Set the Tone – Make everyone feel “safe”.
Tell the team what you are going to do.
Encourage team members to speak up.
Stop to Debrief at the end of the case.
So what can you do? You can try and use the names of the people around them – by using the introductions part of the Checklist to encourage people to introduce themselves and/or by using white boards in operating rooms that we can glance at it if we forget somebody’s name, particular under pressure. Name recognition activates people. It raises their level of awareness, and it also shows them respect. Looking over the ether screen and saying “Anesthesia” is rude, and we all know that. We do it because we can’t remember the anesthesiologist’s name, perhaps, but using a name in that situation is incredibly helpful for the relationship as well as for patient care.
One of our major responsibilities as surgeons is to set the tone at the beginning of the operation. We want a positive tone of openness and one that encourages people to speak up – particularly if patient safety is threatened.

33. This isn’t just about one person and what they need
This isn’t just about one person and what they need. Everyone is in the room for the patient and all of the people around you need your help, encouragement and leadership. Surgery is a team effort and the most effective and safe surgeons recognize that.
It’s very important for us as surgeons to remember that this whole thing isn’t about you. If anything it’s about the patient. Everybody in the room is there for the patient, and all the people that surround us as surgeons need our help, encouragement, and leadership. Surgery is a team effort, and the most effective and safe surgeons recognize that.

34. Safety is staying back from the Edge
“Safety is staying back from the Edge”: This is a little picture to show you what the Checklist can do and why I think it’s so important for surgeons to take control of the parts of the Checklist that they are responsible for – and that’s mostly around the time of the Time Out. Safety is staying back from the edge of the cliff. We don’t want our patients to fall off. Most of us spend our time up on the edge there, but we want to be back further than that so if something goes wrong there’s more margin. The Checklist can help us stay back from the edge.
The Checklist can help you do that.

35. The Checklist Has Already Helped
[insert examples of what the checklist has caught during the testing or how people feel about using the checklist.]
Please see Talking to Your Colleagues – Presentation Guide and Tips Document.
The checklist has already helped. Many hospitals have monitored items that the checklist has caught since they started using it in the testing phase. This is a chance to summarize any of the things that the checklist has caught. We also recommend for a member of one of the surgical teams that tested the checklist share their experiences using the checklist and the benefits that they have seen from the improved communication. We have also included a list of things that the checklist commonly catches:
Anesthesiologist clarified that a generic drug name on the medication list was a beta blocker, and nurse confirmed with patient that the medication had already been taken that day
Type+screen would be needed prior to skin incision.
Beta blocker had not been sent down for patient to take that day.
Clarified and ordered antibiotic.
Provided detail regarding procedure to be completed.
Equipment needed and proper patient positioning during procedure.
Identified need to do an unscheduled central line placement.
Broken equipment was identified and fixed following the procedure.
Applied SCDs due to extended length of case
Missing equipment was identified at the beginning of the case.

36. Next Steps
We are administering a culture survey because we want to know you think about the teamwork, communication, and safety in our operating rooms. Please complete the culture survey.
Room-by-room and team-by-team implementation.
We are rolling the checklist out slowly over the next [insert #] weeks.
We will talk to you and rehearse before we ask you to use it in your room with a live patient.
After you start using the checklist we will assess teamwork in the OR using an observation tool.
Next Steps summarizes steps that you are taking to put the checklist into place. We have highlighted the items that are important to share with your colleagues.

37. Our Plan [Insert your timeline for checklist implementation].
Our Plan is a placeholder for you to summarize your roll-out plan. In particular the dates of when you are starting each service.

38. How Can You Help?
Work with us on putting the checklist into your rooms.
Talk to your colleagues about this project.
Give us feedback.
This slide summarizes what surgeons can do to help with this work.

39. Contact Us with Questions & Feedback
[Insert person to contact, and phone number]
Please insert the contact information for any questions that anybody might have about this project. It is extremely important for your colleagues to know who to contact for questions or concerns.