Surgical checklist - Trying some changes I learned at IHI National Forum

"What can we do by Tuesday?"


You'll hear this phrase a lot when you're at the IHI National Forum, or similar QI events.  It's shorthand for:

 "We're all really excited about the possibilities for improvement that we've talked about.  We have the will to change and we've come up with some great ideas.  But, now comes the hard part: execution.  Once we all get back into our regular work lives, the enthusiasm we're feeling right now can be swept away by the relentless current of clinical tasks.  So, let's deliberately think about execution right now, before we're distracted by our "real work".  What can we try out first thing next week?  Let's make a commitment to a test of change, but make it a small one.  Try it one time, with one patient or colleague."

I made one of those commitments, but I couldn't wait for Tuesday.

While at last week's IHI meeting, I had attended several sessions discussing the surgical safety checklist.  All the speakers emphasized that the real value of the checklist in promoting communication and team building among OR staff.   So, while checking on antibiotic administration and the correct side for the procedure are critical, the checklist holds potential for a deeper benefit. 

The speakers talked about creating a "psychologically safe" environment in which everyone in the OR theatre has permission - in fact, is invited (required?) - to raise any concerns about patient safety. One surgeon told the story of a medical student who called a stop to preparation for surgery because he thought the patient's wrong ear was being operated on.  The staff reviewed the patient's record and determined that they were operating on the correct side, and the medical student was mistaken.  However, the surgeon praised the student for his courage and commitment to patient safety, and asked staff to applaud the student!  Now that's dedication to psychological safety!

In Saskatoon Health Region's current checklist, there's no explicit invitation to speak up like this.  The first version of our checklist began with having all staff in the room introduce themselves to each other and to the patient, but that component was dropped.  I wanted to try reintroducing that element, and also adding a personal invitation to everyone in the room to raise patient safety concerns. I decided to try it Friday (yesterday) morning, with one case. I planned to collect the staff's impressions of the expanded checklist after the surgery was completed.

I started by telling everyone in the room (an anesthetist and 2 OR nurses) about the IHI meeting and what I wanted to test.  We discussed this before we brought the patient into the room.  They agreed to try it.  


Once the patient joined us in the room, I explained that we would do our usual surgical checklist, but that we were also going to add the 2 elements.  We introduced ourselves by name and role, and I invited everyone to use the phrase "I have a concern..." if they had any safety concerns.  


After the surgery was finished and the patient went to the recovery room, we discussed the trial.  (Coincidentally, the nurses had talked about this issue at morning report, so it was fresh on their minds.)  Everyone was keen to have the introductions, particularly as there are often students, residents or other trainees in the room, and this is a way to be sure that everyone know everyone else, as well as their role.  The idea of the safety phrase was also well-received.


Next week, I'll try this again in a new room.  I'll likely be working with a different team. As the idea was well-received yesterday, I don't anticipate having to "sell" it by giving the IHI story again.  What I'm really interested in is the day when someone uses the "I have a concern..." safety phrase.  How will I respond to that interruption?  Will I ensure psychological safety?


Also, I'll be vigilant for occasions where someone could have used the safety phrase, yet didn't.  I suspect that will be the more common situation.  That could happen because of differing views on what a "patient safety concern" is, or because staff don't yet trust that I will be receptive to them raising a concern.