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
01Surgeon
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
01Surgeon
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
01Surgeon
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
01Surgeon
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
01Surgeon
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+
(If your team has more than 5 members, please photocopy this page and fill in the table for the appropriate number of implementation leaders.)
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
stservice(s) to implement
02
Yes, we will be the 2
ndservice(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)
01Planning
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:
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
ndmost important
Patient demand for the Checklist Most important 2
ndmost important
Directives from this surgical service(s)’ leadership Most important 2
ndmost important
Hospital board expectations Most important 2
ndmost important
TOOLONE: Checklist Implementation Leader Survey 5 of 6 Draft Version: March 29, 2011
State hospital association expectations Most important 2
ndmost important
Peer pressure (i.e., between hospitals) Most important 2
ndmost important
Anticipated regulatory pressure Most important 2
ndmost important
Desire within this surgical service(s) for ongoing quality improvement Most important 2
ndmost important Desire within this surgical service(s) to enhance patient safety Most important 2
ndmost important
Reimbursement or other financial concerns Most important 2
ndmost important
An adverse or near-miss event Most important 2
ndmost important
Other: Most important 2
ndmost important
(Survey continues on the next page.)
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.
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.)
01General
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
01General
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
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
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.
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
