Keystone Surgery

1
Keystone Surgery

• How we did it
• Engage
• Educate
• Execute
• Evaluate

2
Engagement

• Subtle Messages
• Keystone Project started in the middle of our
  surgery center building project
• AORN Time Out Protocol
• Wallboard in hall
• Laminated WHO Surgical Safety Checklist in each
  room
• Department of Surgery Meeting November handout
  and discussion

3
Education

• Letters to all surgeons
• Mandatory educational meeting for all OR and
  anesthesia staff
• Each staff member given copy of Keystone surgery
  Challenge handout and a surgical safety
  checklist.
• Presentation..

4
Keystone Surgery

• MHA Keystone Center for Patient Safety and
  Quality
• The MHA Keystone Center is fully committed to
  improving patient care in all Michigan hospitals
  and is proud of its role as a pioneer in patient
  safety and quality improvement.

5
Keystone Surgery

• The John Hopkins University Quality and safety
  Research Group and the MHA Keystone Center are
  partnering with hospital across Michigan to
  implement a perioperative safety program.
• The objective is that all participating
  institutions could know with confidence whether
  their patients are safer a year from now than
  they are today.

6
Who are we?

• 93 participating hospitals
• - 27 urban (including 10 critical access)
• - 21 rural
• - 45 community, 16 w/residents, 3 academic
• - Median bed size 172 (14 -1000)
• - Median annual surgical volume
• In-patient 2148 (34-21,500)
• Outpatient 4442 (469-15,269)

7
Keystone SurgeryCollaborative 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 Forums Never events
  (wrong site/side surgery and retained foreign
  bodies)
• Have 80 of your staff reporting positive safety
  and teamwork climate using a measurement
  instrument that is psychometrically sound.

8
Keystone SurgeryScience of Safety

• Organize for patient safety
• Translate evidence into practice
• SSI and DVT
• Improve Culture and Communication
• CUSP (Comprehensive Unit-Based Safety
  Program)
• Identify and learn from mistakes
• Wrong site/side surgery
• Evaluate progress in Safety

9
How do we create a culture of safety?

• Team Communication
• Familiarity with others
• Standardize what is done, when it is done
• Reduce complexity
• Create independent checks for key processes
• How often do we do what we should
• Learn from mistakes
• How often do we learn from mistakes

10
Team Communication

• Familiarity with others is a critical component
  of effective teamwork
• 74 of all aviation accidents happen on the first
  day of a crew flying together
• Familiarity trumps fatigue
• Highlights the importance of predictable patterns
  of behavior

11
Standardize what is done and when it is done

• Safety Checklist World Health Organization
  (WHO)
• Sign In/Briefing Before induction of
  anesthesia
• Patient has confirmed
• Identity
• Site
• Procedure
• Consent
• Site Marked/Not applicable
• Anesthesia safety check complete
• Pulse Oximeter on patient and functioning
• Known allergy?
• Difficult Airway/aspiration risk?
• Risk of gt500ml blood loss

12
Standardize what is done and when it is done

• Safety Checklist World Health Organization
  (WHO)
• Time Out Before skin incision (Attending
  surgeon MUST be present) ALL ACTIVITY STOPS

13
Standardize what is done and when it is done

• Safety Checklist World Health Organization
  (WHO)
• Sign Out/Debriefing Before surgeon leaves
  operating room
• The name of the procedure recorded
• That instrument, sponge and needle counts are
  correct or not applicable
• How the specimen is labeled (including patient
  name, date, and nurse initials)
• Whether there are any equipment problems to be
  addressed
• Surgeon, anesthesia professional, and nurse
  review the key concerns for recovery and
  management of this patient.

14
VIDEO
15
Create independent checks for key processes

• Process will be audited for compliance and will
  include the following information
• Procedure
• Surgeon
• Names of physicians
• Assistants
• Staff members in the room
• Entire team involved and attentive
• All activity stopped when time out was performed
• All components of time out were included
• Site was correctly marked
• Marked site was visible after draping

16
Learn from our mistakes

• Monthly meetings to discuss mistakes and near
  misses that we can all learn from
• (i.e. not who is right, but what is best for the
  patient)
• The goal For our doctors and nurses to work
  together as a well coordinated team.

17
Execute

• March 2, 2009
• Took WHO safety checklist and made pads of 100
  for each OR suite
• Management floated through suites to answer
  questions and help with time outs and compliance
  (Medley story)
• Staff told to record resistance and call
  management with issues of non-compliance

18
Evaluate

• Spies are sent in periodically to see if steps
  are being followed.
• Safety checklists are collected daily and
  compared to surgery schedule for compliance.
• Staff write notes on all areas when things are
  caught
• Evaluation done weekly for data input to Keystone
  Center.
• New GE upgrade has time out built into charting.