1. The Health Roundtable Decreasing Error Rates in Theatre Sterile Supply Presenter: Peter Mason HospitalQE2 Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1 3-3a_HRT1212-Session2_MASON_QE_SA

2. The Health Roundtable KEY PROBLEM Increasing number of concerns raised by surgeons and theatre nurses about the extent of surgical instrument trays that contained contaminated, broken, missing or incorrect instruments 2

3. The Health Roundtable AIM OF THIS INNOVATION  To decrease error rates in the supply of sterile surgical instruments 3

4. The Health Roundtable BASELINE DATA  Initially, no data was tracked to measure the extent of the problem  All concerns were anecdotal & formal reporting was infrequent  Concerns focussed on potential risk of; - ↑ patient infection rates, surgical delays & costs (Note; on review, there was no correlation between sterile instrument error with the above risks)  There was an ‘Us’ vs. ‘Them’ approach between the theatre and sterile services staff 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED Methodology used: Demonstrated evidence of a problem Brought together staff from across the process Defined the goal to be achieved Process Mapped the problem Identified barriers to best practice Prioritised areas to address (picked the top 3 problems)  Met regularly  Measured performance 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED Barrier 1 - Staff not complying with theatre checklist standard → PDSA - Memo to inform staff re: conforming to standard Barrier 2 – High agency use in Decontamination & Sterilising Service (DSS) / staff not understanding de-contamination process → PDSA – Achieve full FTE requirements in DSS & implement effective orientation / education Barrier 3 – Effective communication at interface between theatre nurse & DSS technician occurred only 61% of time → PDSA - Introduce standardised handover (similar to ISBAR) re: missing / broken / incorrect instruments and those that are ‘high risk’ (Tools were developed to measure performance) 6

7. The Health Roundtable OUTCOMES SO FAR Error rate ↓ 75% from 2011 to current month 7

8. The Health Roundtable LESSONS LEARNT  Memos do not always add value to quality improvement  Employ the right staff and provide them with training about the given process  All staff involved in a given process can add value to improving quality  Standardising how staff communicate adds value  If staff see value in change, it will be supported and sustained 8