Transcript the Presentation slides - Southern Atlantic Healthcare

Southern Atlantic Healthcare Alliance
OR Education Session
January 6, 2016
Jennifer L. Fencl, DNP, RN, CNS-BC, CNOR: Clinical
Nurse Specialist, Operative Services
Terri Sharpe, MHA, BSN, RN, CNOR: Assistant Director,
Short Stay and Pre-Admission Testing
Vangela Swofford, BSN, RN, ASQ-CSSBB, CPHQ: Quality
Facilitator
2
Objectives:
 Describe the background, implications, and risk
factors of performing wronged site surgery/procedures
 Categorize the risk of wrong site surgery in a
healthcare facility
 Illustrate the importance of clear communication and
utilization of the C.U.S. model to share patient safety
issues
 Explain how to use Six Sigma and Lean principles to
identify areas for opportunity
 Construct a fish-bone and time-frame diagram to
identify areas for improvement
3
Break Through Project:
Wrong Site Surgery/Procedure
"Your life today is a result of your thinking yesterday.
Your life tomorrow will be determined by what you
think today."
John C. Maxwell
4
Wrong Site Surgery/Procedure
Hospital / Location: System-wide
Area of Focus: Continuum of patient care
Time procedure is discussed with patient
Procedure
After Procedure
5
Wrong Site Surgery is defined as any procedure
performed on the wrong site or patient or performance
of the wrong procedure.
6
Background
 1995-2005: Wrong Site Surgery ranked #2 frequently reported sentinel
event
 1997: American Academy of Orthopedic surgeons-- initial operative
site
 2001: The North American Spine Surgery-- “Sign, Mark and
Radiograph”
 2002: American College of Surgeons– recommends guidelines for
correct patient, correct site, correct procedure
 2003: TJC promotes Universal Protocol for preventing
wrong site, wrong procedure, wrong person surgery
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Implications
 Patient
 Safety/Medical
 Family
 Emotional
 Surgeon
 Social/Trust
 Staff
 Legal
 Hospital
 Cost
8
Incidence of Wrong Site
Surgery/Procedures
 Incidence (varies)
 0.09 to 4.5 for every 10,000 procedures
 1 for every 27,686 procedures
 40 times a week
9
Specialties at Highest Risk
 Orthopedics
 Neurosurgery
 General
 Ophthalmology
 Anesthesia
10
Risk Factors
 Communication breakdown
 Inadequate safety checks
 Technology not utilized
 Competing demands/distractions
 Human error
 Patient characteristics
 Other
11
Surgery discussed
with patient
Surgery scheduled
Pre-admission
testing/admission
to the hospital
Short Stay, holding
room, procedure
area
Keys to Success
 Communication
 Engagement
 Standardization
 Education
Mission Statement:
We strive to be national leaders in providing exceptional, safe patient care
through clear interprofessional communication and collaboration utilizing
evidence based practice to standardize processes while maintaining fiscal
responsibility. We are committed to providing the correct procedure to the
correct patient at the correct site every time. Every patient, every time.
13
Small Group Work
Reflecting on the incidence of wrong site
procedure/surgery in your organization, what are your
organizations risk category? What would be included in
your mission statement?
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Time to share your work
15
Cone Health
 Categories of error
 Scheduling error
 Process not followed
 Human error
 Communication error
16
Objectives
 Discuss the importance of clear communication
 Define the acronym C.U.S.
 Discuss utilization of the C.U.S. model to share patient
safety issues
C.U.S. Training
“It’s okay to C.U.S”
 Attended North Carolina and Virginia (NOCVA) Safety
Surgery Collaborative Training
 Utilized resources for staff in-services
 Created realistic scenarios staff could face
Importance of Communication
Patient Safety!
The Joint Commission has found that
many times when sentinel events occur
in the OR a member of the surgical
team knew that the event was about to
happen and they didn’t say anything.
Importance of Communication
Patient Safety!
Events that have happened because no one spoke up:
 Wrong Site
 Wrong Procedure
 Wrong Equipment
 Wrong/Missing Implant
 Wrong Medication/Allergy
Why We Don’t Speak Up
 I’m afraid
 I’m embarrassed
 I’m stupid
 They will yell at me
 I might be wrong
 The phyisan is mean
 They won’t listen anyway
 It’s not that important
C.U.S. Training
C = Concern
U = Uncomfortable
S = Stop, this is a Safety Issue
The power of articulating concern for patient safety
C.U.S. Training
 Interactive: divided into small groups
 Time for each group to discuss scenario
 “Dr. Fencl” enters to the room
(remember, it is okay to C.U.S.)
C.U.S. Training
 Responses from each group
 Learning from each other
 Power of articulating your concern for patient safety
Importance of
Clear Concise Communication
 “I’ll be right there”
Importance of
Clear Concise Communication
 “On my way”
Importance of
Clear Concise Communication
 “Give me a minute”
Importance of
Clear Concise Communication
 “Right now”
Importance of
Clear Concise Communication
 “I’ll be right there”
 “On my way”
 “Give me a minute”
 “Right now”
Closed Loop Communication
Communication break-down
 Commonly lead to patient harm.
 They derive from:
 Lack of clarity
 A noisy and chaotic environment
 Failure to confirm that information was understood
History of Closed Loop
Communication
 Early voice radio communication
 Smoke signals and signal flags didn’t work anymore
 Every transmission required a reply
No reply, you assumed that the message was
not received, and you repeated it.
Not Closed Loop Communication
Closed Loop Communication:
How It Works
The sender initiates a message.
1. The receiver accepts the message,
interprets it, and confirms what
was communicated.
2. The sender verifies that the
message was received.
Derived from the Agency for Healthcare Research and Quality, TeamSTEPPS
Closed Loop Communication
Who would like to volunteer?
Implications of C.U.S.ing
 Powerful Communication to share with:
 OR Nursing Residents
 OR RN 3-4 (clinical ladder)
 OR Shared Governance
 Endoscopy
 Outside the OR
Comments/Questions
Six Sigma and Lean Principles
39
Fishbone Diagram
Communication
Orders
Postings
Other
Depot Shuffle (canceled
Orders are there but not signed (in MD box)
no surgeon orders; anesthesia orders
Incorrect
open case to
Incomplete/incorrect Unable to modify cases
tagging of bed with room #,
unless pt shows up)
used
and
additional
orders
needed
patient
document & it's postings (also blocking and
Non-clinical staff posting
surgeon, no pt identifiers
positioning
no
orders
for
surgery
prior
to
anesthesia
incorrect pt
Consults
for
clearance
billing impact)
(could have 2 pts with same
cases (hospital and office)
H&P (complete and
intervention (block); pt signs consent after surgeon and room changes)
Incorrect case related
faxing instead of entering in CHL
Human error
accurate across the
intervention
Ability to post laterality as 'N/A'
Surgeon communication
to room change
continuum of pt
CHL case options not all-inclusive /
Pt arrives without orders
care
wayanes
accesses
pt
charts
verbal
orders
instead
of
entering
in
CHL
CHL limitations for posting options
Access to scheduling / editing
Handoff / report
confusion re: where
procedures process
legibility of written orders
2 similar names in depot; incorrect pt scheduled for sx
surgeon listening to concerns from staff
Use of abbreviations
procedure will be done (ex
(placed in room), anesthesia and staff open case and
Consults for clearance
IR paracentesis vs U/S
'don't call me about order'
start to document
Surgeon booking case
Incorrect order entries
Orders not being entered as MD or RN
Radiology films - marking
laterality
Push for efficiency
Site not marked
working off normal service
mark removed by prep agent
using 2 pt identifiers
timeout
engagement
when patients are seen by surgeon prior
to surgery/procedure
pen not working
armband incorrect on arrival to
holding area (not caught earlier
Turnover Time
sugeon wants to go back for
procedure before lab results
Where consent
signed (office, PAT,
SS, Holding)
social conversations
computer location (RN
back is to field)
Reps / Vendors
surgeon signs consent, not his planned procedure
Consent signing by surgeon
Computer location
(RN back to field)
cellphones, music
Consent for pre-procedure testing/not actual procedure
Engagement with timeout process
Armband on chart, clipboard, etc (not on patient)
Incorrect consent completed
Having pt sign consent
without order for tx
The Occurrence of
Wrong Site Procedures
timing of consent
Changing service
surgical checklist not standardized
Policies
Speed/Productivity
Consent
Distractions
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Wrong Site Surgery/Procedure
Timeline of Critical Events / Issues
MD OFFICE
HOSPITAL
PACU
OR:
Procedure
Incision
Short Stay /
Holding
OR:
After Incision
.
Pre-Procedure
Testing
Pt sees MD
.
Day of Procedure
Pre-Admission
Testing Visit
Procedure
scheduled by
office staff &OR
schedulers
Before Day of Procedure
.
POSTINGS
ORDERS
Incorrect
procedure posted
on schedule
Orders not entered
into CHL by MD
Identifiers: birthday
not confirmed at
posting
Non-clinical staff
scheduling (office
& hospital)
Surgeon
booking
case
Correct Procedure
not option in CHL /
CHL limitations for
posting options
CHL case option
lists not allinclusive (time
blocking and billing
implications
Use of verbal
order instead of
written order for
scheduling
Human
error
Wrong surgery
chosen in CHL
Inability to modify
case options
Ability to post
laterality as N/A
Access to
scheduling/editing
procedures
process
No orders for
surgery prior to
anesthesia
intervention
(block); pt signs
consent after
intervention
Pt arriving without
orders
Abbreviations and
illegible orders
COMMUNICATION
Depot Shuffle
(canceled unless
pt shows up)
Tagging of bed with
room #, surgeon, no pt
identifiers (could have
2 pts with same
surgeon and room
changes)
Way anesthesia
access pt chart
Faxing of orders
instead of entering
in CHL
Orders not
being entered
as an MD or RN
Orders present
but sitting in
MD’s inbox (not
signed)
Incorrect
order entries
Consults
for
clearance
Surgeon
communication
Surgeon listening
to concerns from
staff
‘Don’t call me
about order’
Using anesthesia
orders when no
surgeon orders;
not aware of need
for more until after
surgeon arrives
Handoff/
report
Radiologist &
surgeon
review of
films
POLICIES &
PROCEDURES
Engagement
with timeout
process
Marking
laterality on
radiology films
Armband
incorrect on
arrival to holding
area (not caught
earlier)
Surgical
checklist not
standardized
Incorrect patient
positioning
H&P (completed
and accurate)
across the
continuum of pt
care
CONSENT
DISTRACTIONS
Push for efficiency
Incorrect
consent
completed
Reps/Vendors
Site marking
removed by
prep agent
Turnover time
Site not marked
Working off
normal
service
Pen not working
Armband not on
patient (on
clipboard, chart,
stretcher, etc)
SPEED /
PRODUCTIVITY
Not using 2 patient
identifiers
consistently
Where MD
sees patient
prior to
surgery
MD wanting to go
back for procedure
prior to having lab
results in hand
Pt having
consent without
order for consent
Where consent
signed (office,
PAT, Short Stay,
Holding Area)
Surgeon signs
consent then
states ‘this is not
what I want to do’
Timing of consent
OTHER
Incorrect case
related to room
change
Social
conversations
Open case to start
documentation
and it is the
incorrect patient
Cell phones, music
Confusion about
where the
procedure is to
be done (ex. IR
paracentesis vs
U/S
thoracentesis)
Computer location
(RN back to field)
Two similar names in
depot, incorrect pt is
scheduled for surgery
(placed in room),
anestehsia and staff open
case and start to document
Documentation on
incorrect case due
to room
changes,staff
changes, etc.
41
Small Group Work
Reflecting on the incidence of wrong site
procedure/surgery in your organization, start a fishbone
and timeline of critical events.
42
Time to share your work
43
Key Issues
 CHL
 Postings/Scheduling
 Orders
 Communication/Standardization
 Culture
 Surgical Check-list
 Policy and Procedures
 Distractions
 Competing Demands
 Pressure for efficiency vs safe patient care
44
Outcomes
 Interprofessional Task
 Time-Out Video
Force
 Defining WSS
 Addressing Culture
 Creating Dashboard
 Standardization
 Policy and Procedure
 Quarterly Newsletter
 Electronic Health Record
 Streamlining Orders
 Sharing Work
http://youtu.be/_e37xjBoa
64
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Final Thoughts
Previously stated our keys to success were:
 Communication
 Engagement
 Standardization
 Education
What we learned……this is continuous work that
requires a multidisciplinary approach and great effort.
The final element is a vision for improvement.
46
Executive Support
 Strategic vision
 Overcoming objections (surgeon objections)
 Challenges in community based system with an
electronic health record (EMR)
 Technology/remote support
 Empowering the staff’s voice
 Cultural Relevance
47
Issue Prioritization
 Review the literature
 Define wrong site procedures
 Calculate our rate (over all and per specialty area)
 Data collection (categorize data)
 Create timeline of patient care and identify critical




elements/competing demands
Identify opportunities and action plans
Observe timeline of patient care
Create tools/risk assessments
Implementation/Education
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Southern Atlantic Healthcare Alliance
OR Education Session