Transcript Palmetto Health System Safe Surgery Presentation 8-12

Disclosure Statement
“I have no financial disclosures to
report but I am employed by the
South Carolina Hospital
Association.”
Transforming Surgical Care through
Team-based Communication
Palmetto Health System Presentation
August 12, 2010
Redesigning Health Systems
“The American healthcare delivery system is in
need of fundamental change….Healthcare
today too frequently harms and routinely fails
to deliver its potential benefit…. Between the
healthcare we have and the care we should
receive lies not just a gap, but a chasm”
If 99.9% Were Good Enough…
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IRS lost documents 2 million per year
Major plane crashes 3 per day
Lost items in mail 16,000 per hour
ATM errors 37,000 per hour
Pacemaker incorrectly installed 291 per year
Babies given to wrong parent 12 per day
Erroneous medical procedures 107 per day
IOM Report
• Deaths due to medical errors exceed the number
attributable to 8th leading cause of death.
• More people die in given year as result of medical
errors than from motor vehicle accidents, breast
cancer or AIDS
• Medication errors alone estimated to account for over
7,000 deaths annually
• Up to 100,000 deaths due to healthcare-associated
infections- vast majority are preventable
• Total national costs of preventable adverse events are
estimated to be between $17 - $29 billion
IOM Six Aims for Improvement
• Patient care that is:
• Safe- avoidance of unintended pt. harm
• Effective- evidence-based
• Patient-centered- focused on needs and
rights of the individual patient
• Timely- avoidance of delays & barriers to
patient care flow
• Efficient- elimination of waste
• Equitable- fair access to comparable
health care services for all
“My Mom” Quality/Safety Standard
 How
would you want your Mom treated at
your hospital?
 Every patient in your hospital expects and
deserves that same high level of care/safety
 Now we have to prove how well we’re
performing under this “My Mom” standard
Vision: That all SC hospitals
and providers deliver safe, high
quality healthcare in a caring
and compassionate manner to
each patient, every time
Mission: To establish a culture
of continuous improvement in
the quality, efficacy and safety
of patient care across all
healthcare organizations and
providers statewide
Redefining Performance Excellence
What is the ultimate we believe our
hospitals can and should accomplish to
dramatically improve the safety and
quality of the care and the health of the
patients they serve?
Organizational
culture of safety
Evidence-based
medical care
System
Infrastructure
Patient-centered
care
environment
Serious adverse
events prevention
“Rather than uncoordinated, episodic care, we
need to offer care that is well organized,
coordinated, integrated, characterized by
effective communication, and based on
continuous healing relationships”
-Eric Larson
Creating a Culture of Safety
• Acknowledgement of the high-risk, errorprone nature of an organization’s activities
• Blame-free environment where individuals
are able to report errors and close calls
without punishment
• Expectation of collaboration across ranks to
seek solutions to vulnerabilities
• Willingness on the part of the organization to
direct resources to address safety concerns.
Communication and Education
• Create an environment of mutual trust, respect and
psychological safety
• Actively support open communication and
courageous dialogue system-wide
• Establish a Leadership orientation/training
program to ensure “quality literacy/competency”
• Promote an active learning process for all clinical
staff including physicians (including access to
simulation training)
Why Communication ?
* The overwhelming majority of medical errors
involve communication failure
* Wrong site surgery - somebody knows there’s a
problem but can’t get everyone in the same
movie – often it’s hard to speak up
* The clinical environment has evolved beyond
the limitations of individual human performance
Crew Resource Management
 Focus
on teamwork, communication,
flattening hierarchy, managing error,
situational awareness, decision making
 Non-punitive reporting of near misses,
500,000 reports over 15 years
 Very open culture with regard to error
and safety
The Safe Surgery Saves Lives
Program
The Problem
The 3 Central Problems in Surgical Safety
Throughout the World
• Unrecognized as public health issue
• Lack of data on surgery and outcomes
• We know what to do, but we don’t do it
consistently
Four Categories for Surgical
Standards:
CONTROL OF
INFECTION AND
CONTAMINATION
ANESTHESIA AND
PATIENT
MONITORING
SURGICAL
OPERATOR
QUALITY
ASSURANCE
WHO’s 10 Objectives for Safe Surgery
1. The team will operate on the correct patient at the correct site.
2. The team will use methods known to prevent harm from
administration of anesthetics, while protecting the patient from
pain.
3. The team will recognize and effectively prepare for lifethreatening loss of airway or respiratory function.
4. The team will recognize and effectively prepare for risk of high
blood loss.
5. The team will avoid inducing an allergic or adverse drug
reaction for which the patient is known to be at significant risk.
WHO’s 10 Objectives for Safe Surgery
6. The team will consistently use methods known to minimize the
risk for surgical site infection.
7. The team will prevent inadvertent retention of instruments or
sponges in surgical wounds.
8. The team will secure and accurately identify all surgical
specimens.
9. The team will effectively communicate and exchange critical
information for the safe conduct of the operation.
10. Hospitals and public health systems will establish routine
surveillance of surgical capacity, volume and results.
Why a Checklist?
Pilot Study
International Pilot Study
8 Evaluation Sites - Nearly 8,000 Patients
PAHO I
Toronto, Canada
EURO
EMRO
London, UK
Amman, Jordan
WPRO I
Manila, Philippines
PAHO II
Seattle, USA
WPRO II
AFRO
Ifakara, Tanzania
SEARO
New Delhi, India
Auckland, NZ
Outcomes at Baseline
Site
Cases
Inpatient
Complication
1
2
3
4
5
6
7
8
Total
524
357
497
520
370
496
525
444
3733
11.6%
7.8%
13.5%
7.5%
21.4%
10.1%
12.4%
6.1%
11.0%
Inpatient Death
1.0%
1.1%
0.8%
1.0%
1.4%
3.6%
2.1%
1.4%
1.5%
Results - Process Measures
Baseline
Checklist
P-value
Objective Airway Evaluation
64.0%
77.2%
<0.001
Abx at 0-60 Mins
Except Dirty Cases
56.1%
82.6%
<0.001
Verbal Pt/Site Confirmation
54.4%
92.3%
<0.001
Two IVs /Central Line if
EBL≥500
58.1%
63.2%
0.32
Pulse Oximeter
93.6%
96.8%
<0.001
Sponge Count
84.6%
94.6%
<0.001
All Six Safety Indicators
Done
34.2%
56.7%
<0.001
Results – All Sites
Baseline
Checklist
P value
Cases
3733
3955
-
Death
1.5%
0.8%
0.003
Any Complication
11.0%
7.0%
<0.001
SSI
6.2%
3.4%
<0.001
Unplanned Reoperation
2.4%
1.8%
0.047
Change in Death and Complications by
Income Classification
Change in
Complications
Change in
Death
High Income
10.3% -> 7.1%*
0.9% -> 0.6%
Low and Middle
Income
11.7% -> 6.8%*
* p<0.05
2.1% -> 1.0%*
Survey of Attitudes to Checklist Use
Among Clinicians at Study Site (n=229)
The checklist was easy to use
78.6%
The checklist improved operating room
safety
79.0%
The checklist took a long time to complete
18.3%
Communication was improved through
use of the checklist
The checklist helped prevent errors in the
operating room
If I were having an operation, I would
want the checklist to be used
84.3%
78.2%
92.6%
Where is the Checklist
Today
Participating Hospitals: 3,865
Actively Using the Checklist: 1,657
IHI Sprint
Challenged every hospital in the
U.S. to trial the Checklist with
one surgical team80% of SC Hospitals
Notable Endorsing Organizations
• American College of Surgeons
• American Society of Anesthesiologists
• Association of Perioperative Registered Nurses
(AORN)
• American Academy of Otolaryngology-Head & Neck
surgery
• American Orthopedic Association
• Anesthesia Patient Safety Foundation
• Blue Cross Blue Shield Association
What key steps have other
hospitals followed that have
enabled them to successfully
implement the Checklist?
What Can Make a Difference
• Find a “champion” in each discipline
(anesthesia, nursing, and surgery)
• Buy-in from clinical and hospital leadership
• Modify the Checklist and trial it
• Measurement/Local Evidence
– Reinforce Change
– Show Progress
Checklist Modification Basics
• One size doesn’t fit all
• Need to have full team buy-in
• Don’t remove teamwork items
– Introduction of team members by name
and role
– Review of specific patient concerns
– Discussion of key concerns before patient
leaves the OR
When We Use the Checklist:
• Does the entire team stop all activity at the three
critical points in care?
• Does the team verbally confirm each item on the
Checklist?
• Are the items verified without reliance on memory?
• Does the Checklist promote communication?
Virginia Mason Hospital- Seattle
• In order for the Checklist to work well it has to be
used “right”- requires behavioral change
• Improving communication between all OR team
members is critical to successful implementation.
2010 Annual Meeting of the American Society Anesthesiologists
Operation: Safe Surgery
Vision/Purpose
• Vision: That every patient in South Carolina will
receive surgical care in a safe environment
• Purpose: To create a statewide system of surgical
safety that is built on teamwork and
open communication
Operation: Safe Surgery
Initial Goals
• All SC acute care hospitals will evaluate the
WHO surgical safety checklist with at least one
surgical team
• Surgical teams statewide will be provided direct
access to a focused crew/team resource
management training program
Operation: Safe Surgery
Major Goals
• 100% SC hospitals will commit to checklist use
and CRM-based communication in all ORs
• All SC hospitals and surgical teams will have
direct access to a broad range of surgical safety
educational resources and consultative services
• A unified data management system established to
track and analyze key surgical care process and
outcomes indicators within and across hospitals
Operation: Safe Surgery
Key Challenges
• Attaining senior leadership/medical staff buy-in
• Integration of WHO checklist with TJC universal
protocol requirements
• Spreading use of checklist from one to multiple
surgical teams in each hospital
• Providing access to CRM training statewide
• Creating a user friendly system for tracking impact
of program on patient outcomes
Operation: Safe Surgery
Phase 1 Results
• 55% of SC hospitals evaluated checklist with at least
one surgical team by April 1, 2009
• 25% of SC hospitals committed to evaluating after
Sprint deadline
• 80% total commitment from SC hospitals compared
to 25% national rate
Operation: Safe Surgery
Phase 2
• CRM training program for lead surgical teams in
regional sites across the state
• Training sessions available to all SC hospitals
• Collection and analysis of predefined surgical
safety process and outcomes measures
• Spread checklist/training to other procedural areas
Operation: Safe Surgery
Phase 3
• Achieve goal of 100% SC hospitals actively using
checklist/CRM-based communication in all ORs
• Create statewide surgical safety leadership team
• Establish standard surgical safety performance
dashboard w/ key process and outcomes indicators
• Develop a menu of onsite CRM training and
consultative services available to every SC hospital
• Serve as lead state for WHO surgical safety
program (Dr. Gawande)
“To every person there comes in life that
special moment when one is tapped on the
shoulder and offered the chance to do a
very special thing. What a tragedy if that
moment finds you unprepared or
unqualified for the work which would be
your finest hour.”
Sir Winston Churchill (1874-1965)
Institute for Healthcare Improvement
Short Movie Clip
http://www.ihi.org/IHI/Programs/ImprovementMap/WH
OSurgicalSafetyChecklist.htm