Sunnybrook Health Science Centre SSCL

About SHSC

• Academic Teaching Centre

• Tertiary Care Centre

• Regional Trauma Centre

• 2 Campuses

• 16,000 OR’s per year

• All specialties

SSCL =Good Communication = Better Patient Outcome

Ensures correct• Patient• Surgery• medication• equipment• Supplies• Specimen labeling• Documentation

It’s the right thing to do.

Surgical Safety Checklist

Pilot Implementation

• Goals: – Evaluate the logistics of implementing the

surgical safety checklist in a few surgical services

– Obtain feedback on content and format of checklist

– Obtain feedback on the process of completing the checklist

– Make improvements to the checklist prior to large scale implementation

DRAFT       2009

  May June July Aug Sept Oct Nov Dec

PLANNING

Introduced by Director at Gallie Day                

Senior EVP Approached tb Champion                

To OR Executive Committee                

Select Team, & Physician Champions                

Weekly Meetings                

Feedback/Finalize draft of checklist                

Communication                

Advertise, staff level,pilot physicians                

Building the Case for Change                

Compile stories                

Finalize agenda for rounds                

Accountability list for champions                

Identify the changes required                

Determine pilot compliance metrics                

Finalize data collection method,pilot                

Assess the impact of change on stakeholders                

Pilot in general surgery, cardiac and vascular                

Analyse, review, & post pilot data                

Risk mitigation plan (addressing barriers)                

Create a 'what's in it for me' list                

Develop a communication and roll-out plan                

Create an action plan with clear milestones                

DRAFT       2009 2010

  May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Ongoing

IMPLEMENTATION

Preliminary/informal communciation to all disciplines (i.e. pre-launch info, staff meeting discussions, one-on-one info, etc.)                              

Finalize data collection method                              

Joint Grand Rounds - official launch                              

Release of first month compliance report - all discipline staff meetings/posted                              

Internal champion in-person audits                            

Ongoing data reporting - to ALL OR staff                              Staff/physician feedback re: content/process                              

Final checklist revisions (for MOH or staff)                              Update Senior Leadership & Hospital Board                              

Collate Compliance Data for MOHLTC                              

Public Reporting to MOHLTC                              

Staff satisfaction survey (risk mitigation)                            

Staff satisfaction survey (1-year review)                              

Three Components of checklist

• Briefing – to be completed while patient is awake

• Time Out – immediately prior to incision

• Debriefing – can be conducted while closing

All team members to actively participate

Checklist Aides• Every Operating Room equipped with:

– Large laminated wall poster of the Surgical Safety Checklist

– Standard size (handheld) laminated copy to guide the discussion

• Completion of each section captured on OR record

START DATE: _____________

Checklist Pilot Results

1 2 3 4

• Patient Safety Successes during pilot:– Error on pathology form corrected at debriefing

– Equipment problem identified (unsterile) during briefing

– Heart valve size unavailable identified during briefing

– Patient had opportunity to thank OR staff pre-operatively

– Residents highly engaged

Checklist Pilot Near Miss

Sunnybrook Health Science Centre

Sustaining Improvement Efforts

• Process Indicators to be tracked: – Completion of individual checklist, by

components (briefing, time out, debriefing)

• Monthly reports on our compliance success to OR Management

• Near misses prevented by the SSC documented on safety reports