Call 2:
Evidence Supporting the Use of the
Checklist and The Importance of the
Checklist Implementation Team
Topics Covered on the Last
Webinar
• Checklist Development and Background.
• Why South Carolina?
• The impact of the Safe Surgery 2015:
South Carolina on surgical safety globally.
• Going beyond the “Time Out”.
Meet the Team
Lorri Gibbons, RN, BSN, CPHQ
VP, Quality & Patient Safety
SCHA
Poll 1
• Are you using a surgical checklist that requires the
surgical team to stop and discuss critical items at three
points of time (Before Induction of Anesthesia, Before
Skin Incision, and Before the Patient Leaves the
Room)?
– Yes
– No
• If you answered yes, what percentage of surgical
cases are using this type of checklist routinely?
– <50%
– >50%
– It is used for every patient undergoing surgery
Today’s Topics
• A full review of articles that have been written
about the impact of the checklist.
• The importance of data to physicians and how to
talk to physician’s about data.
• Building a Checklist Implementation Team:
– Poll
– The role that this team plays
– Who should be on the team
– How often the team should meet
– How to find the “right” people to lead this work
A Full Review
of Evidence
Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Population. New England Journal of Medicine. 2009 Jan 29; 360(5):491-9.
International Pilot Study
8 Evaluation Sites - Nearly 8,000 Patients
PAHO I
Toronto, Canada
EURO
EMRO
London, UK
Amman, Jordan
WPRO I
Manila, Philippines
PAHO II
Seattle, USA
WPRO II
AFRO
Ifakara, Tanzania
SEARO
New Delhi, India
Auckland, NZ
Results – All Sites
Baseline
Checklist
P value
Cases
3733
3955
-
Death
1.5%
0.8%
0.003
Any Complication
11.0%
7.0%
<0.001
SSI
6.2%
3.4%
<0.001
Unplanned Reoperation
2.4%
1.8%
0.047
Survey of Attitudes to Checklist Use Among
Clinicians at Study Site (n=229)
The checklist was easy to use
78.6%
The checklist improved operating room safety
79.0%
The checklist took a long time to complete
18.3%
Communication was improved through use of the
checklist
The checklist helped prevent errors in the
operating room
If I were having an operation, I would want the
checklist to be used
84.3%
78.2%
92.6%
Haynes, A et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality
following implementation of a checklist- Based surgical safety intervention. BMJ Qual Saf 2011;20:102-107
Additional Evidence
de Vries EN, et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J
Med 2010; 363:1928-1937
SURPASS Checklist
The Netherlands
• 100 item checklist implemented in 6 high
performing hospitals
• Compared to controls the test hospitals
had a greater than one-third reduction in
complications and achieved an almost
50% reduction in deaths (from 1.5% to
0.8%)
(N=7,580)
de Vries EN, et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363:1928-1937
Neily J, Mills PD, et al. Association Between Implementation of a Medical Team Training
Program. JAMA. 2010 Oct 20;304(15):1693-700
Veterans Health Affairs
• Implemented a surgical team training
program incorporating a modified version
of a surgical checklist in the operating
theatres of 74 facilities
• Experienced initial mortality reduction of
18%1
• One year later, facilities that participated in
the program experienced a risk-adjusted
morbidity reduction of 17% versus 6%2
1. Neily J, Mills PD, et al. Association Between Implementation of a Medical Team Training Program. JAMA. 2010 Oct
20;304(15):1693-700.
2. Young,Xu Y, et al. Association Between Implementation of a Medical Team Training Program and Surgical Mortality. Arch Surgery.
2011. Dec; 146(12):1368-73.
van Klei WA et al. Effects of the Introduction of the WHO “Surgical Safety Checklist” on
In-Hospital Mortality. Annals of Surgery. 2012 Jan 1; 255(1):44-9.
University Medical Center
Utrecht, The Netherlands
• 25,513 adult patients undergoing non-day
surgery.
• Used hospital administrative data and patient
medical records.
• Crude mortality decreased from 3.13% to
2.85%.
• Measured checklist compliance and found that
mortality was significantly lower in patients
with completed checklists.
van Klei WA et al. Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality. Annals of Surgery. 2012
Jan 1; 255(1):44-9.
Takala, R.S.K. et al. A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities
and communication. Acta Anaesthesiol Scand. 2011. Sep 26 (55): 1206-1214.
Finland Study
Four Teaching Hospitals
• Implemented a modified version of the WHO
Checklist
• Studied the impact on communication and processes
by surveying surgical teams pre and post
implementation
Discussion of Critical Events Pre Operatively
Pre Implementation
P < 0.001
Post Implementation
Anesthesiologist
Surgeon
Anesthesiologist
Surgeon
22%
35%
43%
46%
N=1,748
Takala, R.S.K. et al. A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities
and communication. Acta Anaesthesiol Scand. 2011. Sep 26 (55): 1206-1214.
Bliss LA, et al. Thirty-Day Outcomes Support Implementation of a Surgical Safety
Checklist. J Am Coll Surg. 2012 Aug 27.
600-Bed Tertiary Care Facility
in the Northeast US
• Three 60 minute team training sessions
• Use of checklist in high-risk general surgery cases
(73 cases)
• Checklist completion rate >90%
• Checklist use was correlated with decrease in all
measured areas of 30-day morbidity
Bliss, LA et al. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist. J Am Coll Surg. Available online
August 30, 2012.
Stanford University,
United States
• O/E Mortality declined from .88 to .8
• The total number of reported events rose;
however, those that were attributed to
errors/complications decreased from 35.2% to
24.3%
• Mean OR start to incision time was shorter
• There was improvement in the belief (SAQ) that
all personnel take responsibility for patient safety
(N=12,247)
Tsai, Thomas et al. Does a surgical safety checklist improve patient safety culture and outcomes? [Abstract]. In: American
College of Surgeons Annual Clinical Congress. 2010 October 3-7; Washington D.C. Journal of American College of Surgeons.
Truran et al. Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines? The Surgeon
9 ( 2 0 1 1 ) 3 0 9e3 1 1
Semel, ME et al. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff
(Millwood). 2010 Sept; 29 (9);1593-9
Shauna L. et al. Implementing a surgical checklist: More than checking a box. Surgery, 2012 Sep; 152. 331-6.
What Does the Evidence
Mean to Physicians?
There Will
Never Be The
Perfect Study
Evidence
“Driven”
Behavior
Believing
Physician Engagement Observed During a
Surgical Checklist Implementation
Building an Implementation
Team
Poll 2
• Are you listening to the call as a group or
an individual?
– Group
– Individual
Make an Implementation
Team
• Administrator/Quality Improvement Officer
• Anesthesiologists and/or CRNA
• Circulating Nurse
• Scrub Tech
• Surgeon
• Others (Perfusionists, PA’s, Biomedical
Engineers, Anesthesia Techs, Pre-op
nursing, etc)
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.
Recommendations on How Often
and When to Meet as A Team
• Meet regularly.
• Choose someone to organize the meeting
schedule and be a point of contact for people
in your hospital and our team.
• A good time to meet together would be
following each webinar.
• It is better to meet with part of the group than
not at all.
• Your physician champions don’t have to be
part of every meeting.
What Should You Tell
Checklist Implementation
Team Members
This team will be responsible for the following tasks:
– Administering the culture survey
– Modifying and customizing the checklist
– Guiding small scale testing of the checklist
– Devising the implementation plan
– Educating and training clinicians to use the
checklist
– Coaching teams on continued use of the checklist
– Regularly report progress to hospital administration
Homework
• Think about who you are going to have on
your checklist implementation team.
• Please contact Katie Jahreis to administer the
culture survey kjahreis@hsph.harvard.edu.
Questions
Next Webinar:
November 29th, 2012
2:00-3:00
• An in depth discussion of why each
item is on the South Carolina
Checklist Template.
• Overview of what is to come in Part II
and upcoming events.
Office Hours:
Wednesday 2:00-3:00
We Will Be Sending You An
Email With:
• A comprehensive bibliography of all of the
evidence that has been published on the
checklist.
• An article that is a literature review of how
the checklist has been shown to improve
teamwork and communication in the OR.
• A link to watch the recording of today’s
webinar and to download today’s slides.
Resources
Website:
www.safesurgery2015.org
Email:
safesurgery2015@hsph.harvard.edu