Dr. Preston was a participant in IHI's Improvement Advisor Professional Development Program.

Alan Whippy, MD, Sponsor
Phillip Madvig, MD, Executive Champion
James Chang, MD, Executive Champion
Barbara Crawford, RN, Executive Champion
Suzanne Graham, RN, PhD, Safety Leader
Multidisciplinary OR Teams (all 16 regional medical centers)
San Francisco OR Team Leaders
Steve Edwards, MD
Joanne Harwood, RN
Leslie King
Monica Gilliam, RN
Nancy Corbett, RN
Rachel Mueller, RN
Laura Moreno, RN
Sybil Solis, RN
Miriam Casey, RN
Rita Mah, RN
Regional Project Managers
Efren Rosas, MD, Surgical Leader
Doug Grey MD, Surgical Leader
Paul Preston, MD, Improvement Advisor

Outcome Metrics:

• Time Between Surgical Verification Injuries and Retained Foreign Objects: This data is analyzed for location-only surgical verification and retained foreign objects that occur in operating rooms (ORs); ambulatory surgery and eye procedure sites are included, as other locations are not yet impacted by this program. This data is displayed as a T-chart, days between event, and broken down by event type and facility level. This proprietary data is not posted.

Process Metrics:

• Highly Reliable Surgical Team (HRST) formed, meeting regularly, local project support
• HRST Facility Launch completed (requires closing the OR and introducing briefings to all OR staff)
• Preoperative briefings taking place, documented by observational audits
• Whiteboards installed in each OR and used to document the team and patient-specific data for the briefing
• End-of-case debriefings taking place to identify systems issues
• Debriefing data being categorized for analysis and action
• Percent of respondents reporting “good” teamwork climate using 60-question Safety Attitude Questionnaire (SAQ)
• Percent of respondents reporting “good” safety climate using SAQ
• Attaining SCIP (Surgical Care Improvement Project) goals for antibiotic timeliness (see chart below), correct antibiotic, beta blockade, glucose control, temperature control, and thrombosis prevention

Balancing Metrics:

• Operating Room Productivity: First-case start times, turnover less than 30 minutes between cases, last-hour utilization. This proprietary data is not posted; it is currently in run chart format and eventually will be in statistical process control (SPC) format.

• Testing of briefings and tools at three pilot sites: The new workflow, requiring scripted team briefings before induction of anesthesia, was extensively tested for feasibility. The workflow was found to be OK, but scripts required modification and some adaptation to specific surgical areas.
• Eye and cardiac surgery processes tested: Eye and heart surgeries have unique workflows. Using the general briefing tools created for HRST proved a negative test cycle (PDSA) for these domains. We have a very good tool for cardiac surgery after several PDSAs, and we are still working on eye surgery.
• Toolkit created for facility HRST teams (April 2007): Includes many proven tools. This tested the ability to engage teams with work-in-progress tools and proved successful.
• Regional launch for RPMG members (April 2007): A high-profile launch was created for the OR leadership of all facilities. This helped put HRST on the priority list for 2007.
• General tool in place at 16 sites (Nov 2007)
• New commitment of regional project managers (Nov 2007): Regional project managers are going directly to facilities to participate in team meetings and observe briefings. This is working well, clarifying successes and also areas where more work is needed.
• Debriefings, glitch books to capture systems problems, share best practices, new learnings: Very successful at pilots

• IHI tools and concepts were very helpful in moving this project forward. Looking at this project using the Profound Knowledge model (Psychology, Systems, Variation, and Science of Improvement) allowed us to identify strengths and weaknesses and modify processes accordingly.
• Kaiser Permanente already has many strengths that complement IHI concepts. Our core goal and mission and our unified system facilitate improvement. We have strong leadership and operational structures that allow us to make significant change using dashboard data, targets, and incentives. We can use IHI tools to improve these skills by adding SPC data that runs over time.
• We were able to transform OR communications in all of our facilities most of the time. Facilities have developed operational teams that seem to be sustained and very active.
• Front-line staff and teams were not only interested in addressing operational and systemic problems, but required this commitment to buy-in to the briefings and debriefings. This is resulting in data and action with effects on safety, morale, reliability, and efficiency.
• None of our facilities had ever closed the OR to talk as an entire group about safety and operational systems. This was a powerful demonstration of leadership commitment: “I don’t care what you know until I know that you care.”
• This project had strong psychological resonance, a proven intervention that still needed (and needs) refining, and a mixed family of data. Process data is promising; outcome data is lagging and we could use more.
• The initial positive results have increased the regional support considerably. Additional project support has been mobilized to help local teams, and make sure the concepts and behaviors are universally in place. This also allows us to start more inter-facility sharing of best practices, barriers, and learning. A more robust system of observational measures of briefings is under creation, and the results of these briefings will be reported transparently by facility.

• Surgical verification errors will be on our regional quality measures in 2008, a very high-profile dashboard.

• Critical factors in successful spread and permanent adoption of this effort include the following: standardization of the processes, integrating these into fundamental workflow, sustained education and training for all, and ongoing process measures (including observational measures).

Next Steps

• Create a training video for our HRST project, with clear examples of our expected behaviors and why this matters. This is essential to educate new employees and those we missed in 2007.
• Focused systemic work in one or two clinical areas (possibly ophthalmology and total joint surgery) to test optimal workflows and standardization throughout the process.
• Outcome and trigger data streams that we might measure — National Surgical Quality Improvement Program (NSQIP) chart review is robust but expensive. Our new Electronic Medical Record will be powerful and rapid, but may require programming. Recent Harvard efforts to create a surgical Apgar score (using intraoperative blood loss, heart rate, and blood pressure) may be predictive of outcomes and allow continuous tracking and comparisons. These are worth piloting. If we know the actual outcomes of our surgical care, we cannot only measure the true costs of harm and complications, but will also better be able to prove our quality to purchasers and regulators.
• Non-OR procedure areas are a future site for interventions.