The Art and Science of Achieving Compliance to g pChecklists

A/P Sophia Ang BL Vice Chairman Medical BoardPatient Safety and OperationsNational University HospitalSingaporeSophia_ang@nuhs.edu.sg

1. We have a history of being slow to change

• Blood letting and The Lancet. Handwashing.

d bTrained to be autonomous2.

3 Production Pressure3. Production Pressure

Staff have many priorities every dayStaff have many priorities every day

Better AcademiaBetter

FasterEducation

Cheaper                                                            

Protocol Related

1 Science Design of Process is Key1. Science‐Design of Process is Key

N t f k B th ldNo extra forms or work. Bury the old way 

2. Art‐ Transforming Behaviour and CultureMarketing Campaign Political Campaign Military Campaign

If Missing =  social

engineering

=political If Missing resistance

If Missing=loss of momentum

PREVENTION OF PREVENTION OF MISSED CRITICAL INVESTIGATION MISSED CRITICAL INVESTIGATION RESULTS RESULTS

• Hear the PastManual Call Center

• See the Present

• Touch the FutureHybrid System

• Touch the FutureAcknowledgementdocumentedIn Electronic HealthcareRecord

Hear The Past……..Hear The Past……..

Mission Statement

To achieve zero incidence of delayed treatment

due to missed critical investigations by

successfully implementing the Call Centre based

Cl d L C i ti S tClosed Loop Communication System.

Multidisciplinary TeamMultidisciplinary TeamCall Center Medical AffairsLaboratory servicesLaboratory servicesOperationsNursingPhysicianPhysician

Science

1. Reliable sustainableArt

E t f li i i te ab e susta ab e2. Direct to doctor rather than 3rd party 3. Scalable– if another service / lab added

Engagement of clinicians at Medical boardClinical directors/ committee meetings

No extra forms or steps for Doctors LettersEmails

Lab Call Center

Simple Workflow- No extra forms

Lab Call Center

Call Center Contacts DoctorEscalation/DocumentationEscalation/Documentation

Three way conversationThree way conversationLab reads back with doctor

h l h it l l f i

No of critical lab calls to call center a month

Spreadingas quick as possible

pilotwhole hospital- less confusing

haem onco

Pilot phase

haem oncoadjustments

949865

1020

911 947

872 8721000

1200

511

637

872 872

600

800

of c

alls

Jun Jun 0707

Apr Apr 0707

Jan Jan 07 07

Mid Mid Nov Nov

23 23 Oct 06Oct 06

3 3 Oct 06Oct 06

Aug Aug 0606

Jul Jul 0606

Jun 06Jun 06

318382 373

511

400

600

No.

o

Whole Hosp

Radiology

Whole Hosp.

Haematology (excl. OT, ICU & HD)

Chemistry (excl. OT, ICU & HD)

Culture Results

Cancer Ctr

Endocrine Emergency

Lab Med

000o0606

Oct 06Oct 06Oct 06Oct 060606

113 103

0

200

J 06 J l 06A 06S 06O t 06N 06D 06J 07F b 07M 07A 07M 07J 07 J l 07

Whole Hosp.

Cardiac

Hosp.

Jun-06 Jul-06Aug-06Sep-06Oct-06Nov-06Dec-06Jan-07Feb-07Mar-07Apr-07May-07Jun-07 Jul-07

Automated Messaging– ReduceC llCalls

Critical Critical results results

receivedreceived System processes System processes doctor’s reply and doctor’s reply and

returns returns confirmation of confirmation of his action andhis action and

receivedreceived

his action, and his action, and notify all other notify all other

message message recipients of the recipients of the closure of circleclosure of circle--

ofof--carecare

Message Message content is auto content is auto assembled from assembled from backend system backend system

in realin real--timetime1x time 1x time authentication at authentication at shift start and/orshift start and/or

04/12/08 Confidential: © HMS-PL 2008

shift start and/orshift start and/orMultiMulti--factor factor

authenticationauthenticationSimple Reply Simple Reply

AcknowledgementAcknowledgement1, 2 or 31, 2 or 3

Call Centre Assisted Handling Interface

Notification iconNotification iconfor assisted for assisted

handling team handling team

Tracking the Tracking the doctor of caredoctor of careLimited Access Views

04/12/08 Confidential: © HMS-PL 2008

Mean times drop from 30 min to 28.3min limited by lab verfication

37.736 6

40

34.9

32.7

36.6

34.6 34.5

31.6

34.1

33.7

34.434.1

33.3

34.735

29.5

26.4 27.4 28.629.8

26.227.6

26 9

30.1 30.3

28.4 28.3

30

Min

utes

24.825.9

26.9

25.726.6

22.5 22.7

28.3

25

Mean (29 9) Median (29 6)21.5

20

Jun-06Jul-06Aug-06Sep-06Oct-0

6Nov -06Dec-06Jan-07Feb-07Mar-0

7Apr-0

7May-07Jun-07

Jul-07Aug-07Sep-07Oct-0

7Nov -07Dec-07Jan-08Feb-08Mar-0

8Apr-0

8May-08Jun-08

Jul-08Aug-08Sep-08Oct-0

8Nov -08Dec-08Jan-09

Mean (29.9) Median (29.6)

A M A M A

Pilot Manual call Hybrid

Number of Manual Calls Drop Significantly per Month

1600

Number of Manual Calls Drop Significantly per Month

10921149

10571145 1171 1135 1121 1139

12091122

1235

1050

11601258

1403 1404 14411384

1200

1400

1600

670740

939 961 942997

1057 1050

872 872949

865

1020

911 9471005

1063991

852955

10781017

1140

9881050

11451192

1258

752

1032

800

1000

mbe

r of c

alls

167 166

367431

499 487 454392

533 544490

428

318382 373

511

637

400

600Num

113 103

318

0

200

Jun-06Jul-0

6Aug-06Sep-06Oct-0

6Nov-06Dec-06Jan-07Feb-07Mar-0

7Apr-0

7May-07Jun-07

Jul-07

Aug-07Sep-07Oct-0

7Nov-07Dec-07Jan-08Feb-08Mar-0

8Apr-0

8May-08Jun-08

Jul-08

Aug-08Sep-08Oct-0

8Nov-08Dec-08Jan-09

J A S M A M J A S M A M J A S

Calls Made to Notify Doctors Total No. of Critical Results

Communication of Inpatient CLRsCommunication of Inpatient CLRs19–25/11/ 07 14 –20/4/ 08 4 –10/8/08 9 ‐15/2/09

INPATIE NT Audit 1 Audit 2 Audit 3 Audit 4Number of critical results 169 158 177 239Number of critical results 169 158 177 239Number of HMS  / HMS ‐Manual calls 144 / 33 100 / 139Number of direct communication of C LR s 68.0% 67.1% 99.4% 95.0%Number of indirect communication 32.0% 32.9% 0.6% 5.0%% f i ti ithi 60 i * 68 9% 71 9% 96 0% 92 0%%  of c ommunic ation  within  60 mins * 68.9% 71.9% 96.0% 92.0%%  of C LR s  acknowledged by doctors  (with/without time/date) 91.7% 95.6% 100.0% 100%

%  of C LR s  without date/time of doctors '  23 4% 5 9% 0 0% 0 0%notification 23.4% 5.9% 0.0% 0.0%

%  of C L R s  with  documented ac tion** 70.0% 99.3% 98.8% 87.1%%  documented  ac tion  with  no  time 23.1% 12.3%Median time interval from res ultMedian  time interval from  res ult available to  doc tors ' notific ation  (min)

24 19.9 13.4 20.4

Mean time interval from result to dr notification (min) 32.3 55.5 24.05 23.2

Median time interval from result available to an follow‐up action (min) 113 102.9 85 17.9

Interventions  s ince following  audits C lose supervis ion

HMS /manual from J un 08

Hospital–wide HMS  wef Oct 

Dash board introduced at Lab to 

* All cases of which the time of doctors’ notification was 10 minutes earlier than time of results availability were excluded** Cases of which the action had been taken prior to the critical results were excluded.

supervis ion from J un 08 08 monitor HMS  calls

Communication of Outpatient CLRsCommunication of Outpatient CLRs19–25/11/ 07 14 –20/4/ 08 4 –10/8/08 9 ‐15/2/09

OUTPATIE NT Audit 1 Audit 2 Audit 3 Audit 4Number of critical results 41 44 64 70

b f S / S l/ lNumber of HMS /HMS ‐Manual/Manual calls  (EMD)  9 / 29 / 26 13 / 27 / 30

%  of direct communication of C LR s 73.2% 84.1% 95.3% 91.4%%  of indirect communication 26.8% 15.9% 4.7% 8.6%%  of c ommunic ation  within  120 mins * 70.7% 97.7% 95.3% 100.0%%  of C LR s  acknowledged by doctors  (with/without time/date) 97.6% 100.0% 98.4% 100.0%

% of C LR s without date/time of doctors '%  of C LR s  without date/time of doctors  notification 26.8% 2.3% 3.1% 1.4%

%  of C L R s  with  documented  ac tion** 71.1% 97.7% 98.1% 82.8%%  documented  ac tion  with  no  time 23.1% 33.3%Median time interval from result available to doctors ' notification (min) 14 16.7 14 5

Mean time interval from result to dr notification (min) 27.4 18.1 18.6 10.3notification (min)Median time interval from result available to follow up action (min) 286 113.9 30 19

I t ti i f ll i dit C lose  HMS /manual  Hospital–wide HMS f O t

Dash board i t d d t L b t

* All cases of which the time of doctors’ notification was 10 minutes earlier than time of results availability were excluded** Cases of which the action had been taken prior to the critical results were excluded.

Interventions  s ince following  audits supervis ion/

from J un 08  HMS  wef Oct 08

introduced at Lab to monitor HMS  calls

Art and Science

1 Science- Design simple no extra work1. Science Design simple, no extra work

2 No alternatives bury old ways2. No alternatives bury old ways

3. Art - Better the design less behaviour change

4. New challenges always arise. New Tests

PREVENTING WRONG PATIENTPREVENTING WRONG PATIENTWRONG SITEWRONG PROCEDUREWRONG PROCEDURE

Clinical Care

Research

Education

DesignDesign‐USE OF INTELLIGENT DASHBOARD SYSTEM

PERFORMANCE OF CHECKLIST TIED TO BILLING SYSTEM

USE OF SYSTEM ENCOURAGED BY USEFULNESS– FOR CALLING BLOOD /EQUIPMENTUSE OF SYSTEM ENCOURAGED BY USEFULNESS– FOR CALLING BLOOD /EQUIPMENT

The Campaign : OT com/ Surgeons/Nursep g / g /

Patients and Shared Equipmentare RFID tagged

Dashboard in Recovery RoomDashboard in Recovery Room

Tea Room / Waiting room of relativesTea Room / Waiting room of relatives( ID only first 4 numbers and letters)

C t h lComputer on wheels

i h tiin each operating room

Staff present

Pat Info

TimingTiming

Checklists

S i t

Checklists

Service request

Communication with the wardCommunication with OT staff ( AU nurse and attendants )Communication with blood bankChecklists safe surgery / equip prep /patient highlights/ High 5 for WHOTiming of surgery

Sign InFinal Time Out (Pre‐Induction)

should be completed with the Staff presents during the verification prior to Anesthesia Induction

Time Out and Who was Present-- AccountabilityFinal Time Out (Pre‐Indcision)

should be completed with the Staff presents during the verification prior to Anesthesia Induction

Select the present Staffs to complete the Staff Checklist for Surgery Team 

during Pre‐Induction

Click Staff Checklist to display the Staff Checklist popup

Post‐Op ChecklistSign OutPost‐Op checklist should be completed to indicate any special requisite for the patient after surgery

Prompt Occurs When Wrong Patient Brought to Wrong OTP t ti tPrevent wrong patient surgery

Service RequestService Request

• Automatically trigger a notification to service provider to render specific requests via text messaging

• Eg: drugs, blood bank, X-Ray, equipment setup task, surgical material, patient fetching

Pull System - Live Tracking of Blood Request by Touch Screen

Request for Drugs by AnesthetistRequest for Drugs by Anesthetist

Team Member Touch Screen SMSTeam Member Touch Screen SMS

Outcomes

Patient Safety

EfficiencyEfficiency

Compliance in Pre‐op Verification, Site Marking & Time Out

(OT Dashboard & Observational Audit Data)

CS-1 Complete Pre-op Verification

98%

100%

ance

CS-2 Properly Marked Surgical Site

98%

100%

nce

92%

94%

96%

cent

age

of C

ompl

ia

94%

96%

ntag

e of

Com

plia

n

88%

90%

Feb-

12M

ar-1

2Ap

r-12

May

-12

Jun-

12Ju

l-12

Aug-

12Se

p-12

Oct-1

2No

v-12

Dec-

12Ja

n-13

Feb-

13M

ar-1

3Ap

r-13

May

-13

Jun-

13Ju

l-13

Aug-

13Se

p-13

Oct-1

3No

v-13

Dec-

13Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14

Perc

OT Dashboard Observational Audits

90%

92%

Feb-

12M

ar-1

2Ap

r-12

May

-12

Jun-

12Ju

l-12

Aug-

12Se

p-12

Oct-1

2No

v-12

Dec-

12Ja

n-13

Feb-

13M

ar-1

3Ap

r-13

May

-13

Jun-

13Ju

l-13

Aug-

13Se

p-13

Oct-1

3No

v-13

Dec-

13Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14

Perc

e

OT Dashboard Observational AuditsOT Dashboard Observational Audits OT Dashboard Observational Audits

CS-3 Complete Final Time Out • Compliance in pre‐op ifi ti h d

97%

98%

99%

100%

of C

ompl

ianc

e

verification has approved steadily after interventions were put in place

94%

95%

96%

b-12 -12

r-12

-12

-12

l-12

-12

-12

t-12

v-12 -12

-13

b-13 -13

r-13

-13

-13

l-13

-13

-13

t-13

v-13 -13

-14

b-14 -14

r-14

-14

-14

Perc

enta

ge o

• Full compliances for both site marking and time out since Aug 2012

Feb-

Mar

-1Ap

r-M

ay-

Jun- Jul-

Aug-

Sep-

Oct-

Nov-

Dec-

Jan-

Feb-

Mar

-1Ap

r-M

ay-

Jun- Jul-

Aug-

Sep-

Oct-

Nov-

Dec-

Jan-

Feb-

Mar

-1Ap

r-M

ay-

Jun-

OT Dashboard Observational Audits

Aug 2012

Near Miss Patient--- Brought to Wrong OT Flag Detected

By RFID Tracking.y g

Patient listed in 1 OT brought to Another OT and brought back to Listed OT

000CCC771FC7 81981 MOR12 MOR13 MOR13 2000CCC77204A 83410 MOR14 MOR02 MOR02 2000CCC772111 85367 MOR12 MOR07 MOR07 2

OperatedListedWrongOT?

000CCC772111 85367 MOR12 MOR07 MOR07 2000CCC771A80 87003 MOR12 MOR10 MOR10 2000CCC772006 87928 MOR07 MOR04 MOR04 2000CCC771EEC 90238 MOR01 MOR03 MOR03 2000CCC7720C6 91614 MOR12 MOR15 MOR03 MOR03 3000CCC771EDB 87111 MOR12 MOR02 MOR02 2000CCC7720C6 97061 MOR12 MOR10 MOR10 2000CCC771F32 99988 MOR12 MOR01 MOR01 2000CCC772069 102820 MOR14 MOR02 MOR02 2000CCC772069 107725 MOR14 MOR07 MOR07 2000CCC771ED8 108361 MOR15 MOR07 MOR07 2000CCC771EDB 107547 MOR12 MOR04 MOR04 2000CCC77203A 108922 MOR10 MOR01 MOR01 2000CCC77210B 104521 MOR12 MOR05 MOR05 2000CCC7721B5 110817 MOR12 MOR10 MOR10 2000CCC7721B5 110817 MOR12 MOR10 MOR10 2000CCC771FE8 99406 MOR12 MOR15 MOR15 2000CCC77210B 112945 MOR12 MOR13 MOR13 2

T t l 19 CTotal 19 Cases

19 Potential Cases 1 Year ( out of 20 000 major OT cases)

Types of Human ErrorsTypes of Human Errors

Summary of Effect Size of 10 Types of Accident Prevention ProgrammesProgrammes

T f P N b f St di Eff t %Type of Programme Number of Studies Effect %1. Personnel 26 3.7

2 Technology 4 292. Technology 4 293. Behaviour 6 38.64 Poster campaign 2 144.Poster campaign 2 145. Quality Circle 1 206. Exercise after Stress 2 157.Near miss reporting 2 178.International safety rating 4 17

9 . Comprehensive ergonomics

3 51.6

Helander- guide to human

Always a New ChallengeAlways a New Challenge

• 2009 to 2014 no wrong site, wrong procedure or wrong patient.p g p

• 2015- 1 wrong implant from miscommunication upstream of themiscommunication upstream of the consent

• 2015- wrong level spine surgery/wrong side spine injection– distraction byside spine injection distraction by technology and issue of multiple spine levels Localization by xray no guaranteelevels. Localization by xray no guarantee

• Out Patient and Ambulatory areas , DDI.

Art + ScienceArt + Science

• Design- part of workflow, few steps as possible, scalable.

• Better Designed less Campaign and Behaviour change needed

• Be prepared to stand firm to the principlesfor at least 2 years.

• Continuous attention needed.