Keystone Surgery: Improving Perioperative Care in Michigan (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 16, 2009, Chris George made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (4.1 MB) (Plugin Software Help).

Slide 1

Keystone Surgery: Improving Perioperative Care in Michigan

Chris George, RN MS
Project Manager
MHA Keystone Center for Patient Safety and Quality 

Slide 2

Preventable Harm

  • 230 million surgeries / yr worldwide
    • More common than births ( 36 million / yr)
    • 1 in 25 people
  • 25% in-patient surgeries followed by complication
    • 7 million disabling complications / yr
  • 0.5 - 5% deaths following surgery
    • 1 million deaths / yr
  • 50% of all hospital adverse events linked to surgery
    • At least 50% of adverse surgical events are avoidable

Slide 3

Keystone Surgery

  • Learning Community- few existing forums for hospitals to come together to share experiences and improve care.
Keystone Surgery Cohort 1
  • 76 hospitals
  • 36 urban, 38 rural (including 7 critical access)
Keystone Surgery Cohort 2
  • 25 hospitals
  • 14 CAH

Slide 4

Keystone Surgery Collaborative Goals

  • Eliminate surgical site infections, by ensuring that 90% of patients receive evidence-based interventions for preventing surgical site infections
  • Eliminate mislabeled specimens
  • Learn from our mistakes, in particular focusing on the National Quality Forum's "Never" events (wrong site surgery and retained foreign bodies)
  • Have 60% of your staff reporting positive safety and teamwork climate using a measurement instrument that is psychometrically sound.
  • Develop a safety scorecard for perioperative care

Slide 5

The Johns Hopkins Comprehensive Unit-Based Safety Program (CUSP)

  • Educate staff on science of safety
  • Identify defects
  • Assign executive to adopt unit
  • Learn from one defect per quarter
  • Implement teamwork tools

J Patient Safety 2005; Jt Comm J Qual Saf. 2004;30(2):59-68.

Slide 6

2008 OR Teamwork Climate

Graph of the 2008 OR Teamwork Climate which shows more than 50% in need improvement zone.

Slide 7

"The Physicians And Nurses Here Work Together As A Well-Coordinated Team."

Graph of the percentage of respondents that agree

Note: this item is typically negatively correlated with annual nurse turnover rates

Slide 8

Step 5: Implement Teamwork Tools

  • Daily Goals
    • J Crit Care 2003;18: 71-75
  • Morning Briefing
    • Jt Comm J Qual Patient Saf. 2005;31:476-9
  • Learning from Defects
    • Jt Comm J Qual Patient Saf. 2006;32:102-8;
    • Am J Med Qual 2009;24(3):192-5.
  • Team Check Up Tool
    • Jt Comm J Qual Patient Saf. 2008;34:619-623
  • Shadowing
    • Jt Comm J Qual Patient Saf. 2008;34:614-8
  • Briefing and Debriefing
    • Jt Comm J Qual Saf. 2009;35(8):391-397

Slide 9

Image: The New England Journal of Medicine

Article title: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Slide 10

Briefing Checklist


Implementation Instructions: Make sure all team members are in the OR suite and the patient is anesthetized. Just prior to starting the procedure implement the checklist beginning with the introduction of names and roles and work in descending fashion through the list.

I. Introduction of first names and roles.

II. Review critical information
- Do we have the correct patient?
- Is the correct side or site marked?
- Has the procedure been agreed upon?
- Have antibiotics been given?

Jt Comm J Qual Saf 2006;32(6): 351-355

Slide 11

Briefing Checklist

III. Surface and Mitigate Hazards SURGERY - Discuss plans for the surgical procedure:
- Describe critical steps
- Provide team with pertinent information, including problems that may be encountered
- Ask team: If something were to go wrong with this procedure, what would it be, and how could we prevent the problem or mitigate harm?

  • Risks during procedure such as bleeding, fluid loss
  • Surgeon suggests, "If anyone has a concern during the case, please let me know."

- Does everyone know how to use the equipment used in this procedure?

Jt Comm J Qual Saf 2006;32(6): 351-355

Slide 12

Briefing Checklist

ANESTHESIOLOGY - Discuss all relevant issues:
- Patient comorbid disease that will increase risk
- Aspects of surgery that will increase risk, such as need for IV access
- Availability of blood products
- Interventions to prevent complications such as myocardial infarction, surgical site infection

NURSING - Discuss all relevant issues:
- Are all necessary instruments available?
- Will any special equipment be considered?
- Plan for breaks (Relieving nurse to introduce themselves when switching)

Jt Comm J Qual Saf 2006;32(6): 351-355

Slide 13

Briefing - Before Every Procedure

  • Team introduction - first and last names including roles (Circulator writes on board)
  • Do the following match:
  • Patient ID band, Informed Consent (read out loud), Site Marking, OR posting, patient's verbalization of procedure (if patient awake), other clinically relevant documentation (H&P, clinic note)
  • Do we have any safety, equipment, instrument, implant or other questions or concerns?
  • Have antibiotics been given, if indicated?
  • What are the anticipated times of antibiotic redosing?
  • Are glycemic control/beta blockers indicated?
  • Is the patient positioned to minimize injury?
  • Has the Prep been applied properly, without pooling and allowed to dry?
  • Have the goals and critical steps of the procedure been discussed?
  • Is the appropriate amount of blood available?
  • Is DVT prophylaxis indicated? If so, what?
  • Has the patient received anticoagulants?
  • Any Special Precautions? If yes, describe.
  • Are warmers on the patient?
  • Is the time allotted for this procedure an accurate estimate?
  • Has the Attending reviewed latest/final test results for Lab/Radiology? Are Intraoperative X-rays indicated?

Slide 14

De-briefing Checklist

Debriefing - After every procedure

  • Could anything have been done to make this case safer or more efficient?
  • Has the SSI data collection form been completed?
  • Are the patient's name/history number and the surgical specimen name and laterality on the paperwork? (Paperwork/labeling to be independently verified by Surgeon)
  • Did we have problems with instruments?
  • Plan for transition of care to post-op unit discussed? To include:
  • Fluid Management/blood (all slips in chart)
  • Antibiotics - continue post-op (dose/interval)
  • PACU tests/XRays
  • Pain/PCA plan
  • New meds needed (immediate periop)
  • Beta blockers (as required)
  • Glycemic control (as required)
  • DVT prophylaxis

Slide 15

William Beaumont Hospital Royal Oak campus

Graph of 37,133 briefings and debriefings broken up by Teames and Quaters.

Jt Comm J Qual Saf. 2009;35(8):391-397.

Slide 16

Provider Perceptions

Effective strategy to improve communication: 90%
Effective strategy to improve teamwork: 90%
Feasible given my current work load: 70%
Average time to complete: 2.9 minutes

Effective strategy to improve communication: 68%
Effective strategy to improve teamwork: 72%
Feasible given my current work load: 70%
Average time to complete: 2.5 minutes

Jt Comm J Qual Saf. 2009;35(8):391-397.

Slide 17

Briefing Compliance
All Keystone Surgery Teams
7/1/2008 - 8/31/2009

July 200815622270.27%
August 20081,0621,38976.46%
September 20081,8142,40975.3%
October 20081,6142,34069.1%
November 20081,7592,06985.02%
December 20082,8413,34784.88%
January 20097,0669,31675.85%
February 20098,93711,59577.08%
March 200916,31619,83482.26%
April 200915,49118,94181.79%
May 200915,75718,88983.42%
June 200919,69623,76582.88%
July 200914,90917,63184.56%
August 200911,75912,88691.25%

Slide 18

Briefing Problem Identification
All Keystone Surgery Teams
7/1/2008 - 8/31/2009

Jul 2008666.67%00%111.11%111.11%00%111.11%
Aug 2008937.5%416.67%416.67%729.17%00%00%
Sep 2008715.91%1636.36%12.27%1431.82%12.27%511.36%
Oct 20082924.37%4033.61%1613.45%2924.37%21.68%32.52%
Nov 20081827.27%1421.21%23.03%3045.45%11.52%11.52%
Dec 20083525.93%2720%53.7%5037.04%42.96%1410.37%
Jan 20095726.89%5425.47%83.77%6530.66%52.36%2310.85%
Feb 20094822.97%7234.45%62.87%5626.79%41.91%2311%
Mar 200910325.62%9724.13%51.24%13032.34%92.24%5814.43%
Apr 200912929.59%11025.23%194.36%9221.1%163.67%7016.06%
May 200913028.76%11224.78%132.88%12026.55%132.88%6414.16%
Jun 200917531.59%13925.09%183.25%11120.04%101.81%10118.23%
Jul 200913933.33%10023.98%51.2%8921.34%92.16%7517.99%
Aug 20099031.58%7425.96%51.75%6924.21%93.16%3813.33%

Slide 19

Debriefing Compliance
All Keystone Surgery Teams
7/1/2008 - 8/31/2009

July 200816422273.87%
August 20081,0511,38973.57%
September 20081,7792,44872.67%
October 20081,5712,24669.95%
November 20081,6482,04180.74%
December 20082,6563,23082.23%
January 20096,6719,15472.88%
February 20098,36011,24374.36%
March 200915,23219,03780.01%
April 200914,20918,06578.65%
May 200914,67018,33680.01%
June 200918,97223,44880.91%
July 200914,22717,27682.35%
August 200911,31212,59089.85%

Slide 20

Debriefing Problem Identification
All Keystone Surgery Teams
7/1/2008 - 8/31/2009

Jul 20081538.46%1948.72%12.56%12.56%00%37.69%
Aug 20081134.38%1443.75%00%721.88%00%00%
Sep 20083139.74%2025.64%22.56%78.97%00%1823.08%
Oct 20084531.69%5941.55%42.82%149.86%42.82%1611.27%
Nov 20082924.44%5850.88%32.63%65.26%21.75%1614.04%
Dec 20084624.21%8645.26%63.16%157.89%73.68%3015.79%
Jan 20098524.15%16647.16%20.57%3610.23%113.13%5214.77%
Feb 20098425.3%16950.9%51.51%175.12%113.31%4613.86%
Mar 200914923.88%29447.12%162.56%396.25%223.53%10416.67%
Apr 200913726.2%24246.27%81.53%152.87%142.68%10720.46%
May 200914624.58%24541.25%91.52%386.4%152.53%14123.74%
Jun 200919623%41648.83%141.64%465.4%131.53%16719.60%
Jul 200913721.68%32751.74%101.58%416.49%81.27%10917.25%
Aug 200914228.06%23446.25%10.20%275.34%81.58%9418.58%

Slide 21


  • Surgical teams are complex
  • Diffusion of innovation in ORs challenging
  • Data collection burdensome
  • Linking improvement in culture with improved patient outcomes
Current as of December 2009
Internet Citation: Keystone Surgery: Improving Perioperative Care in Michigan (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.