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ORX Award Winner: Patient Safety
Incredibly realistic drills and a staff of true believers protect patients at the Presidio Surgery Center in San Francisco.
Daniel Cook
Publish Date: September 3, 2015
OR Excellence Awards
mimic actual emergencies DRILL TEAM Staff are put through the paces during in-services that mimic actual emergencies.

The staff and physicians at the Presidio Surgery Center in San Francisco take their safety drills seriously. Like watching a fire safety consultant burst into flames in the OR so they can practice extinguishing real flames. That's right. The consultant lays down on a gurney wearing an asbestos vest. He places a butane-soaked pad on his vest and — poof — touches a lighter to it. "It's quite dramatic and gets the point across. It adds to the realism of the drill," says Steven Vitcov, MD, the center's medical director. For stopping at nothing to protect their patients, Presidio Surgery Center's staff and physicians are this year's winner of the OR Excellence Award in Patient Safety.

Serious scenarios
Live fires aside, the center's safety drills are effective and educational because they're based on plausible scenarios that use the clinical data of patients they've cared for recently, like a patient who presented with coronary artery disease and stents and a history of myocardial infarction. They run through what they'd do if the patient ran into trouble in recovery.

During drills, the screening nurse serves as an impartial observer, monitoring the performance of the participants and offering critical feedback on how they performed. "She's an extra set of expert eyes," says Dr. Vitcov. "That's a big deal if you have enough staff to make it happen."

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Staff gathers every other Friday for in-services or to run through the emergency drills. "We run every drill to near completion," says Dr. Vitcov. "The only thing we don't do is call EMS." After each drill is completed, they review what they did well and not so well, and include input from the screening nurse.

It's all hands on deck when patients are in jeopardy, says Dr. Vitcov. Every person in the facility, including members of the business office, has a role to play during each emergency response scenario and they act it out during each drill.

'Safety Freak' Leads By Example

staff drills\ ACTIVE PARTICIPANTS Staff respond well to drills that are interactive, realistic and relevant.

Anesthesiologist Gregory Porter, MD, is a safety freak (his words) perhaps because he moonlights as a volunteer firefighter and paramedic when he's not serving as the medical director of the Sierra Ambulatory Surgery Center in Auburn, Calif.

It's his 22-year career in emergency response training that lets Dr. Porter always see the big picture of patient safety. "There's a calmness, because you're above the chaos," he says, referring to what he's learned from arriving first at house fires and car accidents. "You step back to assess the situation before you step forward."

He says a culture of safety needs to be developed within facilities from the top down. "If you practice it, if you believe in it, your employees will follow," says Dr. Porter, who suggests getting anesthesiologists involved in your patient safety efforts, because that's their primary focus on a daily basis. Says Dr. Porter, "They're not utilized enough in helping to conduct and schedule in-services and educate every member of the staff, from the business office to the OR, about best practices in patient safety."

Engage staff with real-life scenarios, recommends Dr. Porter. Make them fun, interesting and interactive. Staff members often think patients won't be jeopardized on their watch, so safety drills have to be relevant and believable, says Dr. Porter. "If you have an experience or story that you can share from an event you've faced, the lesson will hit home," he explains.

Always open the conversation up to other staff members, because you all come from different backgrounds and have various experiences that can bring valuable insights to the discussion. Above all, be vigilant on daily basis for unexpected events, says Dr. Porter. "You have to realize that things do happen, and the more ready you are for them the better the chance of having a good outcome."

— Daniel Cook

Cautious approach
Dr. Vitcov constantly balances helping to run a revenue-generating center and ensuring the safety of the patients he clears for surgery. He works with his co-medical director and the center's screening nurse to meticulously evaluate patients before they're scheduled for surgery.

"We have a very sophisticated and fairly conservative patient screening process whereby all patients are evaluated with well-described evidence-based screening tools," says Dr. Vitcov. "Patients who fall out are closely reviewed by an internal medicine physician and an anesthesiologist, and if they're inappropriate for surgery in an ASC, we redirect them to our affiliated hospital."

It's a self-righting process, says Dr. Vitcov, because any of the center's 25 anesthesiologists call him out if they encounter a patient they're not comfortable sedating and ask why he approved them for surgery. "I must have a rationale and reasonable way to justify any patients who are approved to undergo surgery at the center," he says.

Dr. Vitcov developed written evidence-based policies to help him make his case when surgeons ask why a patient can't undergo a procedure in the center. "I'll tell them what the literature says about post-op complication risks for similar patients," he says. "Clearly stated written guidelines show surgeons exactly why patients were or weren't approved for surgery."

Dr. Vitcov sets conservative screening thresholds and gradually inches them up as positive outcomes build. For example, he originally set a BMI limit of 40 for the center, but saw that those patients came through surgery in excellent shape. Dr. Vitcov consulted with the center's clinical leadership and decided to expand the BMI limit to 45 for healthy patients with no comorbidities other than obesity. "That was done in the context of checking with several other centers in the nation and asking them what they do," he says. "Some had no limit or a limit of 50."

Clear Communication Protects Patients

teach staff about safet\y PLAY JEOPARDY What's a good way to teach staff about safety?

The Princeton (N.J.) Endoscopy Center has been open for 10 years and much of the original staff remains. It's that familiarity among caregivers that enhances patient safety, says Carroll Harrell, RN, CAPA, the center's director.

"Our communication is terrific," says Ms. Harrell. "It starts at registration. If they see red flags, they place a call to the clinical team and it goes from there. There's familiarity among the staff, so they know how to adjust to problems and no one hesitates to bring an issue to someone's attention or make a suggestion."

Members of the reprocessing staff tag each endoscope that's been cleaned and disinfected, and the tag becomes part of patients' permanent charts. Ms. Harrell verifies scope readiness by conducting random tests for bioburden throughout the day. Safety drills are designed to enhance staff's understanding of the center's many policies and procedures, and attendance is mandatory for all. To keep staff engaged and up to date on any changes in policy, Ms. Harrell developed a Jeopardy-style competition. At first, staff balked at the notion of a surgical game show, but the educational opportunity developed into a spirited competition and turned out to be one of the better in-services Ms. Harrell ever ran.

The center's leadership tailored templates of safety checklists for the pre-op, procedure rooms and PACU. They even created a checklist for the registration desk to ensure they ask patients the right questions during pre-op phone calls.

The recent outbreaks that were linked to inadequately cleaned duodenoscopes have hurt the perceived reputations of GI facilities, even if, like the Princeton Endoscopy Center, they don't use the instruments.

"Patients don't hesitate to bring up what they've heard in the news. We're tuned into that and try to make the entire patient experience as safe and transparent as possible," says Ms. Harrell. "We give them clear explanations of our standards and what we do to protect them from harm."

— Daniel Cook

Daniel Perlov, MD and surgeon Keith Donatto, \MD SPOT ON Co-medical director Daniel Perlov, MD (left), and surgeon Keith Donatto, MD, mark the surgical site before a patient is brought to the OR.

Planning ahead
Dr. Vitcov says Administrator Jessie Scott, MBA, deserves most of the credit for creating a culture of safety. "She's a true believer in patient safety, and that filters down through to the head nurse, who's another true believer," says Dr. Vitcov. "It's only a couple layers down to the frontline nurses in the OR, so they've also become true believers." But even some of Ms. Scott's recommendations have resulted in a few eye rolls in the OR — at least initially. "Several years ago she demanded that anesthesia providers mark sites before placing regional blocks," says Dr. Vitcov. "We didn't think that was necessary, but then a wrong-site block occurred at our affiliated hospital a few weeks later. There was a lot less pushback after that."

Ms. Scott has always been ahead of the curve when it comes to patient safety, and she's instilled that forward-thinking attitude in every member of her staff. "They're the ones who really take patient safety personally," says Dr. Vitcov. "From our techs to our nurses, we have staff champions here."

— Daniel Cook