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ACS NSQIP 30 Day Outcomes Supports Implementation of a Surgical Checklist

ACS NSQIP 30 Day Outcomes Supports Implementation of a Surgical Checklist. Changing Culture. Scott Ellner, DO, MPH, FACS Cynthia Ross-Richardson, MS, BSN, RN, CNOR Saint Francis Hospital and Medical Center University of Connecticut Integrated Surgery Residency May 21, 2012. Objectives.

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ACS NSQIP 30 Day Outcomes Supports Implementation of a Surgical Checklist

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  1. ACS NSQIP 30 Day Outcomes Supports Implementation of a Surgical Checklist Changing Culture Scott Ellner, DO, MPH, FACS Cynthia Ross-Richardson, MS, BSN, RN, CNOR Saint Francis Hospital and Medical Center University of Connecticut Integrated Surgery Residency May 21, 2012

  2. Objectives • Discuss the use of a validated safety attitudes questionnaire to understand behavior in the surgical environment • Discuss OR team training to change culture • Discuss the implementation and use of the AORN surgical checklist • Discuss the use of the American College of Surgeons National Surgical Quality Improvement Program to assess 30-day postoperative complications

  3. Demographics • 600 Bed tertiary care facility • Level 2 Trauma Center • UConn Surgical Residency • 8,000 General surgery cases/yr. • 30 Operating rooms ACS NSQIP since 2007 ACS TQIP since 2011 SFHMC Hartford, Connecticut

  4. Operating Room Team Circa 1914

  5. Operating Room Team Circa 2012

  6. Shame and Blame

  7. Evidence-based Risk-adjusted Data driven = Improved Surgical Outcomes American College of SurgeonsNational Surgical Quality Improvement Program Shukri F. Khuri, MD

  8. 30-Day Adverse Event Rate 3,314 General Surgery Cases Collected by 2010

  9. Post-Operative Urinary Tract Infections Observed Rate: 2.41% Expected Rate: 1.47% O/E Ratio: 1.64 Status:Needs Improvement 2009

  10. Patient Safety Project • Implementation and compliance with AORN (WHO) checklist • Pilot project 75 general surgery cases compared to historical controls to reduce post-operative 30-day complications as measured by NSQIP • Team Training Sessions to Change Culture

  11. Metrics/Outcomes • Reduce NSQIP 30 day post-operative outcomes • Urinary Tract Infection • Surgical Site Infection • Hospital Acquired Pneumonia • Thromboembolic events • Transfusion rate • No Retained Foreign Bodies • Assess Safety Attitudes – Likert Scale • Circulating Nurse Exits • Compliance with AORN Checklist • Qualitative Observations

  12. Identifying Culture Communication Behavior Rituals Tolerance

  13. Safety Attitudes Questionnaire

  14. SAQ Participants N=161

  15. Overall SAQ Results

  16. Pre-Training Observations of Team Communication • Language Barriers • Shared commitment • Assumptions • Efficiency • Interruptions • Side conversation • Multi-tasking • Complacency • Personal Issues • Workload/Staff fluctuation • Fatigue and stress • Disruptive behavior

  17. Why Team Training? • Enhances communication • Addresses improper behavior • Helps to build trust • Gives all employees a voice • Improves the overall safety culture • Encourages leadership

  18. Team Training Tool • Session 1 – Crucial Conversations • Session 2 – Getting What You Want: Communication Strategies That Help You Get What You Need • Session 3 – When the Going Gets Tough: Achieving a Positive Outcome

  19. Launch of Team Training Violence Safety Safety Pool of Shared Meaning Safety Silence

  20. Checklist Introduction

  21. Barriers • Complacency • Resistance • Exposing failures • Challenging years of • embedded culture • Compliance • Training • Uneasy Leadership

  22. OR Change Agents • OR Ambassadors • OR Observers • Executive Leadership

  23. Observed Qualitative Results Good Teamwork. Specimen sent to Pathology with follow-up during case Joking by surgeon at expense of female personnel No equipment malfunctions. Staff in room joined together to announce Time-Out and Debrief CRNA brought open cup of Coffee, raised sheet to cover view of anesthesia area Anesthesia initiating the Time-Out Patient paged overhead by surgical floor while in surgery No site marked for hernia. Circulator recognized and asked surgeon to mark.

  24. Quantitative Results N= 75 general surgery cases

  25. Post-Operative Urinary Tract Infections Observed Rate: 1.23% Expected Rate: 1.43% O/E Ratio: 0.86 Status: As Expected 2009 2011

  26. Post-Operative Pneumonia Observed Rate: 0.65% Expected Rate: 1.24% O/E Ratio: 0.52 Status: Exemplary 2009 2011

  27. Circulating Nurse Exits • Average 9 exits (4 hour case)* • Observed range 0-25 exits (average 3 exits) • Checklist Compliance 97% • Increase in the number of OR exits led to higher rates of patient morbidity *Christian et al. Surgery 2006

  28. Take Home Points • Acknowledge the need for change • Measure baseline attitudes – SAQ • Implement team training curriculum • Observe and audit checklist utilization • Recognize and address barriers • Provide resources for sustainability • Identify metrics to demonstrate change

  29. Thank You

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