Please answer each question by filling in the blank or by marking the box to the left of your answer.

Full text

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TOOLONE: Checklist Implementation Leader Survey 1 of 6 Draft Version: March 29, 2011

SAFE SURGERY 2015: SOUTH CAROLINA

Tool 1: Checklist Implementation Leader Survey

This questionnaire requests information about the hospital in which you work, the surgical service or services in which the Surgical Safety Checklist is being implemented and the person or persons responsible for the implementation process. We refer to these individuals in this survey as “implementation leaders.” If more than one person is responsible for implementation, please feel free to work together as you answer the following questions.

Please answer each question by filling in the blank or by marking the box to the left of your answer.

Implementation Leader(s)

The following items request information about the person or persons responsible for the implementation process. Please use one line for each member of the team leading the implementation. “Years in this role” refers to the cumulative years in your current role at any hospital.

Your primary professional

role: Years in this

role: Do you have an additional administrative title: Years in admin role:

A1

01

Surgeon

02

Anesthesiologist

03

CRNA

04

Surgical nurse

05

Surgical technician

06

Nurse manager

07

Administrator or QI officer

99

Other:

01

< 1

02

1-5

03

6-10

04

10+

00

No additional administrative title.

01

Yes.

Please state:

________________________________________

98

N/A

01

< 1

02

1-5

03

6-10

04

10+

A2

01

Surgeon

02

Anesthesiologist

03

CRNA

04

Surgical nurse

05

Surgical technician

06

Nurse manager

07

Administrator or QI officer

99

Other:

01

< 1

02

1-5

03

6-10

04

10+

00

No additional administrative title.

01

Yes. Please state:

________________________________________

98

N/A

01

< 1

02

1-5

03

6-10

04

10+

A3

01

Surgeon

02

Anesthesiologist

03

CRNA

04

Surgical nurse

05

Surgical technician

06

Nurse manager

07

Administrator or QI officer

99

Other:

01

< 1

02

1-5

03

6-10

04

10+

00

No additional administrative title.

01

Yes. Please state:

________________________________________

98

N/A

01

< 1

02

1-5

03

6-10

04

10+

A4

01

Surgeon

02

Anesthesiologist

03

CRNA

04

Surgical nurse

05

Surgical technician

06

Nurse manager

07

Administrator or QI officer

99

Other:

01

< 1

02

1-5

03

6-10

04

10+

00

No additional administrative title.

01

Yes. Please state:

________________________________________

98

N/A

01

< 1

02

1-5

03

6-10

04

10+

A5

01

Surgeon

02

Anesthesiologist

03

CRNA

04

Surgical nurse

05

Surgical technician

06

Nurse manager

07

Administrator or QI officer

99

Other:

01

< 1

02

1-5

03

6-10

04

10+

00

No additional administrative title.

01

Yes. Please state:

________________________________________

98

N/A

01

< 1

02

1-5

03

6-10

04

10+

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(If your team has more than 5 members, please photocopy this page and fill in the table for the appropriate number of implementation leaders.)

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TOOLONE: Checklist Implementation Leader Survey 3 of 6 Draft Version: March 29, 2011

Implementation Leader(s) cont.

The following items request additional information about the person or persons responsible for the implementation process.

Please rate your level of agreement with each of the following statements from “Strongly disagree” to “Strongly agree”:

6. All implementation leaders chose their roles (as opposed to being assigned to the project).

01

Strongly disagree

02

Disagree

03

Neither agree nor disagree

04

Agree

05

Strongly agree

7. All implementation leaders are fully committed to implementing the Checklist.

01

Strongly disagree

02

Disagree

03

Neither agree nor disagree

04

Agree

05

Strongly agree

8. Senior hospital executives (e.g., CEO, CMO, Senior VP for Quality) have demonstrated a personal interest in the success of Checklist.

01

Strongly disagree

02

Disagree

03

Neither agree nor disagree

04

Agree

05

Strongly agree

9. Senior hospital executives (e.g., CEO, CMO, Senior VP for Quality) will be directly involved in Checklist

implementation.

01

Strongly disagree

02

Disagree

03

Neither agree nor disagree

04

Agree

05

Strongly agree

10. Hospital board members have taken a personal interest in the success of Checklist implementation.

01

Strongly disagree

02

Disagree

03

Neither agree nor disagree

04

Agree

05

Strongly agree

Hospital Information

The following items request information about the hospital in which you are implementing the Surgical Safety Checklist.

11. Hospital name:

12. Total number of operating rooms?

13. Current number of the following surgical staff:

Surgeons : Anesthesiologists:

CRNAs:

Surgical nurses:

Surgical technicians:

14. What percentage of the above staff are directly employed by the hospital:

Surgeons : %

Anesthesiologists: %

CRNAs: %

Surgical nurses: %

Surgical technicians: %

15. Does your hospital have an electronic medical record system? (Select one)

00

No

01

Yes, partially implemented

02

Yes, fully implemented but have not achieved federal standards for “meaningful use”

03

Yes, fully implemented and have achieved standards for meaningful use

Surgical Service(s) Information

The following items request information about the surgical service or services in which you are implementing the Surgical Safety Checklist.

16. Which specialties are included in this implementation process? (Check all that apply)

01

General

02

Trauma

03

Orthopedic

04

Neurosurgery

05

Cardiac

06

Thoracic

07

Vascular

08

Pediatric

09

ENT

10

Urology

11

Ambulatory

99

Other:

17. Have other surgical services already implemented the Surgical Safety Checklist in your hospital?

01

No, we will be the 1

st

service(s) to implement

02

Yes, we will be the 2

nd

service(s) to implement

03

At least two other services have implemented

04

We will be the last service(s) to implement

05

We are implementing the Checklist at the same time as other services

18. How far have you progressed toward Checklist implementation? (Check all stages completed)

01

Planning

02

Piloting (preliminary testing with 1 surgical team)

03

Partially implemented (some teams but not all surgical teams in this unit)

04

Fully implemented (all surgical teams in this unit)

99

Other:

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TOOLONE: Checklist Implementation Leader Survey 4 of 6 Draft Version: March 29, 2011

19. Total number of inpatient surgical procedures performed annually by the surgical service(s) in which you are implementing the Surgical Safety Checklist:

20. Total number of outpatient surgical procedures performed annually by the surgical service(s) in which you are implementing the Surgical Safety Checklist:

Motivation for Implementation

The following items request information about the motivation for Surgical Safety Checklist implementation within this surgical service(s).

Please rate the importance of each item below from 1 “Not at all important”

to 5 “Extremely important” as a source of motivation: Not at all important

Extremely important 2

1 .

Media attention to the Checklist

2 2

. Patient demand for the Checklist 2

3 .

Directives from this surgical service(s)’ leadership

2 4

. Hospital board expectations 2

5 .

State hospital association expectations

2 6 .

Peer pressure (i.e., between hospitals)

2 7

. Anticipated regulatory pressure 2

8 .

Desire within this surgical service(s) for ongoing quality improvement

2 9

. Desire within this surgical service(s) to enhance patient safety 3

0 .

Reimbursement or other financial concerns

3 1 .

An adverse or near-miss event

3 2 .

Other:

33. Of the factors listed above, specify the “Most important” and “Second most” important in motivating Surgical Safety Checklist implementation? (Select only one in each column.)

Media attention to the Checklist Most important 2

nd

most important

Patient demand for the Checklist Most important 2

nd

most important

Directives from this surgical service(s)’ leadership Most important 2

nd

most important

Hospital board expectations Most important 2

nd

most important

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TOOLONE: Checklist Implementation Leader Survey 5 of 6 Draft Version: March 29, 2011

State hospital association expectations Most important 2

nd

most important

Peer pressure (i.e., between hospitals) Most important 2

nd

most important

Anticipated regulatory pressure Most important 2

nd

most important

Desire within this surgical service(s) for ongoing quality improvement Most important 2

nd

most important Desire within this surgical service(s) to enhance patient safety Most important 2

nd

most important

Reimbursement or other financial concerns Most important 2

nd

most important

An adverse or near-miss event Most important 2

nd

most important

Other: Most important 2

nd

most important

(Survey continues on the next page.)

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TOOLONE: Checklist Implementation Leader Survey 6 of 6 Draft Version: March 29, 2011

Joint Commission “Time Out”

The following items request information about the Joint Commission “Time Out” and the priority given to Checklist implementation within this surgical service(s).

Please rate your level of agreement with each of the following statements from 1 “Strongly

disagree” to 7 “Strongly agree”. Please note the scale has changed from 5 to 7 choices. Strongly Disagree

Strongly Agree N/A 3

4. The Joint Commission “Time Out” is used in every OR in every case.

3

5. Regular audits are conducted to ensure that the Joint Commission “Time Out” is used.

3

6. Surgeons consistently participate in the Joint Commission “Time Out.”

3

7. In general, nurses initiate the Joint Commission “Time Out.”

3

8. IChecklist Implementation is a top priority in this surgical service(s).

 Thank you for your time. 

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SAFE SURGERY 2015: SOUTH CAROLINA Tool 2: Surgical Safety Culture Survey

TOOLTWO: Surgical Safety Culture Survey (Pre) Version: April 4, 2011

A. Hospital name:

_________________________

B. Are you (or will you be) the person or one of the people responsible for Checklist implementation in the ORs where you work?

01

Yes

00

No

C. Profession:

01

Surgeon

02

Anesthesiologist

03

CRNA

04

Surgical nurse

05

Physician assistant

06

Surgical technician

07

Perfusionist

99

Other: _____________

D. How many years have you worked in this role?

01

<1

02

1-5

03

6-10

04

10+

E. In which surgical service(s) do you work? (Check all that apply.)

01

General

02

Trauma

03

Orthopedic

04

Neurosurgery

05

Cardiac

06

Thoracic

07

Vascular

08

Pediatric

09

ENT

10

Urology

11

Ambulatory

99

Other: ____________

F. In which service do you work most often? (Check one.)

98

N/A: No primary service

01

General

02

Trauma

03

Orthopedic

04

Neurosurgery

05

Cardiac

06

Thoracic

07

Vascular

08

Pediatric

09

ENT

10

Urology

11

Ambulatory

99

Other: ____________

G. What is your ethnicity?

00

Not Hispanic or Latino

01

Hispanic or Latino

97

Decline to answer

H. What is your race?

01

American Indian / Alaska Native

02

Asian

03

Native Hawaiian or other Pacific Islander

04

Black or African American

05

White

97

Decline to answer

I. Gender:

01

Male

00

Female J. Age:

01

18-25

02

26-35

03

36-45

04

46-55

05

55+

While thinking about the ORs in the surgical service(s) where you work, please indicate your agreement with the following statements on a scale of 1 – 7, with 1 being “Strongly Disagree” and 7 being “Strongly Agree”.

Strongly Disagree

Strongly Agree N/A 1. In the ORs where I work, surgical team members are open to changes that improve

patient safety, even if it means slowing down.

2. In the ORs where I work, the Joint Commission “Time Out” is used by every surgical team in every case.

3. In the ORs where I work, the Joint Commission “Time Out” was difficult to implement.

4. In the ORs where I work, surgical team members all agree on the importance of using checklists in surgery.

5. In the ORs where I work, interest in Checklist implementation is limited to one profession (e.g., surgery, anesthesia, or nursing).

6. In the ORs where I work, I am encouraged to report any patient safety concerns I may have.

7. In the ORs where I work, it is difficult to discuss medical mistakes.

8. In the ORs where I work, surgical team members ask one another for help.

9. In the ORs where I work, it is difficult to speak up when I perceive problems with patient care.

DRAFT

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SAFE SURGERY 2015: SOUTH CAROLINA Tool 2: Surgical Safety Culture Survey

TOOLTWO: Surgical Safety Culture Survey (Pre) Version: April 4, 2011

Strongly Disagree

Strongly Agree N/A 10. In the ORs where I work, team discussions (e.g., briefings or debriefings) are

common.

11. In the ORs where I work, communication breakdowns frequently lead to delays in starting surgical procedures.

12. In the ORs where I work, surgical team members make sure their comments or instructions are heard.

13. In the ORs where I work, surgical team members share key information as it becomes available.

14. In the ORs where I work, surgical team members readily offer to help one another.

15. In the ORs where I work, physicians and nurses work together as a well- coordinated team.

16. In the ORs where I work, surgeons and anesthesia providers work together as a well-coordinated team.

17. In the ORs where I work, surgical team members help me care for patients safely.

18. In the ORs where I work, physician leaders (i.e., surgeons and anesthesiologists) are open to suggestions from all team members.

19. In the ORs where I work, disagreements are resolved appropriately (i.e., with an emphasis not on who is right but what is right for the patient).

20. In the ORs where I work, decision-making is shared among surgical team members in response to changes in patients’ conditions or issues that arise.

21. In the ORs where I work, physician leaders set a positive tone for team interactions.

22. In the ORs where I work, surgical team members communicate with me in a respectful manner.

23. In the ORs where I work, my input about patient care is well received by other surgical team members.

24. In the ORs where I work, I am always treated as a valuable member of the surgical team.

25. In the ORs where I work, errors or mistakes are pointed out without raised voices or condescending remarks.

26. In the ORs where I work, all surgical team members refer to each other by name rather than role.

27. In the ORs where I work, surgical teams always discuss the operative plan (i.e., more than the location of the incision and name of the procedure) before incision.

28. In the ORs where I work, for complex patients or cases, preoperative briefings always include planning for potential problems.

29. In the ORs where I work, postoperative debriefings always include a discussion of key concerns for patient recovery and post-op management.

30. In the ORs where I work, equipment issues or other problems discussed in postoperative debriefings are addressed in a timely manner.

31. I would feel safe being treated here as a patient.

32. If I were having an operation, I would want a surgical safety checklist to be used.

33. Pressure to move quickly from case to case gets in the way of patient safety.

 Thank you for your time. 

DRAFT

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Tool 3: Surgical Teamwork Observation Tool

Date of procedure:______/_______/______

Hospital name:___________________________________

TOOLTHREE: Surgical Teamwork Observation Tool Version: April 4, 2011 Procedure Information

Patient age: _______ Time of incision: ___:___ AM / PM Urgent/emergent case (requiring same-day completion):  Yes  No Patient gender: M F Surgical end time: ___:___ AM / PM Significant nonclinical disruptions:  Yes  No

Surgeon’s specialty: _________________________________ Case delayed >30min:  Yes  No Procedure performed: _________________________________ Patient disposition:  Inpatient  Outpatient Observer Information

Observer age: _____ Observer gender:  M  F Years in current role at this hospital: ____

Observer role:  Nurse Manager  QI / Patient Safety Personnel Other: __________________

The statements in the table below relate to surgical team members’ interactions during this procedure. Please consider the following definitions as you read them:

Clinical leadership: Exerting control or playing a decision-making role in the patient’s clinical care. Any member of the team may demonstrate clinical leadership in the course of a surgical procedure.

Physician leader: A surgeon or anesthesiologist demonstrating clinical leadership.

Team members: Any individual present and participating in a surgical procedure (e.g., physicians, nurses, technicians, etc.) Technical tasks: The specific activities performed by team members in the course of a surgical procedure.

On a scale of 1 – 7, with 1 being “STONGLY DISAGREE” and 7 being “STRONGLY AGREE”, please indicate your agreement with the following statements regarding this procedure:

Strongly Disagree

Strongly Agree N/A 1. Clinical leadership was shared among disciplines depending upon the patient's condition or

issues that arose during the operation.

2. Physician leaders were open to suggestions from all team members.

3. Physician leaders set a positive tone while performing the Checklist.

4. Physician leaders maintained a positive tone throughout the operation.

5. Verbal communication among team members was easy to understand (e.g., clearly articulated and spoken at an adequate volume).

6. Team members shared key information as it became available.

7. Speakers made a visual or spoken effort to confirm that important information was received.

8. Recipients made a visual or spoken effort to confirm that they understood the information communicated.

9. Team members called attention to potential hazards or omissions.

10. New or junior team members spoke up with information they thought the team should know.

11. Team members asked each other for help.

12. Team members helped one another.

13. Team members from different disciplines discussed the patient’s condition and the progress of the operation.

14. Plans were discussed and adapted as needed.

15. Technical tasks were well coordinated among team members.

16. Team members spoke respectfully (e.g., called each other by name instead of by role).

17. Potential errors or mistakes were pointed out without raised voices or condescending remarks.

18. Team members reacted appropriately when their potential errors or mistakes were pointed out.

19. Discussions took place in a calm, learning-oriented fashion.

On a scale of 1 – 7, with 1 being “VERY POOR” and 7 being “EXCELLENT”, please rate your overall impression of how well team members worked together during this procedure:

Very

Poor Excellent NA

20. Please rate clinical teamwork during this procedure.

Please use the back of this form to provide further comments.

(10)

Tool 4: Surgical Safety Checklist Observation Tool

Date of procedure:______/_______/______

Hospital name:______________________________________

TOOLFOUR: Surgical Safety Checklist Implementation Version: April 11, 2011 Procedure Information

Patient age: _______ Time of incision: ___:___ AM / PM Urgent/emergent case (requiring same-day completion):  Yes  No Patient gender: M F Surgical end time: ___:___ AM / PM Significant nonclinical disruptions:  Yes  No

Surgeon’s specialty: _________________________________ Case delayed >30min:  Yes  No Procedure performed: _________________________________ Patient disposition:  Inpatient  Outpatient

Observer Information Observer role:  Circulating Nurse Other: __________________

Observer age: _____ Observer gender:  M  F Years in current role at this hospital: ____

Processes of Care

1. Was an antibiotic given within 1 hour of incision? Yes, w/o prompting Yes, prompted by Checklist No N/A 2. Were compression boots placed (mechanical DVT prophylaxis)? Yes, w/o prompting Yes, prompted by Checklist No N/A 3. Was a warmer placed (for case >1 hour)? Yes, w/o prompting Yes, prompted by Checklist No N/A

Briefing

4. Which of the following individuals participated in confirming the patient’s

identity, procedure or operative site before incision? (Mark all that apply.)

 

Nurse

 

Anesthesia

provider

 

Surgeon

 

Not confirmed 5. Did team members introduce themselves by name and role (e.g., “Lynn, the anesthesiologist.”)? Yes No

5a. If no, is this team established (e.g., introductions performed earlier, regular surgical team)? Yes No

6. Before incision, did the surgeon discuss the operative plan? Yes No

7. Before incision, did the surgeon state the expected duration of the procedure? Yes No

8. Before incision, did the surgeon communicate the expected blood loss (EBL)? Yes No

9. Before incision, did the nurse discuss sterility, equipment, or any other concerns? Yes No

10. Before incision, did the anesthesia provider discuss the anesthesia plan (including airway or other concerns)? Yes No

11. Were all checklist items read aloud, without reliance on memory? Yes No

12. Rate the briefing using the scale and descriptions below. “1” represents a very poor briefing; “7” represents an excellent briefing.

Very poor: If a “time out” or briefing was attempted, it received minimal attention. At least two features of an “excellent” briefing were not covered.

Neither poor nor excellent: Information was shared by team members during a dedicated briefing before the case began. However, at least one feature of an “excellent” briefing was not covered.

Excellent: Information was shared by team members during a dedicated briefing before case began: Surgeon discussed the operative plan. Anesthesia provider discussed the anesthesia plan. Nurse discussed sterility, equipment, or other concerns.

Debriefing

13. Before the patient left the OR, did the team discuss specimen labeling (e.g., labels / patient name read aloud)?  N/A  Yes  No 14. Before the patient left the OR, did the team discuss equipment or other problems that arose?  N/A  Yes  No 15. Before the patient left the OR, did the team discuss key concerns for patient recovery and post-op management?  Yes  No

Buy-In

16. Rate Checklist buy-in using the scale and descriptions below. “1” represents very poor buy-in; “7” represents excellent buy-in.

Very poor: Two or more members of the team continued other activities or conversation continued while performing the Checklist.

Evidence of poor buy-in (e.g., eye-rolling, speed reading).

Neither poor nor excellent: Any member of the team continued other activities or conversation while performing the Checklist.

Excellent: All other activities and conversation stopped while performing the Checklist. All team members appeared interested.

18. Please rate the surgeon’s buy-in.

19. Please rate the anesthesia provider’s buy-in.

20. Please rate the circulating nurse’s buy-in.

21. Which of the following individuals read parts of the Checklist? (Mark all that apply.)

 

Nurse

 

Anesthesia provider

 

Surgeon

Additional Data

22. Did the circulating nurse leave the OR repeatedly to find equipment or to coordinate case-related activities?  N/A  Yes  No 23. Was equipment available and functioning throughout the case? If no, please describe difficulties on the back of this form.  Yes  No 24. Was a potential error or omission averted by the Checklist? If yes, please describe the event on the back of this form.  Yes  No 25. If there is significant EBL, was a type and cross sent or blood products available?  Not discussed  N/A (EBL NS)  Yes  No 26. If there is significant EBL, was adequate IV access discussed and obtained?  N/A (EBL NS)  Yes  No 27. If expected duration of operation > 2 hours, was antibiotic re-dosing discussed?  N/A (< 2h)  Yes  No

Please use the back of this form to provide further comments.

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Figure

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References

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Related subjects :