1. © 2009 Chris George, RN MS Project Manager MHA Keystone Center for Patient Safety and Quality Keystone Surgery: Improving Perioperative Care in Michigan

2. © 2009 Preventable Harm 230 million surgeries / yr worldwide –More common than births ( 36 million / yr) –1 in 25 people 25% in-patient surgeries followed by complication –7 million disabling complications / yr 0.5 – 5% deaths following surgery –1 million deaths / yr 50% of all hospital adverse events linked to surgery –At least 50% of adverse surgical events are avoidable http://www.who.int/patientsafety/challenge/safe.surgery/en/

3. © 2009 Keystone Surgery Learning Community- few existing forums for hospitals to come together to share experiences and improve care. Keystone Surgery Cohort 1 –76 hospitals –36 urban, 38 rural (including 7 critical access) Keystone Surgery Cohort 2 –25 hospitals –14 CAH

4. © 2009 Keystone Surgery Collaborative Goals Eliminate surgical site infections, by ensuring that 90% of patients receive evidence-based interventions for preventing surgical site infections Eliminate mislabeled specimens Learn from our mistakes, in particular focusing on the National Quality Forum’s “Never” events (wrong site surgery and retained foreign bodies) Have 60% of your staff reporting positive safety and teamwork climate using a measurement instrument that is psychometrically sound. Develop a safety scorecard for perioperative care

5. © 2009 The Johns Hopkins Comprehensive Unit-Based Safety Program (CUSP) 1.Educate staff on science of safety http://www.jhsph.edu/ctlt/training/patient_safety.html 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools J Patient Safety 2005; Jt Comm J Qual Saf. 2004;30(2):59-68. http://www.jhsph.edu/ctlt/training/patient_safety.html http://www.jhsph.edu/ctlt/training/patient_safety.html

6. 2008 OR Teamwork Climate

7. © 2009 % of respondents that agree “The Physicians And Nurses Here Work Together As A Well-Coordinated Team.” NOTE: this item is typically negatively correlated with annual nurse turnover rates Bar Chart

8. © 2009 Step 5: Implement Teamwork Tools Daily Goals –J Crit Care 2003;18:71-75 Morning Briefing –Jt Comm J Qual Patient Saf. 2005;31:476-9 Learning from Defects –Jt Comm J Qual Patient Saf. 2006;32:102-8; –Am J Med Qual 2009;24(3):192-5. Team Check Up Tool –Jt Comm J Qual Patient Saf. 2008;34:619-623 Shadowing –Jt Comm J Qual Patient Saf. 2008;34:614-8 Briefing and Debriefing –Jt Comm J Qual Saf. 2009;35(8):391-397

9. NEJM Special Article: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

10. © 2009 Briefing Checklist OR BRIEFING CHECKLIST Implementation Instructions: Make sure all team members are in the OR suite and the patient is anesthetized. Just prior to starting the procedure implement the checklist beginning with the introduction of names and roles and work in descending fashion through the list. I. Introduction of first names and roles. II. Review critical information  Do we have the correct patient?  Is the correct side or site marked?  Has the procedure been agreed upon?  Have antibiotics been given? Jt Comm J Qual Saf 2006;32(6): 351-355

11. © 2009 Briefing Checklist Briefing Checklist III. Surface and Mitigate Hazards SURGERY – Discuss plans for the surgical procedure:  Describe critical steps  Provide team with pertinent information, including problems that may be encountered  Ask team: If something were to go wrong with this procedure, what would it be, and how could we prevent the problem or mitigate harm? o Risks during procedure such as bleeding, fluid loss o Surgeon suggests, “If anyone has a concern during the case, please let me know.”  Does everyone know how to use the equipment used in this procedure? Jt Comm J Qual Saf 2006;32(6): 351-355

12. © 2009 Briefing Checklist ANESTHESIOLOGY – Discuss all relevant issues:  Patient comorbid disease that will increase risk  Aspects of surgery that will increase risk, such as need for IV access  Availability of blood products  Interventions to prevent complications such as myocardial infarction, surgical site infection NURSING – Discuss all relevant issues:  Are all necessary instruments available?  Will any special equipment be considered?  Plan for breaks (Relieving nurse to introduce themselves when switching) Jt Comm J Qual Saf 2006;32(6): 351-355

13. Briefing – Before Every Procedure  Team introduction – first and last names including roles (Circulator writes on board)  Do the following match:  Patient ID band, Informed Consent (read out loud), Site Marking, OR posting, patient’s verbalization of procedure (if patient awake), other clinically relevant documentation (H&P, clinic note)  Do we have any safety, equipment, instrument, implant or other questions or concerns?  Have antibiotics been given, if indicated?  What are the anticipated times of antibiotic redosing?  Are glycemic control/beta blockers indicated?  Is the patient positioned to minimize injury?  Has the Prep been applied properly, without pooling and allowed to dry?  Have the goals and critical steps of the procedure been discussed?  Is the appropriate amount of blood available?  Is DVT prophylaxis indicated? If so, what?  Has the patient received anticoagulants?  Any Special Precautions? If yes, describe.  Are warmers on the patient?  Is the time allotted for this procedure an accurate estimate?  Has the Attending reviewed latest/final test results for Lab/Radiology? Are Intraoperative X-rays indicated? Briefing Checklist: Before Every Procedure

14. © 2009 De-briefing Checklist Debriefing – After every procedure  Could anything have been done to make this case safer or more efficient?  Has the SSI data collection form been completed?  Are the patient’s name/history number and the surgical specimen name and laterality on the paperwork? (Paperwork/labeling to be independently verified by Surgeon)  Did we have problems with instruments?  Plan for transition of care to post-op unit discussed? To include:  Fluid Management/blood (all slips in chart)  Antibiotics – continue post-op (dose/interval)  PACU tests/XRays  Pain/PCA plan  New meds needed (immediate periop)  Beta blockers (as required)  Glycemic control (as required)  DVT prophylaxis

15. William Beaumont Hospital Royal Oak campus 37,133 briefings and debriefings Jt Comm J Qual Saf. 2009;35(8):391-397.

16. © 2009 Provider Perceptions Jt Comm J Qual Saf. 2009;35(8):391-397.

17. Briefing Compliance All Keystone Surgery Teams 7/1/2008 - 8/31/2009 CompletedExpectedPercent July 200815622270.27% August 20081,0621,38976.46% September 20081,8142,40975.3% October 20081,6172,34069.1% November 20081,7592,06985.02% December 20082,8413,34784.88% January 20097,0669,31675.85% February 20098,93711,59577.08% March 200916,31619,83482.26% April 200915,49118,94181.79% May 200915,75718,88983.42% June 200919,69623,76582.88% July 200914,90917,63184.56% August 200911,75912,88691.25% 119,180144,63382.4% Briefing Compliance All Keystone Surgery Teams 7/1/2008 - 8/31/2009

18. Briefing Problem Identification All Keystone Surgery Teams 7/1/2008 - 8/31/2009 Categories CommunicationEquipmentLabPreopRadiologySupply Total% % % % % % Jul 2008 666.67%00%111.11%1 00%111.11% Aug 2008 937.5%416.67%4 729.17%00%0 Sep 2008 715.91%1636.36%12.27%1431.82%12.27%511.36% Oct 2008 2924.37%4033.61%1613.45%2924.37%21.68%32.52% Nov 2008 1827.27%1421.21%23.03%3045.45%11.52%1 Dec 2008 3525.93%2720%53.7%5037.04%42.96%1410.37% Jan 2009 5726.89%5425.47%83.77%6530.66%52.36%2310.85% Feb 2009 4822.97%7234.45%62.87%5626.79%41.91%2311% Mar 2009 10325.62%9724.13%51.24%13032.34%92.24%5814.43% Apr 2009 12929.59%11025.23%194.36%9221.1%163.67%7016.06% May 2009 13028.76%11224.78%132.88%12026.55%132.88%6414.16% Jun 2009 17531.59%13925.09%183.25%11120.04%101.81%10118.23% Jul 2009 13933.33%10023.98%51.2%8921.34%92.16%7517.99% Aug 2009 9031.58%7425.96%51.75%6924.21%93.16%3813.33% 97528.98%85925.54%1083.21%86325.65%832.47%47614.15% Briefing Problem Identification All Keystone Surgery Teams 7/1/2008 - 8/31/2009 Categories

19. Debriefing Compliance All Keystone Surgery Teams 7/1/2008 - 8/31/2009 CompletedExpectedPercent July 200816422273.87% August 20081,0511,38975.67% September 20081,7792,44872.67% October 20081,5712,24669.95% November 20081,6482,04180.74% December 20082,6563,23082.23% January 20096,6719,15472.88% February 20098,36011,24374.36% March 200915,23219,03780.01% April 200914,20918,06578.65% May 200914,67018,33680.01% June 200918,97223,44880.91% July 200914,22717,27682.35% August 200911,31212,59089.85% 112,522140,72579.96% Debriefing Compliance All Keystone Surgery Teams 7/1/2008 - 8/31/2009

20. Debriefing Problem Identification All Keystone Surgery Teams 7/1/2008 - 8/31/2009 Categories CommunicationEquipmentLabPreopRadiologySupply Total% % % % % % Jul 2008 1538.46%1948.72%12.56%1 00%37.69% Aug 2008 1134.38%1443.75%00%721.88%00%0 Sep 2008 3139.74%2025.64%22.56%78.97%00%1823.08% Oct 2008 4531.69%5941.55%42.82%149.86%42.82%1611.27% Nov 2008 2925.44%5850.88%32.63%65.26%21.75%1614.04% Dec 2008 4624.21%8645.26%63.16%157.89%73.68%3015.79% Jan 2009 8524.15%16647.16%20.57%3610.23%113.13%5214.77% Feb 2009 8425.3%16950.9%51.51%175.12%113.31%4613.86% Mar 2009 14923.88%29447.12%162.56%396.25%223.53%10416.67% Apr 2009 13726.2%24246.27%81.53%152.87%142.68%10720.46% May 2009 14624.58%24541.25%91.52%386.4%152.53%14123.74% Jun 2009 19623.%41648.83%141.64%465.4%131.53%16719.60% Jul 2009 13721.68%32751.74%101.58%416.49%81.27%10917.25% Aug 2009 14228.06%23446.25%10.20%275.34%81.58%9418.58% 1,25325.01%2,34946.89%811.62%3096.17%1152.3%90318.02% Debriefing Problem Identification All Keystone Surgery Teams 7/1/2008 - 8/31/2009

21. © 2009 Challenges Surgical teams are complex Diffusion of innovation in ORs challenging Data collection burdensome Linking improvement in culture with improved patient outcomes