Introducing the Checklist 101: Hard Lessons Learned From Life

1. Introducing the Checklist 101:Hard Lessons Learned From Life Bill Berry, MD, MPH Sunil Eappen, MD Lizzie Edmondson

2. Topics Safe Surgery 2015: South Carolina Keys to introducing the checklist Monitoring the checklist at your hospital The call series Your involvement in checklist implementation Next steps

3. Safe Surgery 2015: South Carolina By the end of 2013 every patient undergoing surgery in the state will have a modified version of the checklist used during their operation.

4. The Checklist How many of you know the background of the WHO Surgical Safety Checklist? How many of you are using a modified version of the checklist at your hospital? How many of you tried using the checklist at your hospital, but weren’t able to get others to do it?

5. CEO Participation We asked your CEO to do the following: Engage Executive Leadership Gain the endorsement of the Hospital Board and Medical Executive Committee Meet with clinical leadership to ensure that they are committed to working on this project Identify individuals that will serve as the checklist implementation team in collaboration with clinical leadership

9. Keys to Introducing the Checklist

10. Make an Implementation Team Nursing Administration Anesthesia Surgery

11. 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

12. Start Small – Make Mistakes Small Only expand when you are ready Do not tie yourself to a firm timeline – be flexible Keep pressure on yourself to move forward but remember . . . .no preconceived plan ever survives contact with reality

13. Preparation is Everything Careful preparation is much easier than repairing the damage of moving too quickly

14. Modify and Trial the Checklist Modify the checklist (Tips on next slide) Practice using the checklist outside of the OR and modify as needed Use the modified checklist in one case with one enthusiastic team • Each team member should be engaged and briefed ahead of time – make sure you talk to everybody Debrief and modify the checklist as needed Use the checklist for one day in every case with the same team Debrief and modify as necessary

15. Modification Tips – The Basics • One size doesn’t fit all • Can create buy-in • Remove items that are adequately checked and measured by established safety systems • Don’t remove teamwork items: • Introduction of team members by name and role • All items in the briefing and debriefing sections

16. Focused Avoid adding too many items: • Each section should have 5-9 items • Only add items that are not adequately checked by other mechanisms

17. Brief Each section should take < 1 minute The checklist should never take longer than the procedure

18. The Goal is Two-Fold To improve the performance of processes in the OR that every patient should have done To improve communication and teamwork in the OR

19. Don’t Modify

21. " “Will everyone please state name and role?” "Confirm all team members have introduced themselves by name and role” "We'll start by introducing ourselves and our roles” "Team members introduced themselves by name and role" "Confirm all team members have been introduced and actively participate"

22. Surgeon says: “If anyone on the team sees something that the team should know about, please speak up” Surgeon declares: “If anyone on the team sees something that the team should know about, please speak up anytime during the procedure Surgeon states,“ Remember that all are free to voice any concerns at any time throughout the procedure” Surgeon states, “If you see, suspect, or feel that patient care is compromised, will you speak up?” Surgeon states, “Remember that all are free to voice any concerns at any time throughout the procedure” Surgeon states, “Does anyone have concerns? If you think there is a problem, please speak up”

23. When We Use the Checklist: Does the entire team stop all activity at the three critical points in care? Does the team verbally confirm each item on the checklist? Are the items verified without reliance on memory? Does the checklist promote teamwork?

24. This is Not a Quality Improvement Effort That Can Be Meaningfully Accomplished By the Nursing Staff Alone Avoid the temptation to take the easy way out A checklist that becomes a tick box exercise is no checklist at all Do not count on an “IT” system or electronic documentation to make this effort a success

25. Educate. . .Educate. . .Educate In a “team” Everyone separately

26. “Everyone” Gets Personal Contact Mass emails do not suffice Talk to people • Peer to Peer • Nurse to Physician Do you have a good enough relationship to have this discussion? “Everyone” includes: • Anesthesiologists, CRNAs, Nurses, Scrubs, Surgeons, and techs Use a script to guide the discussion

27. Make A Video Film it in an empty OR Use someone's flipcam or camcorder Many videos are available online, but one from your own place has the most impact

28. Exempla St. Joseph Hospital Checklist Video

29. How NOT to Use the Checklist Video

30. Train and Use Coaches Same people can do observations Trusted and respected Best if known by most

31. Start Where It’s Easiest Use this rule at the beginning and all the way through Start with the “willing” Don’t try to fix problem staff and clinicians

32. Collect Stories Share stories when you educate Post the stories in a prominent shared space An “IHI” story

33. Advertise You cannot spread the word too much Support from the highest places is valuable Support from respected clinicians is essential

34. Monitoring the Checklist

35. Performance of Checklist Observation Tool

36. Performance of Checklist Observation Tool

37. Surgical Teamwork Observation Tool

38. Surgical Teamwork Observation Tool

39. Option 1: Monitoring the Checklist at Your Hospital BRING YOUR OWN DATA TOGETHER AND ANALYZE IT YOURSELF Use all or some of the tools to monitor your progress.

40. Option 2: Participate in a Research Study YOU WILL HELP US LEARN AND IMPROVE SURGICAL CARE WORLDWIDE Use the tools to collect data and send it to HSPH We analyze the data for you We benchmark the data to other SC hospitals No cost to you

41. Safe Surgery 2015: South CarolinaCall Series

42. Safe Surgery 2015: South Carolina Call Series Step by step instruction on checklist implementation from experienced faculty Office hours to work through barriers with individual hospitals Materials to assist with implementation Discussion of measurement tools and use Review of progress and opportunities to improve the implementation

43. Your Involvement as an Implementation Leader Participate on the call series, even if your hospital uses the checklist Coach individuals at your hospital on how to use the checklist Track your hospital’s use of the checklist Give us feedback

44. What Do You Do Now? Return to your hospital and see what steps your CEO has taken If needed help them build the checklist implementation team Schedule a large meeting to educate as many surgical personnel as possible – anytime after June 28th

45. Materials and Resources:www.safesurgery2015.org