A Few Notes About This Presentation

• This presentation is designed to be given to a group of surgeons.

• We recommend that you hold this type of meeting after you have had a chance to have one-on-one conversations with some of your colleagues that might be skeptical.

• We have provided descriptions and some notes that might be helpful to you in the notes section of this presentation.

• We recommend that surgeon leader of the implementation team gives this presentation.

NoCVA Safe Surgery CollaborativePresentation - Surgeons

[ Insert Implementation Team Member Names][ Insert Hospital Name]

Insert Your Hospital’s Logo Here

Our Hospital’s Implementation Team

[insert picture of your checklist implementation team]

Could This Happen Here?

The Case• 45 year old with breast cancer.

• Elective mastectomy.

• Patient wants immediate reconstruction by plastic surgeon.

• General surgeon does mastectomy.

• Preference card is lost so instrument set not standard.

• Very small room.

• Scrub tech leaves because of family emergency.

• Circulator becomes scrub nurse.

More Facts

• Circulating nurse is now covering two OR’s. • Plastic surgeon comes into room “early”.• Wants to begin reconstruction before general

surgeons is finished.• Plastic surgeon “disruptive” saying procedure

going “too slow”.• General surgeon insists on completing the

mastectomy first.

What Happened Here

• The breast specimen was lost.• Surgeons had never worked together before

and did not talk before procedure.• No “plan” for how surgery was to take place.• Nursing staff very stressed by surgeons and

level of workload.• Complete system breakdown in processing

specimens.

What Could Have Helped?• Discussion among the surgical team, where the

following things were discussed prior to skin incision:– Surgeon shares the operative plan where s/he

discusses anything that the team should be aware of.– Team discusses the equipment that is needed for the

case.

• Discussion at the end of the case where surgical teams confirms specimen labeling.

Does anybody want to share something that has happened to

them?

NoCVA Safe Surgery Collaborative• To reduce surgical harm, aligned with Partnership for

Patients• To use of the Surgical Safety Checklist in every

operating room for every patient.• To customize the checklist for our hospital’s unique

needs.• To be part of a larger goal in partnership Safe

Surgery 2015 [Directed by Dr. Atul Gawande at the Harvard School of Public Health].

What is the Evidence?Type of implementation Scope of implementation Impact of

implementation

WHO Surgical Safety Checklist in OR 8 diverse global hospitals

• In-hospital mortality rate1: 1.5% 0.8%

• Post-op complication rate1: 11.0% 7.0%

Team training and use of briefing/ debriefing/checklists in OR

74 VA hospitals 18% decline in annual rate of mortality vs. 7% decline

in control group of hospitals

Comprehensive set of surgery-related checklists in hospital

including during surgery

6 'high-quality' Dutch hospitals

• In-hospital mortality rate: 1.5% 0.8%

• Post-op complication rate: 15.4% 10.6%

A Customized Version of the WHO Surgical Safety Checklist

Tertiary University Medical Center in the Netherlands

• Crude mortality decreased from 3.13% 2.85%.

• Measured checklist compliance and found that mortality was significantly lower in patients

with completed checklists.1. For 4 pilot sites located in developed countries (USA, Canada, UK, New Zealand), results were a decline in the in-hospital mortality rate from 0.9% to 0.6% and a statistically significant decline in post-op complication rate from 10.3% to 7.1%Source: Haynes, AB, et al, N Engl J Med 360:491-9, 29 Jan 2009; de Vries, EN, et al,N Engl J Med 363:1928-37, 11 Nov 2010; Neily, J, et al, J Amer Med Assn 304:1693-1710, 20 Oct 2010; 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.

Virginia Mason Hospital, Seattle

• In order for the Checklist to work well it has to be used “right”.

• Improving communication between all members of the OR team is critical to successful implementation.

2010 Annual Meeting of the American Society Anesthesiologists

Our Hospital’s Checklist

• [Insert your hospitals checklist]

How Did We Customize Our Checklist?

• Summarize items that you customized for your hospital.

Don’t We Already Do All of This?

• It is more than the time out and our usual safety checks.

• This is our chance to build on the time out and make it contribute significantly to every case.

• Encouraging a conversation at the beginning and end of surgery to improve communication.

• Providing structure and consistency so that every patient gets what they need every time.

Show Checklist Demonstration Video

• [Insert your hospital’s demonstration video or another video that you would like to show]

• If you do not have a video many hospitals have role-played using the checklist.

We are very good at what we do….We can be even BETTER

Makary et al., J Am Coll Surg 2006; 202: 746-52Makary et al., J Am Coll Surg 2006; 202: 746-52

We Are Not as Good as We Think

How Can the Checklist Help Us Be Better?

• It makes sure that we do the things that our surgical patients need every time.

• It improves communication, teamwork and the culture of safety in our hospital.

• Can make surgical teams more efficient – It has been known to save time.

Physician Acceptance is the Critical Factor in Successful and

Meaningful Use of the Checklist

HOW YOU ACT DURING THE TIME OUT/CHECKLIST MATTERS

• The Team is looking to you for leadership.• You are setting the tone for the rest of the

operation.• Others will follow your patterns of

communication.• This is an opportunity to make your plan clear,

answer questions, demonstrate openness and professionalism.

How Do We Feel in the OR

• Stressed• Focused• “It’s time to do the CHECKLIST”• “I don’t want to do it – I never did this before

– it makes me feel weird.”• “I am already safe - I don’t need to do it” • “Maybe the surgeon in the next room needs i

t”

How Do Anesthesiologists/CRNA’s Feel in the OR

• Stressed and focused

• “I don’t want to do it – I never did this before – it makes me feel weird – it messes up the way I work”

• “I am already safe - I don’t need to do it”

• “Maybe the team in the next room needs it”

• "Don't these other guys know what they're doing?"

• "Didn't we all just check this stuff? Or did they?”

• "If everyone had the attention to detail that I do, this would not be necessary”

• "Don't make me do another G*% D&#$ piece of paper!!”

• "If it doesn't take long, and we have to, well OK”

• "This really doesn't take that long, and if it keeps us all out of courtrooms. . ."

How Nurses Feel in the OR • “Before going into the OR I need to prepare my approach depending on

surgeon or team.”

• “I know when there will be a battle and I need to prepare my response.”

• “Try to stay positive during the surgical case, no matter what happens.”

• “We carry the load to ensure that the safety checks are completed.”

• “I don’t want to be the enforcer but sometimes need to be for patient safety.”

• “I am not the right person to convince a surgeon who refuses to do this.”

• “I feel shut down when there is not open communication.”

How Do Scrub Techs Feel in the OR• “I am part of the team and am responsible for patient safety as much

as everyone else.”

• “I don’t want to waste time fighting about this- I wish we could just do it!”

• “ I am ready to change my approach, depending on who I am working with in the OR.”

• “The majority of the team will listen and participate, but I may need to help remind the surgeons to follow policies.”

• “Willing to back up circulator and to take on equal responsibility to ensure that this is completed for my patient.”

• “I think that it is the right thing to do.”

• “If I were the patient I would want it done for me.”

The “Scrub Sink Trance”

“Reverence for Induction”

“Respect for the Counts”

Surgeons Can Make A Difference

• It is our responsibility to work to improve the safety and outcomes of our patients.

• We are not powerless to make change.• We are part of a surgical team and often in

the position of leading that team – that is a privilege and an opportunity to make a difference.

Teamwork

• Communication• Coordination• Team performance valued over individual

performance• Wise use of resources• Leadership

What Can You Do?

• Activate people by using their names.• Set the Tone – Make everyone feel “safe”.• Tell the team what you are going to do.• Encourage team members to speak up.• Stop to Debrief at the end of the case.

This isn’t just about one person and what they need. Everyone is in the room for the patient and all

of the people around you need your help, encouragement and leadership. Surgery is a team

effort and the most effective and safe surgeons recognize that.

Safety is staying back from the Edge

The Checklist can help you do that.

The Checklist Has Already Helped

• [insert examples of what the checklist has caught during the testing or how people feel about using the checklist.]

• Please see Talking to Your Colleagues – Presentation Guide and Tips Document.

Next Steps• We are administering a culture survey because we want to

know you think about the teamwork, communication, and safety in our operating rooms. Please complete the culture survey.

• Room-by-room and team-by-team implementation.• We are rolling the checklist out slowly over the next [insert #]

weeks. • We will talk to you and rehearse before we ask you to use it in

your room with a live patient.• After you start using the checklist we will assess teamwork in

the OR using an observation tool.

Our Plan

• [Insert your timeline for checklist implementation].

How Can You Help?

• Work with us on putting the checklist into your rooms.

• Talk to your colleagues about this project.• Give us feedback.

Contact Us with Questions & Feedback

[Insert person to contact, email and phone number]