Problem Addressed

• Highly variable care, leading to preventable complications: Many studies have documented high variability across institutions in the quality of care, including surgery.¹ The quality of surgical care can also vary widely within an institution.^3,4 Consequently, many patients undergoing surgery experience preventable complications. For example, roughly a fourth of patients undergoing major surgery who do not receive appropriate prophylactic treatment develop deep vein thrombosis (DVT), which can lead to a pulmonary embolism, long-term disability from venous insufficiency, and/or death.² An analysis of general surgery procedures in Washington state revealed that reducing variations in care could prevent 1,200 complications each year, thus eliminating the need for 7,000 to 8,000 hospital days and saving $30 million.³
• Poor communication as root cause: Ineffective communication and coordination among surgical team members is a major contributing factor to high complication and morbidity rates.⁵ Team training, which emphasizes communication, has been shown to reduce postoperative morbidity and mortality.⁶
• Few processes to ensure standardized care and communication: While the Institute of Medicine recommends use of systems to standardize care and communication,⁷ many hospitals lack the processes and tools to put these systems into everyday practice.⁸

Description of the Innovative Activity

• Team member introductions, initial discussion: The surgeon begins by asking team members to introduce themselves and explain their roles. The surgeon also invites all clinicians to contribute information relevant to their roles and to provide any feedback and/or raise any patient safety concerns they may have.
• Confirming patient identity, procedure, surgical site: The surgeon, anesthesia team, and nurses confirm the patient's identity (using at least two identifiers), the surgical site, the procedure, and the patient’s position on the operating table.
• Preincision, role-specific reviews of necessary preparations: Specific team members take responsibility for the following prior to incision:
  • Surgeon: The surgeon provides a brief description of the procedure, its expected duration, and any anticipated difficulties, and also notes any atypical instruments or supplies that may be needed. The surgeon also confirms that all needed process steps have occurred to prevent potential complications, including the following: that adequate intravenous access has been established if the risk of blood loss is greater than 500 mL, that all essential images have been displayed in clear view of the team; that the patient has been actively warmed, that glucose levels have been checked in diabetic patients (and insulin started if the glucose level is greater than 140 mg/dL), that postoperative beta blockers have been ordered, that DVT prophylaxis has been given, and that antibiotic prophylaxis has been administered within the past 60 minutes.
  • Anesthesia team: The anesthesiologist and anesthesia nurses discuss patient-specific concerns, such as airway issues, allergies, special medications, or health conditions that could affect recovery.
  • Surgical nursing team: The surgical nurses review patient concerns and ensure that all appropriate equipment and instruments are available and in working order (e.g., that oxygen tanks are full).
• Debriefing after completion of case: When the procedure ends, the surgeon and nurse confirm the following with the team: instrument, sponge, and needle counts (to make sure nothing has been inadvertently left inside the patient); a visual and manual check of the wound to confirm absence of foreign bodies; proper specimen labeling; special instructions for the pathologist (for example, to check at least 12 lymph nodes for colon cancer); the plan for postoperative beta blocker administration; any key concerns related to patient management and recovery; and any steps or actions that could have been performed more effectively during the surgery.

References/Related Articles

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Innovator Disclosures

Results

Results From the University of Washington Medical Center

• Fewer reoperations and complications: The percentage of colectomy patients requiring a reoperation declined significantly after implementation, from 7.8 percent to 3.4 percent. The percentage of colectomy patients requiring postoperative antibiotics or wound opening also fell significantly, from 22 percent to 9 percent.
• Greater adherence to recommended processes: Use of DVT prophylaxis on colectomy patients increased significantly, from roughly half of patients before implementation to 80 percent after. Similarly, use of anastomosis testing jumped from 11 percent to 94 percent of eligible patients after implementation.
• Positive clinician feedback: Qualitative results from a clinician safety attitudes questionnaire (administered before and after implementation) found that surgeons, anesthesiology teams, and surgical nurses believe the program improved team communication and coordination, their impressions of patient safety, and their comfort level in reporting safety concerns to colleagues. Nearly 9 in 10 respondents indicated that they would want the checklist-guided process used if they were undergoing surgery. Sample comments from the post-implementation survey are as follows:
  • “At first the checklist seemed somewhat burdensome due to its length. It now takes me about 1 minute to run through the list, which I don't think is at all excessive.”—general surgeon
  • “I was probably one of the most negative nurses at the start of this project because I thought it was just one more piece of paper to fill out. But now I find it very helpful, especially if the surgeon takes the lead and actively requests the participation of everyone in the room. ”—nurse
  • “In my opinion, the checklist is efficient and might prevent errors, because it allows team members to review the most pertinent features of the upcoming procedure.”—anesthesiologist

Results From WHO Surgical Safety Checklist Pilot⁹

• Fewer deaths: The surgery-related mortality rate fell from 1.5 percent before implementation to 0.8 percent after.
• Fewer complications: Surgery-related complications occurred in 7 percent of patients after implementation, well below the 11 percent rate at baseline. Surgical site infections also fell (from 6.2 percent to 3.4 percent), as did unplanned reoperations (from 2.4 percent to 1.8 percent).

Aggregated Results From Statewide Collaborative in Washington¹⁰

• Greater adherence to recommended processes: The percentage of eligible patients undergoing elective colorectal surgery who received DVT prophylaxis increased from approximately 60 percent to nearly 90 percent. Similarly, the percentage of patients undergoing surgery for colon cancer who had at least 12 lymph nodes removed increased from roughly 57 percent to 82 percent. (At least 12 lymph nodes in the supporting tissues near the cancerous growth should be removed to determine metastasis and the need for chemotherapy.)
• Fewer reoperations: The percentage of colorectal surgery patients requiring a second surgery fell from nearly 7 percent to below 4 percent after implementation.
• Lower LOS: Lower complication rates led to a decline in LOS for colon resections (from 8.5 days to 7.5 days) and gastric bypass surgery (from 3 days to 2 days).

Results From Multicenter Trial in the Netherlands¹¹

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining clinician buy-in: Dr. Dellinger presented the idea of participating in the WHO pilot project to the hospital’s general surgeons at their respective faculty meetings and described the checklist process to surgical nurses on various shifts.
• Creating, displaying checklist posters: Laminated, 2-foot by 3-foot posters of the checklist were made and displayed in all 22 operating rooms.
• Conducting pilot study: The medical center piloted the checklist-guided process between October 2007 and September 2008.
• Adopting program across hospital: Once the pilot ended, the general surgeons agreed to continue using the checklist-guided process in the department of general surgery; other surgeons also heard about the program and began using it themselves. After a presentation by general surgeons to the Surgical Services Steering Committee, the medical center’s chief executive officer, medical director, surgeon-in-chief, and anesthesiologist-in-chief agreed to use the checklist-guided process for all surgeries. To facilitate adoption, Dr. Dellinger attended faculty meetings of all surgical divisions to explain the program. By December 2008, hospital leaders mandated the use of the checklist-guided process for all surgical procedures.
• Expanding statewide: In early 2008, SCOAP developed the previously described initiative to spread the program throughout the state.
• Amending checklist: SCOAP amended the checklist to include additional care steps that should be reliably completed for every surgical case. Examples of such steps include checking blood glucose levels in diabetes patients, continuing beta blockers to reduce the risk of postoperative myocardial infarction, actively warming the patient, and administering venous thrombosis prophylaxis when indicated. SCOAP also removed certain items from the WHO checklist that were already being routinely adhered to by all hospitals in the state (and hence deemed unnecessary for inclusion), such as use of an oximeter during the procedure and several anesthesia-related steps.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: The hospital incurred minimal costs in developing or operating this program. Dr. Dellinger donated his time to program development, and the hospital paid for the creation of the 22 checklist posters (at a cost of approximately $30 each).

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Secure leadership support: Approach top hospital leaders (e.g., chief executive officer, medical director, vice president for health affairs) to seek their endorsement. Explain the initiative and provide any data demonstrating a meaningful impact on care quality and/or financial outcomes. As other clinicians and staff are introduced to the process, having the support of top leaders will emphasize its importance and promote adoption.
• Identify champion: A surgeon champion can highlight the merits of the checklist-guided process, ensure its appropriate use, review its impact, and spearhead periodic reviews and updates of checklist content. Identify a champion who would be willing to emphasize the value of the checklist during meetings and informal communications and ensure that colleagues are exposed to the tool and have opportunities to learn about its value. The champion can also effectively address any colleagues' concerns that arise.
• Pilot test approach: Start with a small group of surgeons committed to testing the process and measuring its impact.
• Involve all relevant clinicians: Surgeons should involve anesthesiologists, anesthesia nurses, and surgical nurses in developing the process.
• Incorporate new process into existing workflow: To ensure clinician support, incorporate the checklist-guided process into existing workflow. For example, at the University of Washington Medical Center’s Division of General Surgery, surgical teams decided to cover portions of the checklist during the Joint Commission–mandated preprocedure surgical “timeout.”
• Emphasize patient safety: Although most of the approximately 15 faculty members in the division of general surgery expressed strong enthusiasm for piloting the approach, one or two expressed reluctance to changing established work patterns. To win their support, Dr. Dellinger posed the following question: “How many of you sitting here would be willing to board an airplane knowing that the pilot was not going to go through his checklist before takeoff?” There were no volunteers. This was followed by, “How many of you think that having an operation is safer than flying an airplane?” By posing that question, Dr. Dellinger crystallized the importance of the program to patient safety and quickly obtained the full support of the two holdouts.

Sustaining This Innovation

• Share data: To encourage continued adherence to the checklist-guided process, measure and periodically share data documenting the positive impact of the program on both process and outcomes measures.

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