DepartmanTarih

IMPROVING COMPLIANCE WITH “SAFE SURGERY CHECKLIST” PROCESS;

A MULTIDISIPLINARY IMPROVEMENT PROJECT

Hisam Alahdab MD, FCCP

Deputy CMO

Anadolu Medical Center, Kocaeli, Turkey

Performance Indicator of Safe SurgeryJune 2014: 89%

1. Pre-procedure Checklist completion: 100%

2. Timeout documentation: 57%3. History Physical completion before surgery: 98%

4. Informed Consent completion before surgery: 99%

2

PDSA: Do / Study Phase: Data Collection and Analysis 1. Low compliance with time out standards: % 57

2. Focus group and personal interviews: Qualitative data

Multiple disciplines involved: Surgeons, anesthesists, nurses and safetyand quality team.

The root causes were defined as:

a. Documentation has both electronic and manuel phases causingconfusion.

b. Forms used are sophistcated with multiple non value addedquestions.

c. Using electronic forms leading to difficulty to do the time out aroundthe operation table.

3

PDSA:

Improvement Actions• Simplification of the forms

• Combination of multiple forms to reduce handoffproblems and improve communication.

• Moving to manual forms to prevent variation andestablish bedside time out.

• Same actions were taken for time out process outsideOR

All the revisions and improvements were done according toWHO, JCI and MoH criteria for safe surgery

4

Old version

528.10.2016

28.10.2016 6

New version

7

Data Analysis and Improvement

8

Data Analysis and Improvement

9

Tracking of Sustainability of Improvement

Ongoing data monitoring and reporting:Time out compliance indicator collected and reported to the

quality council and senior executives

10

PDSA: Action for the next PDSA cycle to do Department Spesific Improvements

The Problem

We encountered a near miss: Wrong site surgery problem in orthopedics

11

Wrong side knee was about to be operated on but did not happen:

Root causes:

• Variations in the way site marking was done (although the rules areclear)

• Poor-compliance with the time out process: The surgeon not askingthe questions loudly, absence of some members of the team duringTime out

• Operators more obsessed with documentation rather then practice

• Lack of standard practice for anti DVT stockings when lowerextremity surgery is planned.

12

PDSA Cycle-2: Do / Study Phase:Root Cause Anlysis

Actions:• Spesific case based educational session for orthopedists

• Stockings are to be applied in the OR before surgery(not on the wards). This is to help uncover the site mark

• Emphasis on the importance of the presence of all teammembers during time out. The Anesthesists were giventhe right not put the patient into sleep until propper Timeout is performed.

• The importance of observations and individual feedback

13

PDSA Cycle-2: Study / Action Phase

Data analysis and assessement

14

Complete Compliance with Time out Checklist(Quarterly data from patients records)

Tracking of Sustainability of Improvement

Ongoing data monitoring and reporting:Time out compliance indicator spesific to orthopedics

collected and reported to the quality council and

senior executives

15

Lessons learned

• Engagement of frontline staff is essential to findapplicable solutions and improve compliance

• Get rid of wastes, be simple and straight to the point

• Tools should rather facilitate communication among caregivers

• Look for the solution at the place of the problem

• Continuous improvement

16

DepartmanTarih

Thank You

hisam.alahdab@anadolusaglik.org