Keystone Surgery: Improving Perioperative Care in Michigan (Text Version)

On September 16, 2009, Chris George made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (4.1 MB).

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Slide 1

Keystone Surgery: Improving Perioperative Care in Michigan

Chris George, RN MS
Project Manager
MHA Keystone Center for Patient Safety and Quality 

Slide 2

Preventable Harm

• 230 million surgeries / yr worldwide
  • More common than births ( 36 million / yr)
  • 1 in 25 people
• 25% in-patient surgeries followed by complication
  • 7 million disabling complications / yr
• 0.5 - 5% deaths following surgery
  • 1 million deaths / yr
• 50% of all hospital adverse events linked to surgery
  • At least 50% of adverse surgical events are avoidable

http://www.who.int/patientsafety/challenge/safe.surgery/en/

Slide 3

Keystone Surgery

• Learning Community- few existing forums for hospitals to come together to share experiences and improve care.

Keystone Surgery Cohort 1

• 76 hospitals
• 36 urban, 38 rural (including 7 critical access)

Keystone Surgery Cohort 2

• 25 hospitals
• 14 CAH

Slide 4

Keystone Surgery Collaborative 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 Forum's "Never" events (wrong site surgery and retained foreign bodies)
• Have 60% of your staff reporting positive safety and teamwork climate using a measurement instrument that is psychometrically sound.
• Develop a safety scorecard for perioperative care

Slide 5

The Johns Hopkins Comprehensive Unit-Based Safety Program (CUSP)

• Educate staff on science of safety
  http://www.jhsph.edu/ctlt/training/patient_safety.html
• Identify defects
• Assign executive to adopt unit
• Learn from one defect per quarter
• Implement teamwork tools

J Patient Safety 2005; Jt Comm J Qual Saf. 2004;30(2):59-68. http://www.jhsph.edu/ctlt/training/patient_safety.html

Slide 6

2008 OR Teamwork Climate

Graph of the 2008 OR Teamwork Climate which shows more than 50% in need improvement zone.

Slide 7

"The Physicians And Nurses Here Work Together As A Well-Coordinated Team."

Graph of the percentage of respondents that agree

Note: this item is typically negatively correlated with annual nurse turnover rates

Slide 8

Step 5: Implement Teamwork Tools

• Daily Goals
  • J Crit Care 2003;18: 71-75
• Morning Briefing
  • Jt Comm J Qual Patient Saf. 2005;31:476-9
• Learning from Defects
  • Jt Comm J Qual Patient Saf. 2006;32:102-8;
  • Am J Med Qual 2009;24(3):192-5.
• Team Check Up Tool
  • Jt Comm J Qual Patient Saf. 2008;34:619-623
• Shadowing
  • Jt Comm J Qual Patient Saf. 2008;34:614-8
• Briefing and Debriefing
  • Jt Comm J Qual Saf. 2009;35(8):391-397

Slide 9

Image: The New England Journal of Medicine

Article title: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Slide 10

Briefing Checklist

OR BRIEFING CHECKLIST

Implementation Instructions: Make sure all team members are in the OR suite and the patient is anesthetized. Just prior to starting the procedure implement the checklist beginning with the introduction of names and roles and work in descending fashion through the list.

I. Introduction of first names and roles.

II. Review critical information
- Do we have the correct patient?
- Is the correct side or site marked?
- Has the procedure been agreed upon?
- Have antibiotics been given?

Jt Comm J Qual Saf 2006;32(6): 351-355

Slide 11

Briefing Checklist

III. Surface and Mitigate Hazards SURGERY - Discuss plans for the surgical procedure:
- Describe critical steps
- Provide team with pertinent information, including problems that may be encountered
- Ask team: If something were to go wrong with this procedure, what would it be, and how could we prevent the problem or mitigate harm?

• Risks during procedure such as bleeding, fluid loss
• Surgeon suggests, "If anyone has a concern during the case, please let me know."

- Does everyone know how to use the equipment used in this procedure?

Jt Comm J Qual Saf 2006;32(6): 351-355

Slide 12

Briefing Checklist

ANESTHESIOLOGY - Discuss all relevant issues:
- Patient comorbid disease that will increase risk
- Aspects of surgery that will increase risk, such as need for IV access
- Availability of blood products
- Interventions to prevent complications such as myocardial infarction, surgical site infection

NURSING - Discuss all relevant issues:
- Are all necessary instruments available?
- Will any special equipment be considered?
- Plan for breaks (Relieving nurse to introduce themselves when switching)

Jt Comm J Qual Saf 2006;32(6): 351-355

Slide 13

Briefing - Before Every Procedure

• Team introduction - first and last names including roles (Circulator writes on board)
• Do the following match:
• Patient ID band, Informed Consent (read out loud), Site Marking, OR posting, patient's verbalization of procedure (if patient awake), other clinically relevant documentation (H&P, clinic note)
• Do we have any safety, equipment, instrument, implant or other questions or concerns?
• Have antibiotics been given, if indicated?
• What are the anticipated times of antibiotic redosing?
• Are glycemic control/beta blockers indicated?
• Is the patient positioned to minimize injury?
• Has the Prep been applied properly, without pooling and allowed to dry?
• Have the goals and critical steps of the procedure been discussed?
• Is the appropriate amount of blood available?
• Is DVT prophylaxis indicated? If so, what?
• Has the patient received anticoagulants?
• Any Special Precautions? If yes, describe.
• Are warmers on the patient?
• Is the time allotted for this procedure an accurate estimate?
• Has the Attending reviewed latest/final test results for Lab/Radiology? Are Intraoperative X-rays indicated?

Slide 14

De-briefing Checklist

Debriefing - After every procedure

• Could anything have been done to make this case safer or more efficient?
• Has the SSI data collection form been completed?
• Are the patient's name/history number and the surgical specimen name and laterality on the paperwork? (Paperwork/labeling to be independently verified by Surgeon)
• Did we have problems with instruments?
• Plan for transition of care to post-op unit discussed? To include:
• Fluid Management/blood (all slips in chart)
• Antibiotics - continue post-op (dose/interval)
• PACU tests/XRays
• Pain/PCA plan
• New meds needed (immediate periop)
• Beta blockers (as required)
• Glycemic control (as required)
• DVT prophylaxis

Slide 15

William Beaumont Hospital Royal Oak campus

Graph of 37,133 briefings and debriefings broken up by Teames and Quaters.

Jt Comm J Qual Saf. 2009;35(8):391-397.

Slide 16

Provider Perceptions

Briefings
Effective strategy to improve communication: 90%
Effective strategy to improve teamwork: 90%
Feasible given my current work load: 70%
Average time to complete: 2.9 minutes

Debriefings
Effective strategy to improve communication: 68%
Effective strategy to improve teamwork: 72%
Feasible given my current work load: 70%
Average time to complete: 2.5 minutes

Jt Comm J Qual Saf. 2009;35(8):391-397.

Slide 17

Briefing Compliance
All Keystone Surgery Teams
7/1/2008 - 8/31/2009

	Completed	Expected	Percent
July 2008	156	222	70.27%
August 2008	1,062	1,389	76.46%
September 2008	1,814	2,409	75.3%
October 2008	1,614	2,340	69.1%
November 2008	1,759	2,069	85.02%
December 2008	2,841	3,347	84.88%
January 2009	7,066	9,316	75.85%
February 2009	8,937	11,595	77.08%
March 2009	16,316	19,834	82.26%
April 2009	15,491	18,941	81.79%
May 2009	15,757	18,889	83.42%
June 2009	19,696	23,765	82.88%
July 2009	14,909	17,631	84.56%
August 2009	11,759	12,886	91.25%
	119,180	144,633	82.4%

Slide 18

Briefing Problem Identification
All Keystone Surgery Teams
7/1/2008 - 8/31/2009
Categories

	Communication		Equipment		Lab		Preop		Radiology		Supply
	Total	%	Total	%	Total	%	Total	%	Total	%	Total	%
Jul 2008	6	66.67%	0	0%	1	11.11%	1	11.11%	0	0%	1	11.11%
Aug 2008	9	37.5%	4	16.67%	4	16.67%	7	29.17%	0	0%	0	0%
Sep 2008	7	15.91%	16	36.36%	1	2.27%	14	31.82%	1	2.27%	5	11.36%
Oct 2008	29	24.37%	40	33.61%	16	13.45%	29	24.37%	2	1.68%	3	2.52%
Nov 2008	18	27.27%	14	21.21%	2	3.03%	30	45.45%	1	1.52%	1	1.52%
Dec 2008	35	25.93%	27	20%	5	3.7%	50	37.04%	4	2.96%	14	10.37%
Jan 2009	57	26.89%	54	25.47%	8	3.77%	65	30.66%	5	2.36%	23	10.85%
Feb 2009	48	22.97%	72	34.45%	6	2.87%	56	26.79%	4	1.91%	23	11%
Mar 2009	103	25.62%	97	24.13%	5	1.24%	130	32.34%	9	2.24%	58	14.43%
Apr 2009	129	29.59%	110	25.23%	19	4.36%	92	21.1%	16	3.67%	70	16.06%
May 2009	130	28.76%	112	24.78%	13	2.88%	120	26.55%	13	2.88%	64	14.16%
Jun 2009	175	31.59%	139	25.09%	18	3.25%	111	20.04%	10	1.81%	101	18.23%
Jul 2009	139	33.33%	100	23.98%	5	1.2%	89	21.34%	9	2.16%	75	17.99%
Aug 2009	90	31.58%	74	25.96%	5	1.75%	69	24.21%	9	3.16%	38	13.33%
	975	28.98%	859	25.54%	108	3.21%	863	25.65%	83	2.47%	476	14.15%

Slide 19

Debriefing Compliance
All Keystone Surgery Teams
7/1/2008 - 8/31/2009

	Completed	Expected	Percent
July 2008	164	222	73.87%
August 2008	1,051	1,389	73.57%
September 2008	1,779	2,448	72.67%
October 2008	1,571	2,246	69.95%
November 2008	1,648	2,041	80.74%
December 2008	2,656	3,230	82.23%
January 2009	6,671	9,154	72.88%
February 2009	8,360	11,243	74.36%
March 2009	15,232	19,037	80.01%
April 2009	14,209	18,065	78.65%
May 2009	14,670	18,336	80.01%
June 2009	18,972	23,448	80.91%
July 2009	14,227	17,276	82.35%
August 2009	11,312	12,590	89.85%
	112,522	140,725	79.96%

Slide 20

Debriefing Problem Identification
All Keystone Surgery Teams
7/1/2008 - 8/31/2009
Categories

	Communication		Equipment		Lab		Preop		Radiology		Supply
	Total	%	Total	%	Total	%	Total	%	Total	%	Total	%
Jul 2008	15	38.46%	19	48.72%	1	2.56%	1	2.56%	0	0%	3	7.69%
Aug 2008	11	34.38%	14	43.75%	0	0%	7	21.88%	0	0%	0	0%
Sep 2008	31	39.74%	20	25.64%	2	2.56%	7	8.97%	0	0%	18	23.08%
Oct 2008	45	31.69%	59	41.55%	4	2.82%	14	9.86%	4	2.82%	16	11.27%
Nov 2008	29	24.44%	58	50.88%	3	2.63%	6	5.26%	2	1.75%	16	14.04%
Dec 2008	46	24.21%	86	45.26%	6	3.16%	15	7.89%	7	3.68%	30	15.79%
Jan 2009	85	24.15%	166	47.16%	2	0.57%	36	10.23%	11	3.13%	52	14.77%
Feb 2009	84	25.3%	169	50.9%	5	1.51%	17	5.12%	11	3.31%	46	13.86%
Mar 2009	149	23.88%	294	47.12%	16	2.56%	39	6.25%	22	3.53%	104	16.67%
Apr 2009	137	26.2%	242	46.27%	8	1.53%	15	2.87%	14	2.68%	107	20.46%
May 2009	146	24.58%	245	41.25%	9	1.52%	38	6.4%	15	2.53%	141	23.74%
Jun 2009	196	23%	416	48.83%	14	1.64%	46	5.4%	13	1.53%	167	19.60%
Jul 2009	137	21.68%	327	51.74%	10	1.58%	41	6.49%	8	1.27%	109	17.25%
Aug 2009	142	28.06%	234	46.25%	1	0.20%	27	5.34%	8	1.58%	94	18.58%
	1,253	25.01%	2,349	46.89%	81	1.62%	309	6.17%	115	2.3%	903	18.02%

Slide 21

Challenges

• Surgical teams are complex
• Diffusion of innovation in ORs challenging
• Data collection burdensome
• Linking improvement in culture with improved patient outcomes