THE SURGICAL SAFETY CHECKLIST;

RHETORIC….. OR ARE WE MAKING A

DIFFERENCE?

OCTOBER 8, 2014

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Before We Get Started

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Discuss the role of communication and

team work in patient safety

Review current data and state of the

SSCL

Discuss and define how we can

measure the effectiveness of the SSCL

Followed by…..interactive discussion

Objectives

Our Guest Speakers:

Dr. Giuseppe Papia

Dr. Michael Leonard

Dr. David Urbach

Ms. Marlies van Dijk

Surgical Safety Checklist

Who Alliance for Patient Safety:

October 2004

Platform to promote Patient Safety

Initiatives

Global Patient Safety Challenges

2005 Clean Care is Safer Care

2007 Safe Surgery Saves Lives

Surgical Safety Checklist

Safe Surgery Saves Lives Campaign:

Improve safety of Surgery across the

globe

Reduce the number of surgical

complications

Reduce the number of surgical deaths

SSCL

No one can stop an

idea whose time has

come

-Voltaire

Between the healthcare

we have and the

healthcare we could have

lies not just a gap, but a

chasm.

Crossing the quality Chasm (IOM)

The Role of Culture and

Teamwork in Safe & Reliable

Surgical Care

Michael Leonard, MD,

Adjunct Professor of Medicine, Duke University

Safe & Reliable Healthcare LLC

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UNMINDFUL “We show up, don’t we?”

Chronically Complacent

REACTIVE “Safety is important. We do a lot every

time we have an accident”

SYSTEMATIC Systems being put into place to manage

most hazards

PROACTIVE “We methodically anticipate”—

prevent problems before they occur

GENERATIVE Organizational Culture “Genetically-

wired” to produce safety

Where is Yours?

Safety Cultures Evolve

Attribution: Prof. Patrick Hudson, Univ. Leiden

Effective Leadership

Set a positive active tone

Think out loud to share

the plan – common

mental model

Continuously invite

people into the

conversation for their

expertise and concern

Use their names

Critical Behaviors

Culture and Leadership

• Ninety-two of the 101 study

hospitals provided copies of their

checklist; of these, 90% used an

unmodified World Health

Organization (WHO) or Canadian

Patient Safety Institute checklist.

Educational materials were made

available to hospitals, but no team

training or other support was

provided.

• The key is recognizing that

changing practice is not a technical

problem that can be solved by

ticking off boxes on a checklist but

a social problem of human

behavior and interaction.

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Teams

WHAT TEAMS DO:

Plan Forward

Reflect Back

Brief (huddle, pause, timeout, check-in)

Debrief

Communicate Clearly Structured Communication SBAR

and Repeat-Back

Manage Conflict Critical Language

The Associated Behaviors:

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• Over ½ of in

hospital adverse

events attributed to

surgical care

• 6313 checklist

reviewed, >40% had

a defect, total

number of defects

6312

• Most problems pre-

op or post-op, not in

the OR

28 33 36 41 45 45 49 49 51 52 55 62 62 73 75 80

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ICU

NIC

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SIC

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PE

DS

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Teamwork Climate Scores Across Facility

HCAHPS 92 50

Medication Errors per Month 2.0 6.1

Days between C Diff Infections 121 40

Days between Stage 3 Pressure Ulcers 52 18

Illustrative Data:

Extracted from

Blinded Client Data

CULTURE IS RELATED TO…

28 33 36 41 45 45 49 49 51 52 55 62 62

73 75 80

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ICU

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PE

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Teamwork Climate Scores Across Facility

Employee Satisfaction 91 55

Employee Injury per 1000 days 0.1 16

Employee Absenteeism per 1000 days 10 15

RN Vacancy Rate 1 9

<60% Score =

Danger Zone

Illustrative Data:

Extracted from

Blinded Client Data

… AND UNFAVORABLE EMPLOYEE

OUTCOMES

Wrong Site Surgery or Retained

Foreign Body in 17 Operating Rooms

Operating Rooms

Debriefing – Linking teamwork

and Improvement

What did we do well ?

What did we learn so

we can do it better the

next time ?

What got in the way that

needs to be fixed ?

REVIEW OF CURRENT

DATA AND STATE OF

SSCL David R Urbach MD MSc

Professor of Surgery and Health Policy, Management and Evaluation,

University of Toronto

Haynes et al NEJM January 2009

Mandatory reporting to Ontario Ministry of

Health and Long-Term Care April 2010

Required Organizational Practice for

Accreditation Canada by January 2011

Rapid dissemination of SSCL

de Vries EN et al. NEJM 2010

de Vries EN et al. NEJM 2010

Mortality according to SSCL use

van Klei WA. Ann Surg 2012

Questions about the evidence

Checklist item “never events”

– e.g. wrong site surgery 10/1,000,000

No correlation with improvement in processes

Very effective (1.5% 0.8%)

– Prevents 1 of every 2 deaths • Literature: 1/20 hospital deaths preventable

– Prevents 1 death per 143 patients • Literature: 1/400 preventable hospital mortality

Urbach DR. NEJM 2014

Urbach DR. NEJM 2014

Urbach DR. NEJM 2014

Ann Surg 2013

Summary

There is inconsistent evidence from

observational studies that Surgical Safety

Checklists improve mortality and other

surgical outcomes

Surgical Safety Checklists improve perceived

teamwork and communication in the operating

room

THE CHECKLIST PARADOX

[title stolen from Lorelei Lingard]

Marlies van Dijk

Director Clinical Improvement

mvandijk@bcpsqc.ca

@tweetvandijk

The RIGHT conversation?

Assumption:

The checklist can improve culture in the operating

room

Makary, 2006 Journal of American College of Surgeons

“the most common cause of failure in leadership

is produced by treating adaptive challenges as

if they were technical problems.”

Ron Heifetz

48

Surgical Culture Change Strategy in BC

Situational Leadership

• Leader or manager of an organization must adjust

their style to fit the development level of the

followers they are trying to influence.

• Up to the leader to change their style, not the follower

to adapt to the leader’s style.

• The style may change continually to meet the needs

of others in the organization based on the situation.

Developed by Kenneth Blanchard and Paul

Hersey.

http://bcpsqc.ca/clinical-improvement/teamwork/resources/

Lorelei Lingard. Collective Competence. TED Talk http://www.youtube.com/watch?v=vI-hifp4u40

Rebecca Brooke. 3 page briefing note. Review of the Evidence for Culture Change: The Interpersonal

Side of Healthcare. [scroll down page: http://bcpsqc.ca/clinical-improvement/teamwork/resources/ ]

Makary MA et al. 2006. “Operating Room Teamwork among Physicians and Nurses: Teamwork in the

Eye of the Beholder. http://www.sciencedirect.com/science/article/pii/S1072751506001177

Culture Change Tool Box. Rebecca Brooke. BC Patient Safety and Quality Council.

http://bcpsqc.ca/clinical-improvement/teamwork/resources/

Checklist Paradox Presentation by Lorelei Lingard. SQAN November 2013.

http://bcpsqc.ca/resources-from-sqans-2013-annual-meeting/

Ken Blanchard. Situational Leadership Technical Facilitator guide.

http://www.kenblanchard.com/getattachment/Solutions/By-Offering/Government-

Solutions/Situational-Leadership-II-(GSA-Approved)/SLII_Green_FG_Look.pdf

Geert Hofstede’s Power Distance Index http://www.clearlycultural.com/

Ron Heifetz, Alexander Grashow and Marty Linsky. The Practice of Adaptive Leadership . Harvard

Business Review Press. http://www.amazon.com/Practice-Adaptive-Leadership-Changing-

Organization/dp/1422105768/ref=sr_1_1?ie=UTF8&qid=1411666918&sr=8-

1&keywords=the+practice+of+adaptive+leadership

References

Interacting in WebEx: Today’s Tools

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Be prepared to use: - Raise hand - CHAT

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CONCLUSIONS: Giuseppe Papia

Summarize the discussion of today’s call

and post on website

Loop back with the CPSI and possible

steps forward and the role of the SSCL

intiative in the Forward with Four

priorities

Maintain an open dialogue with

attendees

Next steps

c

Carla Williams

cwilliams@cpsi-icsp.ca

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