1. Disclosure Statement “I have no financial disclosures to report but I am employed by the South Carolina Hospital Association.”

2. Transforming Surgical Care through Team-based Communication Palmetto Health System Presentation August 12, 2010

3. Redesigning Health Systems “The American healthcare delivery system is in need of fundamental change….Healthcare today too frequently harms and routinely fails to deliver its potential benefit…. Between the healthcare we have and the care we should receive lies not just a gap, but a chasm”

4. If 99.9% Were Good Enough… IRS lost documents  2 million per year Major plane crashes  3 per day Lost items in mail  16,000 per hour ATM errors  37,000 per hour Pacemaker incorrectly installed  291 per year Babies given to wrong parent  12 per day Erroneous medical procedures  107 per day

5. IOM Report Deaths due to medical errors exceed the number attributable to 8th leading cause of death. More people die in given year as result of medical errors than from motor vehicle accidents, breast cancer or AIDS Medication errors alone estimated to account for over 7,000 deaths annually Up to 100,000 deaths due to healthcare-associated infections- vast majority are preventable Total national costs of preventable adverse events are estimated to be between $17 - $29 billion

6. IOM Six Aimsfor Improvement IOM Six Aims for Improvement Patient care that is: Safe- avoidance of unintended pt. harm Effective- evidence-based Patient-centered- focused on needs and rights of the individual patient Timely- avoidance of delays & barriers to patient care flow Efficient- elimination of waste Equitable- fair access to comparable health care services for all

7. “My Mom” Quality/Safety Standard  How would you want your Mom treated at your hospital?  Every patient in your hospital expects and deserves that same high level of care/safety  Now we have to prove how well we’re performing under this “My Mom” standard

8. Vision: Vision: That all SC hospitals and providers deliver safe, high quality healthcare in a caring and compassionate manner to each patient, every time Mission: Mission: To establish a culture of continuous improvement in the quality, efficacy and safety of patient care across all healthcare organizations and providers statewide

9. Redefining Performance Excellence What is the ultimate we believe our hospitals can and should accomplish to dramatically improve the safety and quality of the care and the health of the patients they serve?

10. Organizational culture of safety Evidence-based medical care Patient-centered care environment Serious adverse events prevention SystemInfrastructure

11. “Rather than uncoordinated, episodic care, we need to offer care that is well organized, coordinated, integrated, characterized by effective communication, and based on continuous healing relationships” -Eric Larson

12. Creating a Culture of Safety Acknowledgement of the high-risk, error- prone nature of an organization ’ s activities Blame-free environment where individuals are able to report errors and close calls without punishment Expectation of collaboration across ranks to seek solutions to vulnerabilities Willingness on the part of the organization to direct resources to address safety concerns.

13. Communication and Education Create an environment of mutual trust, respect and psychological safety Actively support open communication and courageous dialogue system-wide Establish a Leadership orientation/training program to ensure “quality literacy/competency” Promote an active learning process for all clinical staff including physicians (including access to simulation training)

14. Why Communication ? *The overwhelming majority of medical errors involve communication failure *Wrong site surgery - somebody knows there’s a problem but can’t get everyone in the same movie – often it’s hard to speak up *The clinical environment has evolved beyond the limitations of individual human performance

15. Crew Resource Management  Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making  Non-punitive reporting of near misses, 500,000 reports over 15 years  Very open culture with regard to error and safety

16. The Safe Surgery Saves Lives Program

17. The Problem

18. The 3 Central Problems in Surgical Safety Throughout the World Unrecognized as public health issue Lack of data on surgery and outcomes We know what to do, but we don’t do it consistently

19. Four Categories for Surgical Standards: CONTROL OF INFECTION AND CONTAMINATION ANESTHESIA AND PATIENT MONITORING SURGICAL OPERATOR QUALITY ASSURANCE

20. WHO’s 10 Objectives for Safe Surgery 1.The team will operate on the correct patient at the correct site. 2.The team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain. 3.The team will recognize and effectively prepare for life- threatening loss of airway or respiratory function. 4.The team will recognize and effectively prepare for risk of high blood loss. 5.The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

21. WHO’s 10 Objectives for Safe Surgery 6. The team will consistently use methods known to minimize the risk for surgical site infection. 7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds. 8. The team will secure and accurately identify all surgical specimens. 9. The team will effectively communicate and exchange critical information for the safe conduct of the operation. 10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.

22. Why a Checklist?

26. Pilot Study

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

29. SiteCases Inpatient Complication Inpatient Death 152411.6%1.0% 23577.8%1.1% 349713.5%0.8% 45207.5%1.0% 537021.4%1.4% 649610.1%3.6% 752512.4%2.1% 84446.1%1.4% Total373311.0%1.5% Outcomes at Baseline

30. Results - Process Measures BaselineChecklistP-value Objective Airway Evaluation 64.0%77.2%<0.001 Abx at 0-60 Mins Except Dirty Cases 56.1%82.6%<0.001 Verbal Pt/Site Confirmation 54.4%92.3%<0.001 Two IVs /Central Line if EBL≥500 58.1%63.2%0.32 Pulse Oximeter 93.6%96.8%<0.001 Sponge Count 84.6%94.6%<0.001 All Six Safety Indicators Done 34.2%56.7%<0.001

31. Results – All Sites BaselineChecklistP value Cases 37333955- Death 1.5%0.8%0.003 Any Complication 11.0%7.0%<0.001 SSI 6.2%3.4%<0.001 Unplanned Reoperation 2.4%1.8%0.047

32. Change in Death and Complications Income Classification Change in Death and Complications by Income Classification Change in Complications Change in Death High Income10.3% -> 7.1%*0.9% -> 0.6% Low and Middle Income 11.7% -> 6.8%*2.1% -> 1.0%* * p<0.05

33. Survey of Attitudes to Checklist Use Among Clinicians at Study Site Survey of Attitudes to Checklist Use Among Clinicians at Study Site (n=229) The checklist was easy to use78.6% The checklist improved operating room safety 79.0% The checklist took a long time to complete18.3% 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%

34. Where is the Checklist Today

35. Participating Hospitals: 3,865 Actively Using the Checklist: 1,657

36. IHI Sprint Challenged every hospital in the U.S. to trial the Checklist with one surgical team- 80% of SC Hospitals

37. Notable Endorsing Organizations American College of Surgeons American Society of Anesthesiologists Association of Perioperative Registered Nurses (AORN) American Academy of Otolaryngology-Head & Neck surgery American Orthopedic Association Anesthesia Patient Safety Foundation Blue Cross Blue Shield Association

38. What key steps have other hospitals followed that have enabled them to successfully implement the Checklist?

39. What Can Make a Difference Find a “champion” in each discipline (anesthesia, nursing, and surgery) Buy-in from clinical and hospital leadership Modify the Checklist and trial it Measurement/Local Evidence – Reinforce Change – Show Progress

40. Checklist Modification Basics One size doesn’t fit all Need to have full team buy-in Don’t remove teamwork items –Introduction of team members by name and role –Review of specific patient concerns –Discussion of key concerns before patient leaves the OR

41. Does the entire team stop all activity at the three critical points in care? Does the team verbally confirm each item on the Checklist? Are the items verified without reliance on memory? Does the Checklist promote communication? When We Use the Checklist When We Use the Checklist :

45. Virginia Mason Hospital- Seattle In order for the Checklist to work well it has to be used “right”- requires behavioral change Improving communication between all OR team members is critical to successful implementation. 2010 Annual Meeting of the American Society Anesthesiologists

46. Operation: Safe Surgery Vision/Purpose Vision: That every patient in South Carolina will receive surgical care in a safe environment Purpose: To create a statewide system of surgical safety that is built on teamwork and open communication

47. All SC acute care hospitals will evaluate the WHO surgical safety checklist with at least one surgical team Surgical teams statewide will be provideddirect access to a focused crew/team resource management training program Operation: Safe Surgery Initial Goals

48. 100% SC hospitals will commit to checklist use and CRM-based communication in all ORs All SC hospitals and surgical teams will have direct access to a broad range of surgical safety educational resources and consultative services A unified data management system established to track and analyze key surgical care process and outcomes indicators within and across hospitals Operation: Safe Surgery Major Goals

49. Operation: Safe Surgery Key Challenges Attaining senior leadership/medical staff buy-in Integration of WHO checklist with TJC universal protocol requirements Spreading use of checklist from one to multiple surgical teams in each hospital Providing access to CRM training statewide Creating a user friendly system for tracking impact of program on patient outcomes

50. Operation: Safe Surgery Phase 1 Results 55% of SC hospitals evaluated checklist with at least one surgical team by April 1, 2009 25% of SC hospitals committed to evaluating after Sprint deadline 80% total commitment from SC hospitals compared to 25% national rate

51. Operation: Safe Surgery Phase 2 CRM training program for lead surgical teams in regional sites across the state Training sessions available to all SC hospitals Collection and analysis of predefined surgical safety process and outcomes measures Spread checklist/training to other procedural areas

52. Operation: Safe Surgery Phase 3 Achieve goal of 100% SC hospitals actively using checklist/CRM-based communication in all ORs Create statewide surgical safety leadership team Establish standard surgical safety performance dashboard w/ key process and outcomes indicators Develop a menu of onsite CRM training and consultative services available to every SC hospital Serve as lead state for WHO surgical safety program (Dr. Gawande)

53. “To every person there comes in life that special moment when one is tapped on the shoulder and offered the chance to do a very special thing. What a tragedy if that moment finds you unprepared or unqualified for the work which would be your finest hour.” Sir Winston Churchill (1874-1965)

54. Institute for Healthcare Improvement Short Movie Clip http://www.ihi.org/IHI/Programs/ImprovementMap/WH OSurgicalSafetyChecklist.htm