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Transcript of MGH
Wrong-site surgery occurs in all surgical specialties but is most common among orthopedic surgeons and neurosurgeons, with 68% of claims in the United States related to orthopedic surgery.
A recent survey of AAOS members revealed that 5.6% of reported medical errors were wrong-site procedures or wrong procedures: of these, approximately 59% involved the wrong side, 23% another. Introduction
Since 1811, Massachusetts General Hospital has been committed to delivering standard-setting medical care. Throughout the decades, the hospital has had a consistent commitment to advancing that care through pioneering research and educating future health care professionals. Introduction Six Sigma Improvement Project Eliminating the wrong procedures in orthopedic surgeries Control Develop indicators to control and check the process. 17/1/2013 31/1/2013 Improve Implementing the universal protocol to eliminate wrong procedures in orthopedic surgery. 16/12/2012 16/1/2013 Analyze Developing a flowdiagram of the process.
Root cause analysis diagram to analyze the actual causes of the problem.
Data collection of the most frequent causes of wrong procedures by Pareto diagram. 1/12/2012 15/12/2012 Measure
Determine actual performance &percentage of wrong procedures in orthopedic surgery.
Determine our sigma level. 16/11/2012 30/11/2012 Define Collection of patient questionnaires and surveys to determine their CTQs.
Defining the problem.
Developing a charter. 1/10/2012 15/11/2012 DMAIC Activity Start - End The project team decided to conduct a survey and distribute patient questionnaire to evaluate their patients' perception of the quality of the service provided and to determine their CTQs requirements. Voice of the patient(VOP) Project name: Eliminating the wrong orthopedic surgical procedures.
Department: Orthopedic department.
Process impacted: wrong procedures.
Start Date: October, 2012.
End Date: January ,2013. Team Members:
Yellow belt:Surgical scrub nurses,technicians.
Orange Belt: Dr. Peter Dunn, Dr. Joseph Barr,Dr.Ring and Dr.James Herndon and auditors from center of quality&safety and orthopedic residents.
Green Belt: Dr.Rubash and Head nurse of
operating room .
Black Belt: Dr. Meyer.
Champion: Hospital C.E.O. Problem Statement:
Wrong procedures is negatively impacting the reputation of the hospital, resulting in decreased patient’s satisfaction, limiting revenue opportunities, and generating patient loss to outpatient diagnostic centers.
The purpose of this project is to utilize six sigma methodologies to understand the characteristics of the current process that are limiting the ability of the department to appropriately ensure the patient’s safety as regards surgical procedures performed, to be completed within 4 months.
The consequences for not doing this project are decreased the patients satisfaction, loss of patient safety as regards surgical procedures performed and loss of revenue. Goal Statement:
By January,2013, decrease our errors due to wrong surgical orthopedic procedures (wrong patient,wrong site ,wrong side and wrong procedure) to 0%. Project Scope:
Wrong procedures (Patient,Site, Side, Marking) from pre-operative assessment till post-operative assessment including day case surgeries and in-patients.
Out of Scope: Multi-department surgeries. Patient CTQs: from VOP:
Disclosure if any error or problem occurred.
Cost of surgical procedure.
Benefits and Risks of the operation.
Alternatives to surgery.
Length of stay.
Risk of non treatment.
Wound healing. Project Plan:
Control: 17/1/2013-31/1/2013 Charter Dr Bothina Ahmed.
Dr Ebaa Ibrahim.
Dr Eman Awad.
Dr Osama Yehia.
Dr Hani Rahmatallah.
Dr Belal Mohamed . Together for quality group Together for quality group Harry E. Rubash, MD Chief, Department of Orthopaedic Surgery James H. (Jim) Herndon, MD, MBA Chairman Emeritus, Partners Department of Orthopaedic Surgery David Ring, MD, PhD Chief, Hand and Upper Extremity Service Director
Center for Quality Measurement and Improvement Peter Francis Dunn, MD Executive Medical Director,
Perioperative Administration Joseph Seaton Barr,MD Orthopaedic Surgeon POSTOPERATIVE PHASE:
Checking for the performed operation and its results using a checklist.
Completion of required operative and postoperative notes.
Establish policy and procedure for patient information
if something went wrong or if there are any complications. OPERATIVE PHASE:
1-Perform a time out:
Conduct a time-out immediately before starting the invasive procedure or making the incision.
Designate a member of the team to start the time-out.CC
Use a Standardized time-out checklist.
Involve the immediate members of the procedure team in the time-out: the person performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.
All relevant members of the procedure team should actively communicate during the time-out.
During the time-out, obtain agreement among the team members on at least the following: Correct identity of the patient, Correct site and Procedure to be performed
If the same patient will have two or more procedures and if the procedures will not be performed by the same person, conduct a time-out before each procedure is begun.
Document the completion of the time-out.
Resolve all questions and concerns before the procedure is begun
clarify circumstances under which a second time out is required . PREOPERATIVE PHASE:
1- Preprocedure verification process:
Verify the correct procedure, for the correct patient, at the correct site by involving all team members and the patient if possible (patient speak back) and if the patient can’t confirm use the patient armband, or contact patient caregiver.
Share the data and allow the team to ask questions and create an environment in which staff are expected to speak up when they have a patient safety concern .
Use a standardized checklist to verify the availability of items needed for the procedure (required blood products, implants, devices, or special equipment) and that they pertain to the proper patient.
Use a standardized checklist to verify the presence of relevant documentation required such as (signed surgical consent, history and physical examination, physician orders and properly displayed and labeled results of diagnostic and radiological tests). SCHEDULING AND PREPARATION FOR OPERATION:
Establish a policy and procedure for booking and scheduling operating rooms.
Use a standardized forms to confirm the accuracy of the operating room schedule to avoid delays and over crowd.
Use limited entry points for primary documentation (physician orders, booking/scheduling form) to a single fax number to avoid overbooked schedules.
Build on relationships with physicians and their offices to improve the accuracy of information received and methods used to confirm the accuracy of the operating room schedule
Confirm the presence and accuracy of primary documents critical to the verification process prior to the day of surgery for inpatients and on the same day for day case surgeries (signed surgical consent, history and physical, and physician orders)
Establish a procedure for informing the surgeons about their next day surgeries and their exact times and their confirmation.
2- Marking the procedure site:
Marking the surgical site is performed by a licensed independent practitioner (surgeon) who is ultimately accountable for the procedure and will be present when the procedure is performed.
Mark the surgical site using a single-use surgical skin marker with a consistent mark type (e.g., surgeon’s initials) placed as close as anatomically possible to the incision site
Involve the patient in the site-marking process, if possible.
Make the mark sufficiently permanent and unambiguous to be visible after skin preparation and draping.
If the surgical site can’t be marked, document why and what is the alternative mark used eg (Adhesive markers ).
Do not move to anesthesia induction before surgeon has marked the site and marking in surgical site checklist. 2- During operation
Point and touch verification of the surgical site mark by the surgeon and scrub technician before proceeding(development of a surgical safety checklist )
Reduce noise and cease all other activity in operating room.
Perform a pause between each procedure that occurs within a single case to ensure that each procedure is performed accurately and according to the procedure, site and laterality contained within the signed surgical consent. ORGANIZATION CULTURE:
Empower all team members to participate in processes designed to reduce the risk of wrong site surgery; everyone is expected to speak.
Demonstrate leadership’s commitment to implement standardized work processes for all steps – scheduling, pre-op/holding, operating room and postoperative phase.
Educate staff by using active learning techniques rather than communicating only through e-mails or posters.
Utilize a team approach when teaching all staff how the process should be executed.
Utilize indicators for key processes and monitor compliance in all steps of the process (scheduling/booking, pre-op/holding, operating room) .
Hold all caregivers and staff accountable for their role in risk reduction; organization should define roles.
Creation of multiple disciplinary investigation team if a wrong site surgery event occured.
Celebrate success; everyone should be aware of improvement. Impact Matrix A pilot test to check the implement ability of the proposed policies and regulations was conducted during a period of 2 weeks. The results showed that the new tracking system proved to be very effective. Specially, that the number of wrong site orthopedic surgeries decreased significantly. Pilot test Analyze Scatter diagram Pareto diagram Poor placement
monitors in the operating room. Equipment underestimation of
minor procedures. Unscheduled consultations. Staff Lack of communication between staff
due to language barriers. Marketplace competition and pressure to
increase surgical volume leads to shortcuts
and variation in practice. Policy changes made with inadequate or
inconsistent staff education. Staff is passive or not empowered to speak up. Inconsistent organizational focus on
patient safety. Senior leadership is not actively engaged. Organization culture Time Outs do not occur when there are
multiple procedures performed by multiple
providers in a single operative case. Time Out performed
without full participation. Time Out process occurs before all staff are
ready or before prep. and drape occurs. Distractions and rushing during Time Out. Site mark(s) removed during prep. or covered
by surgical draping. Primary documentation not used to verify
patient, procedure, site and side. Ineffective hand-off
communication or briefing
Process. During procedure Lack of intraoperative site verification when
multiple procedures performed by the same
Provider. Inadequate patient verification by team. Alternate site marking process
doesn’t exist or isn’t used. Rushing during patient verification. Inconsistent or absent time
out process . Inconsistent site marks
used by physicians. Stickers used in lieu of marking the skin. Site mark made with non-approved surgical
site marker. Surgeon does not mark site in pre-op/holding. Someone other than surgeon marks site. Inconsistent use of site marking protocol. Paperwork problems identified in pre-op but
resolved in a different location. incorrect Primary documents (consent, history and
physical, surgeon’s booking orders, operating
room schedule) missing, inconsistent or incorrect. Pre-operative holding Missing consent , history and physical or
surgeon’s orders at time of booking. Unapproved abbreviations , cross outs and
illegible handwriting used on booking form. Schedulers accept verbal requests for
surgical bookings instead of written documents. Booking documents not verified by office schedulers. Scheduling Wrong procedures in
orthopedic surgeries Personnel changes. Shortage of equipment. Swiss cheese Scatter diagram is a graphical tool used to describe the relationship between two variables. From this diagram it becomes clear that there is strong positive correlation between wrong procedures and marker issues. Control Quality Control Spread Sheet Feedback loop An audit was carried out to ensure the implementation of the improvement. It was carried out in a morning shift and in a night shift. The auditing focused on the controls put above. Data collection forms were reviewed and most of non compliances occurred during the night shift. As the team now knows root causes of wrong procedures of orthopedic surgeries we have to control our project by selecting certain indicators,measuring actual performance after improvement then comparing it with baseline performance.
To maintain our project a quality control spreadsheet was constructed. Thank you Define Dr.Meyer Timed activities SIPOC Diagram
[Supplier — Inputs — Process — Outputs — Customers] Outputs Process Inputs Measure Wrong-site surgery occurs in all surgical specialties but is most common among orthopedic surgeons and neurosurgeons. In USA 68% of wrong site surgeries are related to orthopedic surgeries (Cowell, 1998). A recent survey of AAOS members revealed that 5.6% of reported medical errors were wrong site procedures or wrong procedures: of these, approximately 59% involved wrong the wrong side, 23% another wrong site, 14% wrong procedure and 5% the wrong patient (Wong et al., 2009). According to the current situation in the Massachusetts General Hospital we are operating at
3 sigma level.
Application of a 6 sigma project to eliminate wrong procedures in orthopedic surgeries will help raise our hospital sigma level in particular in wrong side and wrong site orthopedic procedures. Estimating our sigma level Congratulations