© 2009

Chris George, RN MSProject Manager

MHA Keystone Center for Patient Safety and Quality

Keystone Surgery: Improving Keystone Surgery: Improving Perioperative Care in MichiganPerioperative Care in Michigan

© 2009

Preventable HarmPreventable 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/

© 2009

Keystone SurgeryKeystone 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

© 2009

Keystone SurgeryKeystone SurgeryCollaborative GoalsCollaborative 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

© 2009

The Johns Hopkins Comprehensive The Johns Hopkins Comprehensive Unit-Based Safety Program (CUSP)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

2008 OR Teamwork Climate

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% o

f res

pond

ents

that

agr

ee“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

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Step 5: Implement Step 5: Implement Teamwork ToolsTeamwork 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

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

© 2009

Briefing ChecklistBriefing 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

© 2009

Briefing ChecklistBriefing Checklist

III. Surface and Mitigate HazardsSURGERY – 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 losso 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

© 2009

Briefing ChecklistBriefing 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

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

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De-briefing ChecklistDe-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

William Beaumont Hospital Royal Oak campus

37,133 briefings and debriefings Jt Comm J Qual Saf. 2009;35(8):391-397.

© 2009

Provider PerceptionsProvider Perceptions

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

Briefing ComplianceAll Keystone Surgery Teams

7/1/2008 - 8/31/2009 

Completed Expected PercentJuly 2008 156 222 70.27%August 2008 1,062 1,389 76.46%September 2008 1,814 2,409 75.3%October 2008 1,617 2,340 69.1%November 2008 1,759 2,069 85.02%December 2008 2,841 3,347 84.88%January 2009 7,066 9,316 75.85%February 2009 8,937 11,595 77.08%March 2009 16,316 19,834 82.26%April 2009 15,491 18,941 81.79%May 2009 15,757 18,889 83.42%June 2009 19,696 23,765 82.88%July 2009 14,909 17,631 84.56%August 2009 11,759 12,886 91.25%

119,180 144,633 82.4%

Briefing ComplianceAll Keystone

Surgery Teams7/1/2008 - 8/31/2009

Briefing Problem IdentificationAll Keystone Surgery Teams

7/1/2008 - 8/31/2009Categories

Communication Equipment Lab Preop Radiology Supply

Total % Total % Total % Total % Total % Total %Jul 2008 6 66.67% 0 0% 1 11.11% 1 11.11% 0 0% 1 11.11%

Aug 2008 9 37.5% 4 16.67% 4 16.67% 7 29.17% 0 0% 0 0%

Sep 2008 7 15.91% 16 36.36% 1 2.27% 14 31.82% 1 2.27% 5 11.36%

Oct 2008 29 24.37% 40 33.61% 16 13.45% 29 24.37% 2 1.68% 3 2.52%

Nov 2008 18 27.27% 14 21.21% 2 3.03% 30 45.45% 1 1.52% 1 1.52%

Dec 2008 35 25.93% 27 20% 5 3.7% 50 37.04% 4 2.96% 14 10.37%

Jan 2009 57 26.89% 54 25.47% 8 3.77% 65 30.66% 5 2.36% 23 10.85%

Feb 2009 48 22.97% 72 34.45% 6 2.87% 56 26.79% 4 1.91% 23 11%

Mar 2009 103 25.62% 97 24.13% 5 1.24% 130 32.34% 9 2.24% 58 14.43%

Apr 2009 129 29.59% 110 25.23% 19 4.36% 92 21.1% 16 3.67% 70 16.06%

May 2009 130 28.76% 112 24.78% 13 2.88% 120 26.55% 13 2.88% 64 14.16%Jun 2009 175 31.59% 139 25.09% 18 3.25% 111 20.04% 10 1.81% 101 18.23%

Jul 2009 139 33.33% 100 23.98% 5 1.2% 89 21.34% 9 2.16% 75 17.99%

Aug 2009 90 31.58% 74 25.96% 5 1.75% 69 24.21% 9 3.16% 38 13.33%

975 28.98% 859 25.54% 108 3.21% 863 25.65% 83 2.47% 476 14.15%

Debriefing ComplianceAll Keystone Surgery Teams

7/1/2008 - 8/31/2009 

Completed Expected PercentJuly 2008 164 222 73.87%August 2008 1,051 1,389 75.67%September 2008 1,779 2,448 72.67%October 2008 1,571 2,246 69.95%November 2008 1,648 2,041 80.74%December 2008 2,656 3,230 82.23%January 2009 6,671 9,154 72.88%February 2009 8,360 11,243 74.36%March 2009 15,232 19,037 80.01%April 2009 14,209 18,065 78.65%May 2009 14,670 18,336 80.01%June 2009 18,972 23,448 80.91%July 2009 14,227 17,276 82.35%August 2009 11,312 12,590 89.85%

112,522 140,725 79.96%

Debriefing ComplianceAll Keystone Surgery Teams

7/1/2008 - 8/31/2009

Debriefing Problem IdentificationAll Keystone Surgery Teams

7/1/2008 - 8/31/2009Categories

Communication Equipment Lab Preop Radiology Supply

Total % Total % Total % Total % Total % Total %Jul 2008 15 38.46% 19 48.72% 1 2.56% 1 2.56% 0 0% 3 7.69%

Aug 2008 11 34.38% 14 43.75% 0 0% 7 21.88% 0 0% 0 0%

Sep 2008 31 39.74% 20 25.64% 2 2.56% 7 8.97% 0 0% 18 23.08%

Oct 2008 45 31.69% 59 41.55% 4 2.82% 14 9.86% 4 2.82% 16 11.27%

Nov 2008 29 25.44% 58 50.88% 3 2.63% 6 5.26% 2 1.75% 16 14.04%

Dec 2008 46 24.21% 86 45.26% 6 3.16% 15 7.89% 7 3.68% 30 15.79%

Jan 2009 85 24.15% 166 47.16% 2 0.57% 36 10.23% 11 3.13% 52 14.77%

Feb 2009 84 25.3% 169 50.9% 5 1.51% 17 5.12% 11 3.31% 46 13.86%

Mar 2009 149 23.88% 294 47.12% 16 2.56% 39 6.25% 22 3.53% 104 16.67%

Apr 2009 137 26.2% 242 46.27% 8 1.53% 15 2.87% 14 2.68% 107 20.46%

May 2009 146 24.58% 245 41.25% 9 1.52% 38 6.4% 15 2.53% 141 23.74%

Jun 2009 196 23.% 416 48.83% 14 1.64% 46 5.4% 13 1.53% 167 19.60%

Jul 2009 137 21.68% 327 51.74% 10 1.58% 41 6.49% 8 1.27% 109 17.25%

Aug 2009 142 28.06% 234 46.25% 1 0.20% 27 5.34% 8 1.58% 94 18.58%

1,253 25.01% 2,349 46.89% 81 1.62% 309 6.17% 115 2.3% 903 18.02%

Debriefing Problem

IdentificationAll Keystone

Surgery Teams7/1/2008 - 8/31/2009

© 2009

ChallengesChallenges

• Surgical teams are complex• Diffusion of innovation in ORs challenging• Data collection burdensome• Linking improvement in culture with improved patient

outcomes