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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 • 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 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 Operating Room Team Circa 1914 Operating Room Team Circa 2012 Shame and Blame American College of Surgeons National Surgical Quality Improvement Program • Evidence-based • Risk-adjusted • Data driven = Improved Surgical Outcomes Shukri F. Khuri, MD 30-Day Adverse Event Rate 3,314 General Surgery Cases Collected by 2010 25% 20.14% 20% 15% 10% 7.61% 5% 6.74% 3.33% 2.81% 0.99% 0% All 30-day Morbidity DVT/PE HAP SSI Transfusion UTI Post-Operative Urinary Tract Infections Observed Rate: 2.41% Expected Rate: 1.47% O/E Ratio: 1.64 Status: Needs Improvement 2009 Patient Safety Project • Implementation and compliance with AORN (WHO) checklist • Pilot project 75 general surgery cases compared to historical controls to reduce post-operative 30day complications as measured by NSQIP • Team Training Sessions to Change Culture 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 Identifying Culture Communication Behavior Rituals Tolerance Safety Attitudes Questionnaire 12. In the OR, it is difficult to discuss errors. 1 2 3 4 5 N/A 21. The culture in the ORs here makes it easy to learn from the errors of others. 1 2 3 4 5 N/A 46. All the personnel in the ORs here take responsibility for patient safety. 1 2 3 4 5 N/A SAQ Participants N=161 Overall SAQ Results 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 Why Team Training? • Enhances communication • Addresses improper behavior • Helps to build trust • Gives all employees a voice • Improves the overall safety culture • Encourages leadership 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 Launch of Team Training Violence Safety Pool of Shared Safety Meaning Safety Silence Checklist Introduction Barriers 1) 2) 3) 4) Complacency Resistance Exposing failures Challenging years of embedded culture 5) Compliance 6) Training 7) Uneasy Leadership OR Change Agents • OR Ambassadors • OR Observers • Executive Leadership Observed Qualitative Results Good Teamwork. Specimen sent to Pathology with followup 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. Quantitative Results N= 75 general surgery cases 25% 20.14% 20% 15% 10% 7.61% 6.85% 5.48% 5% 0.99% 0.00% 6.74% 3.33% 2.74% 2.81% 0.00% 0.00% 0% All 30-day Morbidity DVT/PE HAP Pre-Intervention SSI Post-Intervention Transfusion UTI Post-Operative Urinary Tract Infections Observed Rate: 1.23% Expected Rate: 1.43% O/E Ratio: 0.86 Status: As Expected 2009 2011 Post-Operative Pneumonia Observed Rate: 0.65% Expected Rate: 1.24% O/E Ratio: 0.52 Status: Exemplary 2011 2009 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 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 Thank You