South Carolina hospitals use a checklist to increase safety in the operating room.

As part of a novel program, 14 hospitals in South Carolina reduced post-surgery mortality rates by 22% through the simple act of using a checklist in their operating rooms. The hospitals, which account for almost 40% of the state’s inpatient surgeries, completed the Safe Surgery South Carolina program from 2010 to 2013. During that time, their post-surgical death rates dropped from 3.38% to 2.84%. For hospitals not completing the program, the rates rose from 3.5% to 3.71% during the same period.

The key to the program was a checklist used by surgical teams before, during, and after surgery. It lists practical checkpoints such as identifying the surgical site, providing the operative plan, anticipating aspiration risk, and counting the instruments, needles, and sponges before the patient leaves the room.

But the checklist is not simply about marking off boxes showing that certain procedures and protocols are being followed. Rather, the checklist is designed to engender interaction among surgical team members.

“It’s less about specific things on the checklist and more about the process of engaging a team and creating an environment where people are sharing information and feel safe to speak up when concerns arise,” said Alex B. Haynes, MD, MPH, associate professor of surgery at Harvard Medical School in Boston and director of the Safe Surgery program at Ariadne Labs. “That’s far more important than any particular item on the checklist. It’s not about steps to do to have a safe operation, but about the type of information they need to have.”

Looking South

Dr Haynes was part of the World Health Organization (WHO) program that developed the original surgery safety checklist in 2007. The checklist was tested in 8 hospitals in 8 cities worldwide. Prior to using the checklist, the death rate in these hospitals was 1.5%, and 11% of inpatients had surgery-related complications. After implementation, the death and complication rates fell to 0.8% and 7%, respectively.

After its introduction, a wide range of hospitals embraced the checklist, but over time the hospitals began to see signs of implementation failure, Dr Haynes said. “Hospitals were putting it [the checklist] up on the wall, telling everyone to use it and thinking that would work,” he said. “We knew a structured approach would yield more tangible benefits.”

Dr Haynes and his colleagues (including surgeon Atul Gawande, MD, director of Ariadne Labs) looked to South Carolina because of the state’s large-scale work mobilizing hospitals to reduce the number of early elective deliveries and improve heart attack care. “It seemed like fertile ground for this kind of study,” Dr Haynes said.

After discussion and consultation, the Ariadne group struck a partnership with the South Carolina Hospital Association. The organizations had a kickoff where all the state’s hospitals committed to implementing the checklist.

Every enlisted hospital went through a multi-step program to successfully implement the checklist. Lorri Gibbons, vice president of development for the association, said the process was not only about the clinical steps, but communication as well. Implementation included customizing the checklist for each hospital, small-scale testing, observation, and coaching.

“The checklist should be used to enhance, not supplant, the teams,” Dr Haynes said. “It’s not there to tell them how to do surgery or to be a burden. It’s to make sure people talk to each other in ways that promote awareness of what they are there to do that day.”

Only 14 hospitals ended up completing everything that was asked of them for the study, but all hospitals committed to implementing the checklist to some degree, Gibbons said.  

A team approach

When the checklist was first put in place, Gibbons said people thought it was a “check-off list” or a more demanding version of The Joint Commission’s “time-out” (where the surgical team pauses to make sure they are working on the right patient, procedure, and anatomic site).

But Gibbons said the list is more about empowering communication among team members in the operating room. It offers a scripted list of things that should be discussed by each member of the team and encourages introductions.

“There has been a lot of research that shows when people are given the chance to introduce themselves in a group of people, they are more likely to speak up in group,” she said. “It’s meant to enhance communication of the entire team from the circulator to the anesthesiologist, and the surgeon to the scrub nurse.”

The list focuses on the time prior to administering anesthesia, the period before incision, and the sign out, before the patient leaves the room. It is designed to be a universal template and can be used for any type of procedure.

“The team performing an open-heart surgery will have a different conversation than for cataract surgery,” Dr Haynes said. “It’s intended to be modified and not done the same way in every place but used to fit the needs of each institution … keeping in mind it isn’t the solution for every aspect of peri-operative safety.”

He added: “You need to meet people where they are and work with them to do something that works at their institution with their priorities, resources, and needs.”

Gibbons said she hopes to have similar checklists in a range of areas, including in specialty suites or for procedures like colonoscopies.

“They don’t have to be long, involved things,” she said. “It’s about getting the team to talk to make sure they know about the patient, have everything ready and have any special instructions.”

The hospitals had to report on their safety procedures before and after putting the checklist in place. Dr Haynes said there were definite improvements in the safety culture of the hospitals.

“Safety is complex and multifactorial,” he said. “There may be a time when someone inadvertently contaminates their gloves, and if someone notices it may point it out or not. The operating room isn’t necessarily an environment where that is encouraged and made the norm for the nurse to point that out.”

Lessons learned

The checklists take buy-in from every person on the team, especially those at the top. It is best to identify someone at each organization to champion the efforts and collect a team that can integrate the checklist into their current safety practices and workflow.

In addition, the issue should not be forced. “You can’t mandate something and say, ‘Tomorrow everyone is going to do the checklist,’’ Gibbons said. “Medicine is competitive, so if you have 1 team that is implementing it, and their cases are going smoother and they are leaving earlier, other teams start to take notice.”