1. 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

2. 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 2 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

3. 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 3 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

4. 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 4 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

5. 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…” 5 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

6. W. Wayne Babcock, M.D

7. “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.”

9. 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 9 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

10. Delivering optimal care to our patients from memory alone? “The frequency of cognitive aid use correlated significantly with the MH treatment score….” 10 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015 Latent knowledge activation? Prospective memory cue?

11. What we can learn from aviation… 11 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

12. PILOTS TRAIN TO FLY THE PLANE AND DEAL WITH EMERGENCIES 12 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

13. Pilots Train In…  CRM – Communication – Teamwork  How to use checklists 13 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

14. 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 14 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

15. Access in OR  Consistent location  Easy to see and reach when needed  Does not block daily workflow 15 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

16. L&D, Operating Rooms Easily accessible by entrance Located next to that other emergency equipment! Easily visible 16 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

17. Lights, Camera…Simulation! 17 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

18. 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 18 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

19. 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 19 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

20. 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? 20 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

21. Roles not clear, too many cooks in the kitchen! 21 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

22. Roles defined, everybody knows where to go! 22 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

23. 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) 23 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

24. Fire Simulation improvements Gas valves labeled for specific OR 24 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

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

26. 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 26 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

27. L&D Simulations Entire wall knocked out and moved back further for greater access; OR monitors relocated to make more room for neonatal staff; 27 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

28. 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, 2015 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. 28

29. 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! 29 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015

30. 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, 2015 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. 30

31. The team that trains together makes music together! 31 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only. October 25, 2015