A CSSI project

Oregon hospitals take aim on improving surgical outcomes

Sometimes lives are saved by evolutionary changes in health care. A slight tweak in the way things have always been done. A small hospital in a small town heartily embraces a change that will make no headlines, but means a great deal to the patients scheduled for surgery there.

Such a change is happening at Silverton Hospital. Silverton is among the Oregon hospitals—over 75 percent of them—that are adopting the Surgical Safety Checklist developed by the World Health Organization (WHO).

It’s been estimated that if every hospital in the United States followed suit, the reduction of complications and preventable death could save the country up to $40 billion each year.

The checklist is a deceptively simple concept: At certain points in a surgery, team members verify verbally that they are performing the right procedure on the right part of the right patient. They confirm with each other that the team is prepared for difficult situations that may come up. They make sure they are in agreement on key post-operative issues.

But it really is deeper than marking items on a list.

“It’s a process of getting used to a different way of interacting,” says Leslie Ray, PhD, RN, field coordinator for the Oregon Patient Safety Commission. “And that’s not a trivial thing to ask of folks.”

The Surgical Safety Checklist is akin to the aviation industry’s Cockpit (or Crew) Resource Management (CRM). Both are really changes in team communication and collaboration.

In the late 1970s, analyses of airline disasters showed that flight crews were unwilling to challenge the authority of the pilot. Sometimes there were fatal consequences, including the collision of two Boeing 747s in 1977 in the Canary Islands Tenerife and the 1978 crash of United Airlines Flight 173 in east Portland. Cockpit Resource Management allows flight crew members to raise questions and concerns without fears of repercussions.

Checklist is a state priority

In Oregon, surgical checklists have been used in one form or another, Leslie says. But records continued to show that that adverse incidents continued to occur because checklist procedures weren’t followed, she says.

“That’s why the Oregon IHI network has been working so hard to move the Oregon Surgical Safety Checklist across the state,” Leslie says.

The Oregon IHI Network consists of organizations that have pledged to implement quality improvement measures promoted by the Institute for Healthcare Improvement. The network includes Acumentra Health, CareOregon, Oregon Association of Hospitals and Health Systems, Oregon Medical Association, Oregon Nurses Association, the Oregon Patient Safety Commission and the Oregon Rural Healthcare Quality Network. The IHI Network collaborated with the Columbia River Region Chapter of the Association of Perioperative Registered Nurses (AORN) and the Metro Area Surgical Services Management Organization to develop an Oregon Safe Surgical Checklist.

Silverton Hospital's Surgical Safety Checklist implementation team includes Andrea Beyer, Judy Borgen, Miriam Shelton, Ray Willey and Pam Kloft. Photos courtesy Silverton Hospital

The WHO checklist, is organized in three phases and requires the surgical team to review several elements at these three critical times: (A) before induction of anesthesia, (B) before skin incision, and (C) after the surgery, but before the patient leaves room. First, the Oregon group added best practices identified by the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations interested in improving surgical care by working to reduce surgical complications. Second, working with the AORN group, the checklist was revised based on recommendations from the them which included procedures required for hospital accreditation.

• A printer-friendly PDF of the Oregon Surgical Safety Checklist is available here.

Surgical safety at Silverton Hospital

Creating the checklist was the easy part. Harder is to get the training and resources to make the change.

At Silverton Hospital, the transition has been supported by CareOregon’s Care Support and System Innovations program (CSSI). This year, seven hospitals are completing improvement projects through CSSI. Three—Silverton, Willamette Falls and Tuality—are working on surgical checklists.

The teams from these hospitals have gotten together to share information, says Betty Campbell, CSSI Program Coordinator. Each has taken an approach suitable for its own situation.

• Willamette Falls started by learning Crucial Conversations, a trademarked approach to communicating when stakes are high.
• Tuality began by surveying staff on patient safety. Its surgical teams are adopting the checklist one phase at a time.
• Silverton has been using a pre-procedure checklist since 2003. Now it is using a methodical approach to educating and implementing a list they’ve updated with the WHO surgical checklist.

Silverton’s team includes Ray Willey, director of Quality Risk Services.

Ray credits team members Andrea Beyer, RN, BSN, and Miriam Shelton, RN, MSN, for developing education tools that were critical to the change.

Miriam developed web-based training based on SCIP which all staff members completed before the checklist was implemented. Andrea worked with Judy Borgen, RN, BSN, the assistant manager of Surgical Services, and also a team member, to redesign the surgical documentation process to streamline it and make it consistent with the checklist.

Andrea used a variety of process improvement tools and education to learn from and inform the surgical teams.

Generating a lot of interest was a series of posters designed for the non-physician different members of the team.

“We did some brief case studies,” Andrea says. “We would describe a particular surgical situation on posters we’d hang in the lounge, on bathroom doors, wherever, then ask a question about it.”

The poster might ask people to identify three variations from the SCIP protocols in the scenario.

“It brought a LOT of discussion, and that’s what I was hoping for,” Andrea says. Even some of the surgeons provided answers.

“I thought it was a really effective way to bring people together,” she says.

Surveys before and after implementation measured and guided progress.

“The main point I took from the initial survey before the checklist was that the staff thought they needed more of a pause, more time to communicate with other staff members,” Andrea says. “On the follow-up survey, they felt more of a team consensus. They felt they could communicate more within the team, that they had been heard from before the surgery, and it was more organized.”

Mark Rowley is the checklist's physician champion at Silverton Hospital

Key was having the support and guidance of the Surgical Services Manager Pam Kloft, RN, who is the team “coach.” She facilitated critical communication between the surgeons and the team. Also important was having the support of hospital and physician leadership. Dr. Mark Rowley, the Surgery chair and a member of the quality improvement team, piloted the checklist in his operating room.

“It was nice to kick it off there, because he had been involved in our meetings, was aware of it and was very positive,” Andrea says. “It went more smoothly for people to see a surgeon who was excited and proactive about the checklist.”

Silverton started the process in April, conducted the first surgery using the checklist in June and now all high-volume surgical teams are using it (a PDF of the Silverton Hospital checklist is here). Other surgeons with a lower volume of procedures are being schooled. The hospital is looking to expand into the Family Birth Center operating room.

Silverton’s team is now monitoring outcomes. It’s still too soon for results from several measures, but observational audits show good use of the checklist.

One concern hospitals and surgeons typically have is that the checklist will add too much costly time to the procedure. Silverton’s experience is that additional time needed is miniscule, perhaps a minute or two.

Presentations to be made at CSSI Conference

Silverton hopes to have more data from its outcomes measures when they team presents at the annual CSSI Conference in a few months. Reports from Willamette Falls, Tuality and the other hospitals and clinics participating in CSSI this year will also be presented.

About the WHO Surgical Safety Checklist
In analyzing the effectiveness of the checklist, researchers gathered data from eight hospitals around the world, for nearly 8,000 patients who’d had surgeries. For comparison, about half the data was for procedures completed before the checklist was adopted.

The hospitals included those in low-income countries as well as in high-income countries (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, Wash.).

The rate of complications from the surgeries fell from 11 percent to 7 percent, and the death rate was cut nearly in half, from 1.5 percent to 0.8 percent.

More on the checklist is available in The Wall Street Journal and an article on the effectiveness research has been published in The New England Journal of Medicine.

Oregon’s Surgical Safety Checklist

As of December 2009, 58 Oregon hospitals are performing surgical procedures.

Of the 48 that have provided information to the Oregon Patient Safety Commission, 39 are using a surgical checklist based on the WHO model.