Disclosure Statement

1. Disclosure Statement “I have no financial disclosures to report but I am employed by the South Carolina Hospital Association.”

2. Transforming Surgical Care through Team-based Communication Palmetto Health System Presentation August 12, 2010

3. Redesigning Health Systems “The American healthcare delivery system is in need of fundamental change….Healthcare today too frequently harms and routinely fails to deliver its potential benefit…. Between the healthcare we have and the care we should receive lies not just a gap, but a chasm”

4. If 99.9% Were Good Enough… • IRS lost documents 2 million per year • Major plane crashes 3 per day • Lost items in mail 16,000 per hour • ATM errors 37,000 per hour • Pacemaker incorrectly installed 291 per year • Babies given to wrong parent 12 per day • Erroneous medical procedures 107 per day

5. IOM Report • Deaths due to medical errors exceed the number attributable to 8th leading cause of death. • More people die in given year as result of medical errors than from motor vehicle accidents, breast cancer or AIDS • Medication errors alone estimated to account for over 7,000 deaths annually • Up to 100,000 deaths due to healthcare-associated infections- vast majority are preventable • Total national costs of preventable adverse events are estimated to be between $17 - $29 billion

6. IOM Six Aimsfor Improvement • Patient care that is: • Safe-avoidance of unintended pt. harm • Effective-evidence-based • Patient-centered- focused on needs and rights of the individual patient • Timely-avoidance of delays & barriers to patient care flow • Efficient-elimination of waste • Equitable-fair access to comparable health care services for all

7. “My Mom” Quality/Safety Standard • How would you want your Mom treated at your hospital? • Every patient in your hospital expects and deserves that same high level of care/safety • Now we have to prove how well we’re performing under this “My Mom” standard

8. Vision:That all SC hospitals and providers deliver safe, high quality healthcare in a caring and compassionate manner to each patient, every time Mission: To establish a culture of continuous improvement in the quality, efficacy and safety of patient care across all healthcare organizations and providers statewide

9. Redefining Performance Excellence What is the ultimate we believe our hospitals can and should accomplish to dramatically improve the safety and quality of the care and the health of the patients they serve?

11. “Rather than uncoordinated, episodic care, we need to offer care that is well organized, coordinated, integrated, characterized by effective communication, and based on continuous healing relationships” -Eric Larson

12. Creating a Culture of Safety Acknowledgement of the high-risk, error-prone nature of an organization’s activities Blame-free environment where individuals are able to report errors and close calls without punishment Expectation of collaboration across ranks to seek solutions to vulnerabilities Willingness on the part of the organization to direct resources to address safety concerns.

13. Communication and Education • Create an environment of mutual trust, respect and psychological safety • Actively support open communication and courageous dialogue system-wide • Establish a Leadership orientation/training program to ensure “quality literacy/competency” • Promote an active learning process for all clinical staff including physicians (including access to simulation training)

14. Why Communication ? • The overwhelming majority of medical errors involve communication failure • Wrong site surgery - somebody knows there’s a problem but can’t get everyone in the same movie – often it’s hard to speak up • The clinical environment has evolved beyond the limitations of individual human performance

15. Crew Resource Management • Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making • Non-punitive reporting of near misses, 500,000 reports over 15 years • Very open culture with regard to error and safety

16. The Safe Surgery Saves Lives Program

17. The Problem

18. The 3 Central Problems in Surgical Safety Throughout the World • Unrecognized as public health issue • Lack of data on surgery and outcomes • We know what to do, but we don’t do it consistently

19. Four Categories for Surgical Standards:

20. WHO’s 10 Objectives for Safe Surgery • The team will operate on the correct patient at the correct site. • The team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain. • The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function. • The team will recognize and effectively prepare for risk of high blood loss. • The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

21. WHO’s 10 Objectives for Safe Surgery 6. The team will consistently use methods known to minimize the risk for surgical site infection. 7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds. 8. The team will secure and accurately identify all surgical specimens. 9. The team will effectively communicate and exchange critical information for the safe conduct of the operation. 10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.

22. Why a Checklist?

26. Pilot Study

27. International Pilot Study 8 Evaluation Sites - Nearly 8,000 Patients EURO EMRO PAHO I London, UK Amman, Jordan Toronto, Canada WPRO I Manila, Philippines PAHO II Seattle, USA WPRO II AFRO Auckland, NZ Ifakara, Tanzania SEARO New Delhi, India

29. Outcomes at Baseline

30. Results - Process Measures

31. Results – All Sites

32. Change in Death and Complications by Income Classification * p<0.05

33. Survey of Attitudes to Checklist Use Among Clinicians at Study Site (n=229)

34. Where is the Checklist Today

35. Participating Hospitals: 3,865 Actively Using the Checklist: 1,657

36. IHI Sprint Challenged every hospital in the U.S. to trial the Checklist with one surgical team- 80% of SC Hospitals

37. Notable Endorsing Organizations • American College of Surgeons • American Society of Anesthesiologists • Association of Perioperative Registered Nurses (AORN) • American Academy of Otolaryngology-Head & Neck surgery • American Orthopedic Association • Anesthesia Patient Safety Foundation • Blue Cross Blue Shield Association

38. What key steps have other hospitals followed that have enabled them to successfully implement the Checklist?

39. What Can Make a Difference • Find a “champion” in each discipline (anesthesia, nursing, and surgery) • Buy-in from clinical and hospital leadership • Modify the Checklist and trial it • Measurement/Local Evidence • Reinforce Change • Show Progress

40. Checklist Modification Basics • One size doesn’t fit all • Need to have full team buy-in • Don’t remove teamwork items • Introduction of team members by name and role • Review of specific patient concerns • Discussion of key concerns before patient leaves the OR

41. When We Use the Checklist: • Does the entire team stop all activity at the three critical points in care? • Does the team verbally confirm each item on the Checklist? • Are the items verified without reliance on memory? • Does the Checklist promote communication?

45. Virginia Mason Hospital- Seattle • In order for the Checklist to work well it has to be used “right”- requires behavioral change • Improving communication between all OR team members is critical to successful implementation. 2010 Annual Meeting of the American Society Anesthesiologists

46. Operation: Safe SurgeryVision/Purpose • Vision: That every patient in South Carolina will receive surgical care in a safe environment • Purpose: To create a statewide system of surgical safety that is built on teamwork and open communication

47. Operation: Safe SurgeryInitial Goals • All SC acute care hospitals will evaluate the WHO surgical safety checklist with at least one surgical team • Surgical teams statewide will be provided direct access to a focused crew/team resource management training program

48. Operation: Safe SurgeryMajor Goals • 100% SC hospitals will commit to checklist use and CRM-based communication in all ORs • All SC hospitals and surgical teams will have direct access to a broad range of surgical safety educational resources and consultative services • A unified data management system established to track and analyze key surgical care process and outcomes indicators within and across hospitals

49. Operation: Safe SurgeryKey Challenges • Attaining senior leadership/medical staff buy-in • Integration of WHO checklist with TJC universal protocol requirements • Spreading use of checklist from one to multiple surgical teams in each hospital • Providing access to CRM training statewide • Creating a user friendly system for tracking impact of program on patient outcomes

50. Operation: Safe SurgeryPhase 1 Results • 55% of SC hospitals evaluated checklist with at least one surgical team by April 1, 2009 • 25% of SC hospitals committed to evaluating after Sprint deadline • 80% total commitment from SC hospitals compared to 25% national rate