1. Vanderbilt Healthcare Improvement Group
Tim Lockney, Scott Hagan
Vice Presidents, School of Medicine
February 9, 2011

2. Outline Safe Surgery project Efforts and Recognitions
Future Goals and Directions

3. Safe Surgery: Context
JCAHO Universal Protocol for pre-incision time out
July VUMC implemented OR electronic whiteboards to improve time out compliance
Intervention paired with mandatory OR staff training
The time out involves a sequenced protocol that uses a checklist format to verify patient identity, confirm the surgical plan, encourage team members to voice concerns, and plans for unanticipated problems.
The benefits of the time out procedure with respect to patient morbidity, mortality, and complication rates have been well documented [2,3]; however, it is estimated that over half of the complications following surgery are still preventable [4], likely due to poor compliance with this procedure.

4. Safe Surgery Objectives
VUMC Administration: Create and implement an electronic checklist intervention to facilitate surgical team compliance with known pre-incision patient safety practices in the OR at VUMC.
VHIG: Measure surgical team compliance with the pre-procedural time out protocol at VUMC both before and after implementation of this electronic checklist system

5. Intervention
Direct observational analyses of pre-procedural time outs were performed on 80 cases before and 80 cases after implementation of the ECS.
Every operating room electronic whiteboard was equipped with a checklist visible from every area of the operating room so that everyone sees the same information at the designated time of the time out procedure (See Figure 1). This electronic checklist system is also automated and interactive, providing feedback on checklist items in real time.
The time outs were performed by the surgical team which included: surgical and anesthesia residents, fellows, and attendings; nursing staff including CRNAs, scrub nurses, and circulating nurses; and OR technicians.

6. For each case, the observers recorded a compliance score (yes=1; No=0) for each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. (See Figure 2)
The pre- and post-observations were conducted by three students who achieved high inter-rater reliability during pre-study training. (κ = 0.83)
Observational data collection for each phase spanned six weeks, with pre-intervention data collection ending one month before implementation and post-intervention data collection commencing one month after implementation.

7. Safe Surgery: Results Composite score of all items: Pre-Intervention:
50.8% ± 13.3 (Min = 0%, Max = 82%)
Post-Intervention:
86.3% ± 13.0 (Min = 36%, Max = 100%)
There is a highly significant difference (p<0.0001) between mean composite scores in the pre- and post-intervention observations.
Mean duration of time-out:
28.3 seconds ± 8.7 (Min = 0, Max = 64)
35.2 seconds ± 11.8 (Min = 14, Max = 70)
There is a significant difference (p=0.001) between mean time-out durations in the pre- and post-intervention observations.

8. Safe Surgery: Conclusions
Implementation of a standardized, interactive electronic checklist system can dramatically increase compliance with pre-procedural time outs in the OR
Improving compliance to best practices requires both training AND culture change (more difficult).
Top-down model may facilitate attitudes/culture change
“Secret Shopping” is a validated observation method which reduces bias.

9. Safe Surgery
International Forum on Quality and Safety in Health Care 2011 April 5-8
More data collection in March - stronger
Manuscript(s) after this

10. VHIG Recognitions and Awards
Featured in the 2011 IHI Annual Report "Leading the New Way”

11. VHIG Recognitions and Awards
VHIG the subject of feature article in IHI Annual Report 2011
Awarded “Special Recognition for Excellence in a Student-Led Curricular Initiative” in the Duncan Neuhauser Curricular Innovation Award competition at the 2010 Academy for Healthcare Improvement International Scientific Symposium on Improving the Quality and Value of Health Care
One of 11 chapters selected to present at the Chapter Congress
Elective was recognized at the Academy for Healthcare Improvement (AHI) International Scientific Symposium on Improving the Quality and Value of Health Care

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13. Future Goals Speaker Series Publication of QI Elective Efforts
ICU Project – Daily Goals Worksheets, and/or another project related to surgical pathway
Development of the QI track for the new medical school curriculum
Aggressive mobilization after surgery (Drs. Nealon and Nesbitt)
Recruitment meeting Feb. 17 – Business, Medicine, and Nursing students
Involve Peabody students?