Introducing the Checklist 101: Hard Lessons Learned From Life

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Introducing the Checklist 101Hard Lessons
Learned From Life

• Bill Berry, MD, MPH
• Sunil Eappen, MD
• Lizzie Edmondson

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Topics

• Safe Surgery 2015 South Carolina
• Keys to introducing the checklist
• Monitoring the checklist at your hospital
• The call series
• Your involvement in checklist implementation
• Next steps

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Safe Surgery 2015 South Carolina

• By the end of 2013 every patient undergoing
  surgery in the state will have a modified version
  of the checklist used during their operation.

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The Checklist

• How many of you know the background of the WHO
  Surgical Safety Checklist?
• How many of you are using a modified version of
  the checklist at your hospital?
• How many of you tried using the checklist at your
  hospital, but werent able to get others to do
  it?

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CEO Participation

• We asked your CEO to do the following
• Engage Executive Leadership
• Gain the endorsement of the Hospital Board and
  Medical Executive Committee
• Meet with clinical leadership to ensure that they
  are committed to working on this project
• Identify individuals that will serve as the
  checklist implementation team in collaboration
  with clinical leadership

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Keys to Introducing the Checklist
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Make an Implementation Team

• Nursing
• Administration
• Anesthesia
• Surgery

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Find Clinical Champions

• The nurses will know
• Pick those who are respected and who will be
  supportive
• The support of formal leadership is absolutely
  necessary but those leaders are often not the
  ones who should guide this effort directly

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Start Small Make Mistakes Small

• Only expand when you are ready
• Do not tie yourself to a firm timeline be
  flexible
• Keep pressure on yourself to move forward but
  remember . . . .no preconceived plan ever
  survives contact with reality

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Preparation is Everything

• Careful preparation is much easier than repairing
  the damage of moving too quickly

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Modify and Trial the Checklist

• Modify the checklist (Tips on next slide)
• Practice using the checklist outside of the OR
  and modify as needed
• Use the modified checklist in one case with one
  enthusiastic team
• Each team member should be engaged and briefed
  ahead of time make sure you talk to everybody
• Debrief and modify the checklist as needed
• Use the checklist for one day in every case with
  the same team
• Debrief and modify as necessary

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Modification Tips The Basics

• One size doesnt fit all
• Can create buy-in
• Remove items that are adequately checked and
  measured by established safety systems
• Dont remove teamwork items
• Introduction of team members by name and role
• All items in the briefing and debriefing sections

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Focused

• Avoid adding too many items
• Each section should have 5-9 items
• Only add items that are not adequately checked by
  other mechanisms

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Brief

• Each section should take lt 1 minute
• The checklist should never take longer than
  the procedure

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The Goal is Two-Fold

• To improve the performance of processes in the OR
  that every patient should have done
• To improve communication and teamwork in the OR

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Dont Modify
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• Will everyone please state name and role?
• "Confirm all team members have introduced
  themselves by name and role
• "We'll start by introducing ourselves and our
  roles
• "Team members introduced themselves by name and
  role"
• "Confirm all team members have been introduced
  and actively participate"

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• Surgeon says If anyone on the team sees
  something that the team should know about, please
  speak up
• Surgeon declares If anyone on the team sees
  something that the team should know about, please
  speak up anytime during the procedure
• Surgeon states, Remember that all are free to
  voice any concerns at any time throughout the
  procedure
• Surgeon states, If you see, suspect, or feel
  that patient care is compromised, will you speak
  up?
• Surgeon states, Remember that all are free to
  voice any concerns at any time throughout the
  procedure
• Surgeon states, Does anyone have concerns? If
  you think there is a problem, please speak up

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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 teamwork?

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This is Not a Quality Improvement Effort That Can
Be Meaningfully Accomplished By the Nursing Staff
Alone

• Avoid the temptation to take the easy way out
• A checklist that becomes a tick box exercise is
  no checklist at all
• Do not count on an IT system or electronic
  documentation to make this effort a success

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Educate. . .Educate. . .Educate

• In a team
• Everyone separately

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Everyone Gets Personal Contact

• Mass emails do not suffice
• Talk to people
• Peer to Peer
• Nurse to Physician
• Do you have a good enough relationship to have
  this discussion?
• Everyone includes
• Anesthesiologists, CRNAs, Nurses, Scrubs,
  Surgeons, and techs
• Use a script to guide the discussion

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Make A Video

• Film it in an empty OR
• Use someone's flipcam or camcorder
• Many videos are available online, but one from
  your own place has the most impact

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Exempla St. Joseph Hospital Checklist Video
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How NOT to Use the Checklist Video
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Train and Use Coaches

• Same people can do observations
• Trusted and respected
• Best if known by most

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Start Where Its Easiest

• Use this rule at the beginning and all the way
  through
• Start with the willing
• Dont try to fix problem staff and clinicians

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Collect Stories

• Share stories when you educate
• Post the stories in a prominent shared space
• An IHI story

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Advertise

• You cannot spread the word too much
• Support from the highest places is valuable
• Support from respected clinicians is essential

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Monitoring the Checklist
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Performance of Checklist Observation Tool
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Performance of Checklist Observation Tool
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Surgical Teamwork Observation Tool
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Surgical Teamwork Observation Tool
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Option 1 Monitoring the Checklist at Your
Hospital

• Use all or some of the tools to monitor your
  progress.

BRING YOUR OWN DATA TOGETHER AND ANALYZE IT
YOURSELF
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Option 2 Participate in a Research Study

• Use the tools to collect data and send it to
  HSPH
• We analyze the data for you
• We benchmark the data to other SC hospitals
• No cost to you

YOU WILL HELP US LEARN AND IMPROVE SURGICAL CARE
WORLDWIDE
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Safe Surgery 2015 South CarolinaCall Series
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Safe Surgery 2015 South Carolina Call Series

• Step by step instruction on checklist
  implementation from experienced faculty
• Office hours to work through barriers with
  individual hospitals
• Materials to assist with implementation
• Discussion of measurement tools and use
• Review of progress and opportunities to improve
  the implementation

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Your Involvement as an Implementation Leader

• Participate on the call series, even if your
  hospital uses the checklist
• Coach individuals at your hospital on how to use
  the checklist
• Track your hospitals use of the checklist
• Give us feedback

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What Do You Do Now?

• Return to your hospital and see what steps your
  CEO has taken
• If needed help them build the checklist
  implementation team
• Schedule a large meeting to educate as many
  surgical personnel as possible anytime after
  June 28th

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Materials and Resourceswww.safesurgery2015.org