TRUE TO FORM Checklists ensure surgical teams follow standardized pre-op protocols.

It's one thing to have a surgery safety checklist. It's quite another to use it consistently and properly before each and every case. The South Carolina Hospital Association awarded our hospital with a Safe Surgery Designation because of the ways we use our checklists. Here are the steps we took to be recognized as a local leader in protecting patients.

Survey the staff on checklist usage
Does your surgical team complete every section of the safety checklist before every case? We thought our team did, until it came time to apply for the Safe Surgery Designation. The form asked if each element on our safety checklist is completed for every patient, every time. I couldn't in good conscience answer the question, because I'm not in the room when the OR team conducts pre-op time outs and runs through the checklist.

That's when we polled our staff to find out. You should do the same. Create a survey based on the elements listed on your checklist that asks staff to check "yes" or "no" next to each element to indicate if they perform the task for every patient. Keep the survey anonymous to ensure you get honest feedback. You might be surprised to find, like we did, that the compliance rate isn't as high as you'd like it to be.

Partner with physicians
If you're not at 100% compliance, you need to find out why. Present the data to your physicians and start the conversation based on the results of the survey tool. To make real change happen, your docs must be on board with your efforts to improve checklist usage. A general surgeon and anesthesiologist championed our cause, and their efforts were instrumental in getting the surgical team to buy into the importance of completing the checklist for every patient.

Don't make protocols for completing the checklist so structured that it becomes a burden for teams to complete or doesn't fit with how individual surgeons prefer to work. For example, one of our surgeons likes to complete the checklist after he's gowned and gloved and ready to cut. Another physician likes to complete it before the patient is draped, so he can easily see the intended surgical site. Allow for those variations, as long as the core elements of the checklist are covered.

Assign roles
The checklist prompts a conversation among the surgical team members, who should each know their role and what they have to cover. The surgeon should not be the only one talking and asking for confirmation to yes-or-no questions. Each team member must announce their name and position before going over their part of the checklist. Here are the roles we've assigned:

• The circulating nurse announces the patient's name and date of birth and the scheduled procedure, including the specific location of the surgical site. She alerts the team to any allergies the patient might have and confirms that pre-op antibiotics were administered on time.
• The anesthesia provider relays the patient's ASA class and alerts the team of potential anesthesia-related problems during the case.
• The surgical technologist confirms that the sterile indicators are good and that she doesn't anticipate any equipment-related problems.
• The surgeon always speaks last to confirm the procedure, tells the team how long the case should last and discusses the potential for complications. The one scripted line every surgeon must say before cutting: "If anyone at any time sees something abnormal during this case, please speak up."

It might seem like a waste of time to have members of the surgical team introduce themselves before every case, especially if you work in a small center with a close-knit crew. But the pre-op introductions are important, even when everyone knows one another. That small gesture serves as an icebreaker and ensures every member of the team is engaged in the procedure and actively involved in the checklist process. Plus, studies have shown that someone who talks during the pre-op time out is more likely to speak up during the procedure if something seems amiss.

Monitor real-time compliance
Surgeons should lead the pre-op time out, but you should also assign a leader in the OR who's responsible for ensuring the surgical team covers every element of the checklist — and prevents surgery from commencing until they do. The anesthesia provider is well suited to fill that role. When the incision is about to be made and the checklist should be completed, they're done putting the patient to sleep and can direct their full attention to the time out. The surgeon drives the process, but the anesthesia provider ensures everyone is participating and all the elements of the checklist are covered.

Debrief
Debriefing is an important yet sometimes overlooked element of patient safety. In reviewing the surgical procedure that was just performed, the OR team ensures that counts are correct, notes any specimens that were sent out and brainstorms anything it could have done better to make the case safer and more efficient. Debriefing was the hardest section of the checklist for us to score 100% compliance on, so we hung a sign on the inside of the OR door that says keep calm and debrief. We also created a debriefing form with the following checkboxes: equipment issues, recovery concerns, instrument issues and other. The circulating nurse can note, for example, that scissors weren't sharp, the camera wasn't working correctly or the patient was hypothermic. The charge nurse receives the sheets from the day's cases, resolves whatever issues she can and passes the rest along to me, the director of surgical services.

We track the issues brought to our attention on the debrief sheets, noting which ones have been resolved and which we're still working on, and post the status for each on a bulletin board at the surgical department's front desk. We also present that info at department of surgery meetings. Sharing the progress of addressing concerns raised by the surgical team proves they're getting tangible results from their efforts and keeps staff and surgeons invested in our efforts to maintain checklist compliance. OSM