1. Call 2: Evidence Supporting the Use of the Checklist and The Importance of the Checklist Implementation Team

2. Topics Covered on the Last Webinar
Checklist Development and Background.
Why South Carolina?
The impact of the Safe Surgery 2015: South Carolina on surgical safety globally.
Going beyond the “Time Out”.

3. Lorri Gibbons, RN, BSN, CPHQ VP, Quality & Patient Safety
Meet the Team
Lorri Gibbons, RN, BSN, CPHQ
VP, Quality & Patient Safety
SCHA

4. Poll 1
Are you using a surgical checklist that requires the surgical team to stop and discuss critical items at three points of time (Before Induction of Anesthesia, Before Skin Incision, and Before the Patient Leaves the Room)?
Yes No
If you answered yes, what percentage of surgical cases are using this type of checklist routinely?
<50%
>50%
It is used for every patient undergoing surgery

5. Today’s Topics
A full review of articles that have been written about the impact of the checklist.
The importance of data to physicians and how to talk to physician’s about data.
Building a Checklist Implementation Team:
Poll
The role that this team plays
Who should be on the team
How often the team should meet
How to find the “right” people to lead this work

6. A Full Review of Evidence

7. Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine Jan 29; 360(5):491-9.

9. International Pilot Study 8 Evaluation Sites - Nearly 8,000 Patients
EURO
EMRO
PAHO I
London, UK
Amman, Jordan
Toronto, Canada
WPRO I
Manila, Philippines
PAHO II
Seattle, USA
AFRO
WPRO II
Ifakara, Tanzania
Auckland, NZ
SEARO
New Delhi, India

10. Results – All Sites 3733 3955 - 1.5% 0.8% 0.003 11.0% 7.0% <0.001
Baseline
Checklist
P value
Cases
3733
3955 -
Death
1.5%
0.8%
0.003
Any Complication
11.0%
7.0%
<0.001
SSI
6.2%
3.4%
Unplanned Reoperation
2.4%
1.8%
0.047

11. Survey of Attitudes to Checklist Use Among Clinicians at Study Site (n=229)
The checklist was easy to use
78.6%
The checklist improved operating room safety
79.0%
The checklist took a long time to complete
18.3%
Communication was improved through use of the checklist
84.3%
The checklist helped prevent errors in the operating room
78.2%
If I were having an operation, I would want the checklist to be used
92.6%
Haynes, A et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist- Based surgical safety intervention. BMJ Qual Saf 2011;20:

13. Additional Evidence

14. de Vries EN, et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363:

15. SURPASS Checklist The Netherlands
100 item checklist implemented in 6 high performing hospitals
Compared to controls the test hospitals had a greater than one-third reduction in complications and achieved an almost 50% reduction in deaths (from 1.5% to 0.8%)
(N=7,580)
de Vries EN, et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363:

16. Neily J, Mills PD, et al. Association Between Implementation of a Medical Team Training Program. JAMA Oct 20;304(15):

17. Veterans Health Affairs
Implemented a surgical team training program incorporating a modified version of a surgical checklist in the operating theatres of 74 facilities
Experienced initial mortality reduction of 18%1
One year later, facilities that participated in the program experienced a risk-adjusted morbidity reduction of 17% versus 6%2
1. Neily J, Mills PD, et al. Association Between Implementation of a Medical Team Training Program. JAMA Oct 20;304(15):
2. Young,Xu Y, et al. Association Between Implementation of a Medical Team Training Program and Surgical Mortality. Arch Surgery Dec; 146(12):

18. Forth significant study again from the Netherlands – just published in January this year
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.

19. University Medical Center Utrecht, The Netherlands
25,513 adult patients undergoing non-day surgery.
Used hospital administrative data and patient medical records.
Crude mortality decreased from 3.13% to 2.85%.
Measured checklist compliance and found that mortality was significantly lower in patients with completed checklists.
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.

20. Takala, R.S.K. et al. A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities
and communication. Acta Anaesthesiol Scand Sep 26 (55):

21. Finland Study Four Teaching Hospitals
Implemented a modified version of the WHO Checklist
Studied the impact on communication and processes by surveying surgical teams pre and post implementation
Discussion of Critical Events Pre Operatively
Pre Implementation
Post Implementation
Anesthesiologist
Surgeon
22%
35%
43%
46%
P < 0.001
N=1,748
Takala, R.S.K. et al. A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities
and communication. Acta Anaesthesiol Scand Sep 26 (55):

22. Checklist. J Am Coll Surg. 2012 Aug 27.
Bliss LA, et al. Thirty-Day Outcomes Support Implementation of a Surgical Safety
Checklist. J Am Coll Surg Aug 27.

23. 600-Bed Tertiary Care Facility in the Northeast US
Three 60 minute team training sessions
Use of checklist in high-risk general surgery cases (73 cases)
Checklist completion rate >90%
Checklist use was correlated with decrease in all measured areas of 30-day morbidity
Bliss, LA et al. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist. J Am Coll Surg. Available online
August 30, 2012.

24. Stanford University, United States
O/E Mortality declined from .88 to .8
The total number of reported events rose; however, those that were attributed to errors/complications decreased from 35.2% to 24.3%
Mean OR start to incision time was shorter
There was improvement in the belief (SAQ) that all personnel take responsibility for patient safety
(N=12,247)
Tsai, Thomas et al. Does a surgical safety checklist improve patient safety culture and outcomes? [Abstract]. In: American College of Surgeons Annual Clinical Congress October 3-7; Washington D.C. Journal of American College of Surgeons.

25. Compliance to NICE VTE guidelines were prospectively assessed in all general
surgery patients over two separate audit periods, before and after 6 months of the routine
use of the WHO checklist. Correct completion of the checklist was verified.
Results: 370 patients (173 [47%] male, 197 [53%] female, mean age 61.6 yrs). Non compliance
to NICE VTE guidelines was reduced form 16/233 (6.9%) to 3/137 (2.1%) after introduction of
the checklist ( p 1/ Fisher exact test). Non compliance was reduced in both emergency
and elective procedures.
Conclusions: Establishment of theWHOchecklist for routine use in all general surgery patients
may significantly improve VTE guideline compliance of all general surgery patients
Truran et al. Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines? The Surgeon 9 ( ) 3 0 9e3 1 1

26. Semel, ME et al. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood) Sept; 29 (9);1593-9

27. During a 7-week period, a prospective study was performed to evaluate the completion of all
preincision components of the surgical checklist. Pediatric surgical operations were selected for direct
observation. In addition, a poststudy survey was used to assess perception and understanding of the
checklist process.
Results. A total of 142 pediatric surgical cases were observed. Hospital reported data demonstrated
100% compliance with the preincision phase of the checklist for these cases. None of the cases completely
executed all items on the checklist, and the average number of checklist items performed in the observed
cases was 4 of 13. The most commonly performed checkpoint were the confirmation of patient name and
procedure (99%) and the ‘‘timeout’’ at the start of the checklist (97%). The rest of the checkpoints were
performed in less than 60% of cases. Adherence did not increase during the observation period.
Conclusion. These data show that despite the 100% documented completion of the preincision phase of
the checklist; most of the individual checkpoints are either not executed as designed or not executed at all.
These findings demonstrate lack of checklist implementation fidelity, which may be a reflection a poor
implementation and dissemination strategy. (
Shauna L. et al. Implementing a surgical checklist: More than checking a box. Surgery, 2012 Sep;

28. What Does the Evidence Mean to Physicians?

29. There Will Never Be The Perfect Study
Individuals can always find something to argue about in data Data is often used as the argument to not change or adopt behaviors/tools that improve patient safety

30. Evidence “Driven” Behavior

31. Believing

32. Physician Engagement Observed During a Surgical Checklist Implementation

33. Building an Implementation Team

34. Poll 2 Are you listening to the call as a group or an individual?
Suggest we remove

35. Make an Implementation Team
Administrator/Quality Improvement Officer
Anesthesiologists and/or CRNA
Circulating Nurse
Scrub Tech
Surgeon
Others (Perfusionists, PA’s, Biomedical Engineers, Anesthesia Techs, Pre-op nursing, etc)

36. Find Clinical Champions
The nurses will know.
Pick those who are respected and who will be supportive.
The support of “formal” leadership is absolutely necessary but those leaders are often not the ones who should guide this effort directly.

37. Recommendations on How Often and When to Meet as A Team
Meet regularly.
Choose someone to organize the meeting schedule and be a point of contact for people in your hospital and our team.
A good time to meet together would be following each webinar.
It is better to meet with part of the group than not at all.
Your physician champions don’t have to be part of every meeting.

38. What Should You Tell Checklist Implementation Team Members
This team will be responsible for the following tasks:
Administering the culture survey
Modifying and customizing the checklist
Guiding small scale testing of the checklist
Devising the implementation plan
Educating and training clinicians to use the checklist
Coaching teams on continued use of the checklist
Regularly report progress to hospital administration

39. Homework
Think about who you are going to have on your checklist implementation team.
Please contact Katie Jahreis to administer the culture survey

40. ?
Questions

41. Next Webinar: November 29th, 2012 2:00-3:00
An in depth discussion of why each item is on the South Carolina Checklist Template.
Overview of what is to come in Part II and upcoming events.

42. Office Hours: Wednesday 2:00-3:00

43. We Will Be Sending You An Email With:
A comprehensive bibliography of all of the evidence that has been published on the checklist.
An article that is a literature review of how the checklist has been shown to improve teamwork and communication in the OR.
A link to watch the recording of today’s webinar and to download today’s slides.

44. Resources Website: www.safesurgery2015.org