Safe Surgery Collaborative
Eastern Health Team Charter
Key Elements:
Background to
the problem:
Responses
A. VTE Prophylaxis
Project Description
Venous thromboembolism prevention is largely guided by the American College of
Physician’s Chest Guidelines (ACPCG), which provides specific prophylaxis for each
surgical subset. The team will develop division specific VTE prophylaxis order sets
that meet the requirements of these guidelines, Accreditation Canada’s ROP, and
best-informed practice. A regional working group will be established to develop
order sets stakeholders (e.g., clinical pharmacists, acute care nurse practitioners,
clinical educators, physicians, and anaesthesiologists). With the assistance of the
quality and safety leader, the team will develop PDSA cycles to evaluate the order
sets and report all progress and measurements for feedback from the
implementation working group. Once complete and approved, the protocols will be
spread throughout all of Regional Surgical Services. The team will monitor
compliance, as required by the implementation working group, with VTE prophylaxis,
as reported by the managers or senior leaders of each site.
B. Antibiotic Prophylaxis
Project Description
Surgical site infection is the most common healthcare associated infection among
surgical patients, with 77% of patient deaths reported to be related to infection. One
of the most important interventions in preventing surgical site infections is the
optimization of antimicrobial prophylaxis. The Regional Surgical Services Program is
part of a national patient safety initiative aimed at reducing surgical site infections.
The key interventions in this initiative include: ensuring that appropriate patients
receive the appropriate antibiotic prophylaxis between 0 to 60 minutes prior to the
time of incision in the operating room; and that the antibiotic is stopped after the
appropriate duration. To facilitate this, guidelines have been standardized to outline
drug choices and dosages for prophylaxis in each of the surgical divisions.
Prophylaxis guidelines have been developed based on a review of the current
literature and practices across Canada. Based on these developed guidelines, the
surgical antibiotic prophylaxis program will be implemented across all sites of
Eastern Health. The SSSL implementation team will monitor compliance with
antibiotic prophylaxis.
C. Safe Surgery Checklist
Project Description
The EH Safe Surgery Checklist is based on the World Health Organization’s (WHO)
‘Safe Surgery Saves Lives’ campaign aimed at improving patient safety in operating
rooms worldwide by reducing possible adverse events during surgical procedures.
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This checklist does not replace existing procedures or safety checks, but builds on
them to ensure the entire interdisciplinary team is involved in the safety
communication at three critical points: before the induction of anaesthesia
(Briefing), before skin incision (Time Out), and before the patient leaves the OR
(Debriefing).
The team will develop a checklist prior to implementation that meets the
requirements of Accreditation Canada Required Organizational Practice, AHS Safe
Surgery Checklist manual, and the WHO 10 essential objectives for safe surgery. This
checklist will be adapted to suit the needs and responsibilities of current surgical
services at each of the sites. The adapted checklist will have input from key
stakeholders. With the assistance of the clinical quality and safety leader, the team
will develop PDSA cycles to evaluate the adapted checklist. Full implementation of
the safe surgery checklist (developed and approved) will be instituted by June 2012.
Compliance rates and process and outcome measures will be monitored.
Statement of
the problem:
AIM for
improvement:
What are we
trying to
accomplish?
Goal #1: To decrease the number of surgical site infections.
Goal #2: To decrease the number of preventable VTE events within Regional Surgical
Services.
Goal #3: The operating room will reduce the number of preventable surgical
complications and further improve surgical outcomes for patients.
Scope
A. VTE Prophylaxis
In-Scope
1. Communicate and educate all Regional Surgical Services staff regarding VTE
prophylaxis.
2. Support and endorse the use of VTE prophylaxis order sets.
3. Provide role modeling and positive peer influence to colleagues.
4. Report concerns and problems associated with the initiative to the Quality
and Safety Leader and/or Eastern Health Safe Surgery Saves Lives
Implementation Team.
Out-of-Scope
1. Obstetrics and pediatrics.
Dependencies on Other Projects and/or Initiatives
1. The Eastern Health VTE Steering Committee is currently working on a global
policy and implementation plan for Eastern Health.
2. Will require resources (e.g. identification of staff) to collect and analyze
outcome and process measures.
3. EH SSSL implementation team will develop a plan and distribute to all sites
4. Evidence of VTE events will be obtained through review of CSRS electronic
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reporting system reports.
5. Support the use of posters and other promotional material.
B. Antibiotic Prophylaxis
In-Scope
1. Communication and education of all Regional Surgical Services and Children
and Women’s Health staff and physicians regarding Antibiotic Prophylaxis.
2. Support and endorse the use of antibiotic prophylaxis guidelines.
3. Provide role modeling and positive peer influence to colleagues.
4. Report concerns and problems associated with the initiative to the Quality
and Safety Leader and/or Eastern Health Safe Surgery Saves Lives
Implementation Team.
5. Develop, approve, and implement pediatric guidelines for antibiotic
prophylaxis.
Out-of-Scope
Dependencies on Other Projects and/or Initiatives
1. Will require resources (e.g. identification of Infection Prevention and Control
practitioner) to collect and analyze surgical site infection outcome and
process measures.
2. EH SSSL implementation team will develop plan and distribute to all sites.
3. Support the use of posters and other promotional material.
C. Safe Surgery Check List
In-Scope
1. Communication and education of all OR staff and physicians regarding Safe
Surgery Checklist.
2. Support and endorse the use of an Eastern Health Safe Surgery Checklist.
3. Provide role modeling and positive peer influence to colleagues.
4. Report concerns and problems associated with the checklist to the quality
and safety leader and/or Eastern Health Safe Surgery Saves Lives
Implementation Team.
Out-of-Scope
Dependencies on Other Projects and Initiatives
1. EH SSSL implementation team will develop a plan and distribute to all sites.
2. Evidence of near miss events and occurrences will be obtained from review
of reports from CSRS electronic reporting system.
3. Will require resources (e.g. identification of staff) to collect and analyze audit
process and outcome measures.
4. Support the use of posters and other promotional material.
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Improvement
Objectives
A. VTE Prophylaxis
1. By January 2013, VTE protocols will be developed for each surgical subspecialty.
2. By September 2013, VTE prophylaxis will be implemented at all sites.
B. Antibiotic Prophylaxis
1. By September 2013, all sites of Eastern Health will be providing all appropriate
surgical patients with the right antibiotic prophylaxis, at the right time, and for
the right duration.
Improvement
Measures:
How will we
know the
change is an
improvement?
C. Safe Surgery Checklist
1. The team will develop a standardized surgery checklist and adapt for all sites
within Eastern Health by April 2012.
2. By September 2013, Regional Surgical Services will be consistently using surgical
safety checklists throughout all sites of Eastern Health.
Outcome Measure:
A. VTE Prophylaxis
1. Number of surgical patients who develop PE/DVT/VTE.
B. Antibiotic Prophylaxis
1. Percentage of surgical patients who develop surgical site infections in targeted
populations.
C. Safe Surgery Checklist
1. Percentage of surgical patients who experience a preventable operative
complication.
2. Percentage of near misses identified.
Process Measures:
A.
1.
2.
3.
VTE Prophylaxis
Percentage of protocols developed.
Percentage of appropriate patients who received appropriate VTE prophylaxis.
Percentage of patients who were not appropriate for VTE
B.
1.
2.
Antibiotic Prophylaxis
Percentage of antibiotics given within 0 – 60 minutes of incision.
Percentage of antibiotics stopped as per protocol.
C.
1.
2.
Safe Surgery Checklist
Percentage of adapted checklists approved and implemented.
Percentage of compliance with three components of the checklist.
Balancing Measure:
A.
VTE Prophylaxis
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B. Antibiotic Prophylaxis
1. Percentage of surgical patients who receive appropriate antibiotic prophylaxis
who develop antibiotic related occurrences (e.g. c. difficile).
C. Safe Surgery Checklist
Change Ideas:
What Changes
can we try/test
to see if they
will lead to an
improvement?
Manage Variation
Resources:
People
Executive Sponsor:
Ms. Pat Coish Snow, Vice President, Adult Acute Care
Project Team Leads:
Ms. Elaine Warren, Regional Director, Surgical Services (Surgery)
Ms. Maria Tracey, Regional Director, Surgical Services (Perioperative)
Project Steering Committee Team:
Ms. Elaine Warren, Regional Director, Surgical Services (Surgery)
Ms. Maria Tracey, Regional Director, Surgical Services (Perioperative)
Dr. Rod Martin, Chief of Surgery
Dr. Jim Flynn, Chief of Anaesthesia
Dr. Darryl Boone,
Dr. Jeremy Pridham,
Ms. Dale Nixon, Quality and Safety Leader
Ms. Donna Ronayne, Regional Manager, Infection Prevention and Control
Project Team
Names
Roles and Responsibilities
Elaine Warren and Maria Tracey
Process Owner (Manager)
Dale Nixon and Lynnette Woodrow
Quality Improvement Support
Glenda Tapp and Joanne Peddle
Clinical Champion
TBD
Physician Champion
Michelle Cantu and Gail Wells
Clarenville Members
Linda Drover/ Leslie Ann Rowsell
Burin Members
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Tonya Somerton/ Karen Hanley
Carbonear Members
Diane Parsons
Women’s Health
Michelle Cooper and Darlene Osmond
Children’s Health Members
Infection Prevention and Control
Members
Aims must be fully implemented across the Regional Surgical Services Program by
September 2014.
Existing Financial Resources:
 In-kind resources (e.g. personnel, library services, conference calling
capabilities).
Roles and Responsibilities:
 Sharing context knowledge, skill and experience.
 Communicating and developing a shared understanding within the team of
the processes to be improved or changed.
 Testing change ideas within the team and in the real work context.
 Leading and supporting coworkers to adapt the new process.
 Completing tasks or assignments within and between meetings.
 Establishing two-way communication with their colleagues and the team.
 Facilitating the use of improvement tools and techniques.
 Monitoring and facilitating healthy team behaviours.
 Providing technical expertise and guidance focusing on team process.
 Supporting the team leader to plan effective team meetings.
 Assisting with measurement for improvement, e.g. data collection, analyzers
and display.
 Learning and sharing new skills from and with each other.
Donna Ronayne/ Lorilee Kelly
Resources: Time
Resources:
Financial
Team
Commitments
and Principles
for working
together
Constraints
Executive
Sponsor (ES)
Commitments
Principles for working together
 Consult with Atlantic Node proactively and as needed (before team gets
overwhelmed). Demonstrate mutual respect, seek out and listen to other
team member’s perspectives.
 Hold regular meetings with minutes prepared.
 Have a communication plan to reflect issues, discussion points, action steps
and responsibilities.
 Share the workload.
 Include other interested partners that we identify.
 Share successes with each other, the site, and the organization.
 Start small with our PDSA cycles and bite off manageable pieces, unit by unit if
necessary.
 Connect and consult with FFLS Faculty through scheduled team calls.
Identification of resources for collection and analyzing data is an immense challenge.
Roles and Responsibilities:
 Clarifying the improvement mandate and aligning it within the organization’s
strategic and operational objectives.
 Connecting and communicating with appropriate stakeholders.
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Role of ES is to
remove barriers
and free up
resources for
team to
succeed.
Team Lead
(Process Owner)
Measurement
Lead
Team Members
Commitments
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Allowing time and other resources.
Establishing an accountability mechanism.
Facilitating the work of the team within the larger organization.
Engaging a team leader and a coach.
Roles and Responsibilities:
 Completing and clarifying the team charter in a manner that ensures the
support of team members and team sponsor.
 Organizing and running effective meetings and maintaining team records, i.e.
minutes, correspondence, improvement data.
 Facilitating work within the team and ensuring participation at and between
meetings.
 Communicate about the improvement work with the sponsor, team members,
stakeholders, and the larger organization.
Roles and Responsibilities:
 Ensure that data is collected and submitted consistently to Safer Healthcare
Now!
Team meetings will be held using teleconferencing or webinar technology.
Team meetings will be scheduled monthly and decisions will be made by consensus.
A communication plan will be developed to facilitate communication within the team
and to stakeholders.
Draft Terms of Reference
Purpose
The project team will develop, implement, and evaluate this project.
Functions of the Committee
 Identify existing resources
 Complete environmental scans as needed
 Identify best practice
 Plan, develop, implement, and evaluate the project
 Act as champions during project
Meetings
 The team will meet monthly.
 The team will participate in the collaborative learning series every 2 months.
 Special meetings, if required, will be called by the co-leads.
Agenda
 The agenda will be prepared and distributed to all members prior to the
meeting.
Records
 Minutes will be taken and circulated to the group within 1 week of meeting.
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Deliverables and
Key Milestones
A. VTE Prophylaxis
Deliverables/Key Milestones
Date Start
Date End
Date Start
Date End
Date Start
Date End
Implementation plan (including communication
and evaluation plans) developed and approved
Establishment of regional working group
Development of surgical subspecialty specific
VTE prophylaxis protocols and order sets
Approval from appropriate committee
structures, including Regional Surgical Services
Committees
Implementation
Evaluation
B. Antibiotic Prophylaxis
Deliverables/Key Milestones
Implementation plan (including communication
and evaluation plans) developed and approved
Development and approval of pediatric
antibiotic prophylaxis guidelines
Development and approval of regional policy
Implementation
Evaluation
C. Safe Surgery Checklist
Deliverables/Key Milestones
Implementation plan (including communication
and evaluation plans) developed and approved
Establishment of regional working group
Development of standardized, adapted SSCL for
all sites
Approval from appropriate committee
structures, including Regional Surgical Services
Committees
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Implementation
Evaluation
Communication
Plan
Communication Strategy
Stakeholders
Internal Stakeholders
 VP of Acute Care
 Program Leadership
 Division Managers
 Employees: Clinical, Support
 Physicians
 Professional Networks
External Stakeholders
 Patients/Families
 Public/Community-at-large
 Key Community Groups (e.g. family physicians)
 Department of Health and Community Services
Tactics
Target Audience
Vice President of
Acute Care
Program Leadership
Division Managers
Topic
Communication Tool /
Tactic
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Employees
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Timeline
Department Reports
Email
Leadership Meetings
Department Reports
Email
Leadership Meetings
Department Reports
Meetings
Email
Departmental
Newsletters (Loop)
Intranet / Internet
Shared Quarterly
Reports
Cognos
Letter
Flyer/Brochure
Question and Answer
Forum
Poster
Intranet
Email
Paystub Inserts
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
Meeting
Schedule:
Departmental
Newsletters (Loop)
 Bulletin Boards
 Orientations
 Meetings
 Break Rooms
 Education Days
Physicians
 Letter
 Flyer/Brochure
 FAQs
 Physician Lounges
 Departmental
Newsletters (Loop)
 Tabletops
 Media
 Email
 Internet/Intranet
 EH Physician Listserv
 EH Physician Portal
Patients
 Flyer/Brochure
 Tent Cards
 Posters
 Connect issues they
have access to
 Bulletin Boards
 Display Kiosks
 Patient Rooms
 Media
 Gift Shop
Public/Community PSA
at-large
 Media
 Emails
 Internet
Key Community
 Letters
Groups
 Email
 Media
 Internet
Department of
 Letters
Health and
 Email
Community Services
 Media
 Internet
Collaborative Learning Series Meetings have been scheduled for every 2 months.
Learning Series 2: January 18, 2012
Learning Series 3: March 06, 2011
Learning Series 4: May 16, 2012
Learning Series 5: July 11, 2012
Learning Series 6: September 12, 2012
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Team Meetings will be scheduled monthly.
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