1. Call 3: Background of Each Checklist Item

2. Topics Covered on the Last Webinar 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: –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

3. Meet the Team Lizzie Edmondson Surgical Area Senior Program Manager Harvard School of Public Health

4. Today’s Topics Poll An in depth discussion of why each item is on the South Carolina Checklist Template. Overview of what is to come in 2013 –Part II of the webinar series –January 23, 2013 In-Person Meeting

5. Poll 1 When the checklist is performed in your ORs, does the surgeon share the following information when all team members are present: (Click on the information that is routinely shared by surgeons in your hospital) –Operative plan –Possible difficulties –Expected duration –Anticipated blood loss –Implants or special equipment needed How often do the surgeons in your hospital share this information with the entire team? –<50% –>50% –Every case performed

6. Background of Checklist Items JC/Standard of Practice WHO/SC Checklist SCIP

7. South Carolina Checklist Integrates routine safety practices from the Joint Commission, Surgical Care Improvement Project and the WHO Surgical Safety Checklist Into One Streamlined Process

8. A Key Step In Successful Implementation: Educating Surgical Team Members About Checklist Items

9. JC/Standard of Practice WHO/SC Checklist SCIP

10. Before Induction of Anesthesia Where should it take place? A best practice is to have this part of the checklist performed in the OR. Why should this be performed in the OR? While many of these items are performed in the pre-op area most hospitals do not perform these safety checks together as a team. It is important to have the surgical tech involved in this conversation – Hospitals that perform this section in the OR have had techs contribute important information. At a minimum who should participate? Anesthesiologist/CRNA Circulating Nurse Surgical tech

11. Verify Patient Identification A Joint Commission The intent is: –To reliably identify the individual as the person for whom the service or treatment is intended; –Match the service or treatment to that identifier. Use at least two ways to identify patients. Acceptable identifiers include the patient’s name, date of birth, medical record number or other person specific identifiers.

12. Verify Surgical Site A Joint Commission Assures the procedure is performed on the correct place on the patient’s body. The surgical site must be confirmed multiple times before skin incision.

13. Verify Surgical Procedure to be Performed Matches the Consent A Joint Commission Team members will verify that the consent is consistent with the patient’s expectations and the teams understanding of the intended procedure/site.

14. Verify Site Marked A Joint Commission Verifying correct site marking in the operating room prior to induction is a redundancy step for the patient and team to assure the correct site was marked, and that there are not any discprencies.

15. Verify Known Allergies The WHO/SC Checklist This item confirms that the team is aware of any allergies that pose a risk to the patient. There have been cases where the patient has told different care providers different information. It is important for the surgical team to confirm this multiple times with the patient and amongst the surgical team.

16. Verify Patient Positioning Past Joint Commission Requirement/Standard of Practice This step verifies that the team is prepared and aware of the intended patient position for the procedure and that positioning devices are available.

17. Verify the Anesthesia Safety Check Has Been Completed The WHO/SC Checklist This is a verbal verification that a complete formal inspection of the anesthetic equipment, medications, and patient’s anesthetic risk was performed before the case.

18. Anesthesia Provider Shares Anticipated Airway or Aspiration Risk The WHO/SC Checklist This is a prompt for the anesthesia provider to share information from the airway assessment that was performed on the patient in the pre-op holding area.

19. Anesthesia Provider Shares Risk of Significant Blood loss The WHO/SC Checklist This is a prompt for the anesthesia provider to share information with the rest of the team. If the patient is at risk for significant blood loss the team should discuss if two IVs/central access are planned, type and crossmatch/screen, and confirm blood availability. The checklist asks for the team to discuss blood loss one more time when the surgeon is present. There are times when the surgeon is the only person that holds this information.

20. Anesthesia Provider Shares Risk of Hypothermia Surgical Care Improvement Project (SCIP) SCIP recommends that patients should be warmed if the duration of the procedure is > 1 hour. This item is to confirm if warming is needed and in place.

21. Anesthesia Provider Shares Risk of Venous Thromboembolism Surgical Care Improvement Project (SCIP)/CMS Quality Measure If a patient is at risk for a DVT the surgical team should confirm that boots and/or anticoagulants are in place.

22. JC/Standard of Practice WHO/SC Checklist SCIP

23. Before Skin Incision: The Briefing Where should it take place:? In the OR, immediately before skin incision Why should this be performed? The Joint Commission gave us a place to stop with the Time Out. The SC Checklist asks the team to discuss additional information at this time. At a minimum who should participate? Anesthesiologist/CRNA Circulating Nurse Surgeon Surgical tech Other people that are in the room

24. Entire Surgical Team: Is everyone ready to perform the time out? SC Checklist This is a prompt to get everybody that is in the OR to stop and participate in the Joint Commission Time Out and the Briefing.

25. Entire Surgical Team: Please State Your Name and Role WHO/SC Checklist Teams are more efficient when they refer to each other by name. Research has shown that if somebody says something at the beginning of a case and is activated they will be more likely to voice their concerns if they see something. Everyone that is in the room should introduce themselves at this time including, reps, observers, and students.

26. Patient’s Name, Surgical Procedure to Be Performed, and Surgical Site A Joint Commission It is required for the entire surgical team to verify the patient’s name, the surgical procedure to be performed, and the surgical site before skin incision. The Joint Commission now requires that all surgical team members actively participate in the Time Out.

27. Has antibiotic prophylaxis been given within the last 60 minutes? Surgical Care Improvement Project (SCIP)/CMS Quality Measure This is a prompt for the anesthesia provider to verbally confirm with the team that the antibiotics have been completely infused prior to skin incision. It is also recommend that a plan for antibiotic re-dosing is also discussed at this time.

28. Surgeon Shares: Operative Plan WHO/SC Checklist This is an opportunity for the surgeon to share critical information with the surgical team.

29. Surgeon Shares: Possible Difficulties WHO/SC Checklist This is a prompt for the surgeon to discuss anything unique about the procedure and non-routine steps. If no difficulties are expected the surgeon may state that they do not expect anything unusual and that it is a routine case.

30. Surgeon Shares: Expected Duration WHO/SC Checklist It is recommended that the surgeon inform the team of the expected duration. Informing the team of the expected duration helps the anesthesiologist plan appropriately and for the nursing team to plan for subsequent procedures.

31. Surgeon Shares: Anticipated Blood Loss WHO/SC Checklist This is another check to confirm the estimated blood loss. It is recommended that blood loss be discussed multiple times, especially when the surgeon is not in the room before the induction of anesthesia.

32. Surgeon Shares: Implants or Special Equipment Needed WHO/SC Checklist (Previously Recommended by TJC) It is recommended that the surgeon briefly discuss the equipment and implants that are needed for the case. Discussing equipment and implant issues before skin incision have been shown to decrease the number of times the circulator leaves the room, ultimately decreasing OR time.

33. Anesthesia Provider Shares: Anesthetic Plan WHO/SC Checklist It is recommended that the anesthesiologist/CRNA shares the anesthetic plan with the surgical team, particularly any concerns with major morbidities.

34. Anesthesia Provider Shares: Airway Concerns WHO/SC Checklist This is a prompt for the anesthesiologist/CRNA to share airway concerns with the surgical team. If there are no airway concerns the anesthesiologist/CRNA may state that there they do not have any concerns.

35. Anesthesia Provider Shares: Other Concerns WHO/SC Checklist This is a prompt for the anesthesiologist/CRNA to share any other concerns that they might have about the patient. Sometimes people won’t share concerns unless they are given the specific opportunity to do so.

36. Circulating Nurse and Scrub Tech Share Sterility, Indicator Results Standard of Practice It is recommended that the scrub nurse/ technologist verbally confirm that the sterilization was performed and that for heat sterilized instruments, a sterility indicator has verified successful sterilization. It is important to have the scrub nurse/technologist contribute to the briefing.

37. Circulating Nurse and Scrub Tech Share Equipment Issues WHO/SC Checklist (Previously Recommended by TJC) It is recommended that the circulating nurse and Scrub Tech raise any concerns about instrumentation immediately before skin incision.

38. Circulating Nurse and Scrub Tech Share Other Concerns WHO/SC Checklist This is an opportunity for the circulating nurse and scrub tech to share any other concerns that they have. Sometimes people won’t share concerns unless they are given the specific opportunity to do so.

39. Surgeon Says: “Does anybody have any concerns? If you see something that concerns you during this case please speak up.” WHO/SC Checklist This statement helps set a tone of openness during the case and encourages team members to verbalize any concerns regarding patient care.

40. JC/Standard of Practice WHO/SC Checklist SCIP

41. Before The Patient Leaves The Room: The Debriefing Where should it take place? In the OR, after the sponge counts have been confirmed Why should this be performed? This is an opportunity for the entire surgical team to come together one last time and talk about the patient. At a minimum who should participate? Anesthesiologist/CRNA Circulating Nurse Surgeon Surgical tech Other people that are in the room

42. Circulating Nurse Reviews With the Team: Instrument, Sponge, and Need Counts Are Correct Standard of Practice This items prompts the circulating nurse to announce the final count status to the team. This allows teams to appropriately reconcile counts as needed.

43. Circulating Nurse Reviews With the Team: Name of Procedure Performed WHO/SC Checklist This item prompts the team to verbally confirm the name of the procedure that was performed. The nurse should confirm with the surgeon how to record what procedure was done and how it should be recorded in the patient records.

44. Circulating Nurse Reviews With the Team: Specimen Labeling WHO/SC Checklist This item prompts the nurse to read back the specimen labeling including the patient’s name, specimen description, and any orienting marks to the surgical team. This will help prevent mislabeling or mishandling of specimens.

45. The Entire Team Discusses: Equipment Problems That Need to Be Addressed WHO/SC Checklist This is an opportunity to discuss any equipment problems. This is an opportunity to fix many of the equipment issues that frustrate surgical team members. We highly recommend that your hospital develops a system to capture this feedback and fixes equipment problems when they are identified.

46. The Entire Team Discusses: Key Concerns for Patient Recovery and Management WHO/SC Checklist This is an opportunity for the entire surgical team to have a conversation about the patient before the end of the case. It is recommended that team members review post- op recovery and management plan focusing on intraoperative or anesthetic issues that might affect the patient.

47. The Entire Team Discusses: What Could Have Been Done to Make This Case Safe and More Efficient? WHO/SC Checklist The final item on the checklist prompts the team to discuss anything that they could have done to improve patient safety or efficiency. The goal of this item is to improve team communication and promote transparency.

48. Overview Of What Is To Come In 2013

49. Part II of the Educational Series February 7, 2013 Topics that will be covered: Checklist Customization Small-Scale Testing Physician Engagement Wide-Scale Implementation Monitoring Your Progress Sustaining Checklist Use

50. Second Surgical Teamwork Collaborative Meeting Wednesday, January 23 rd, 2013 South Carolina Hospital Association Columbia, SC

51. Before We See You In January Form a checklist implementation team and schedule regular meetings. Block time to participate in the Part II of the Educational Series. This will start February 7 th, 2013. If you haven’t already, administer the Safe Surgery 2015 Culture Survey. Please contact Katie Jahreis to get started (kjahreis@hsph.harvard.edu). If you feel like your hospital has a good checklist and it is used routinely ask Ashley Kay Childers to come to your hospital for a site visit (childer@clemson.edu).

52. We Will Still Be Holding Office Hours: Wednesdays 2:00- 3:00

53. ? ? Questions

54. We Will Be Sending You An Email With: A document that describes where each checklist item is derived from and references to the literature supporting each item. A link to watch the recording of today’s webinar and to download today’s slides.

55. Resources Website: www.safesurgery2015.org Email: safesurgery2015@hsph.harvard.edu