Guy’s and St Thomas’ NHS Foundation Trust employs around 10,000 staff and has approximately 850,000 patient contacts each year. With the help of Patient Safety First, over the last 12 months the trust has been working to implement the Surgical Safety Checklist to improve communication and teamwork and ensure patients are receiving the safest care possible. The result is a trust with operating theatres that are run by teams that communicate well, are efficient and effective and that always put patient safety first.
Guy’s and St Thomas’ NHS Foundation Trust has been working over the past year to implement the World Health Organisation Surgical Safety Checklist as part of Patient Safety First’s reducing harm in perioperative care intervention. The trust is a large organisation based across two sites, so introducing the checklist was not an easy task but results have so far proved positive with staff surveys showing improved communication, and checklists being reliably carried out on a regular basis.
Creation of the Patient Safety Working Group
Implementation of the checklist was coordinated by a specially-created working group, led by a consultant vascular surgeon. Along with clinical staff, anaesthetists and managers the group had a large amount of nursing representation with deputy chief nurses and sisters from different theatres on board, and staff nurses were invited to give feedback on areas relevant to them.
From the beginning, the working group emphasised the importance of engaging with frontline clinical staff who would be using the checklist in their day to day roles.
Implementing the checklist
The checklist was first introduced as a pilot on the St Thomas’ Hospital site before it was implemented across the whole trust in January 2010. Implementation has been far from a ‘one size fits all’ approach. The he working group has collaborated with staff to adapt the checklist to suit the needs of different specialties. For example, the question on anticipated blood loss had to be adapted for use in paediatric theatres as the wording was inappropriate for that patient group. Similarly, the checklist was adapted for dental operations as many of the questions wouldn’t apply to dental theatres.
One of the key things that we wanted to ensure was that the checklist wouldn’t create any unnecessary paperwork for nursing staff. As a result the checklist was printed onto an A3 board in each theatre which we write on instead of a separate piece of paper. We also adapted the perioperative care plan to include a colour-coded section for recording the checklist being completed and to highlight any issues raised. Making the checklist more visual in this way has helped the team to focus communications and discuss plans for the operation more effectively.
The Nurses’ role
In order to implement the checklist effectively, it was essential to engage all staff to ensure the theatre team worked together. Nursing staff have been involved at all stages of the implementation project and theatre sisters have been key in, educating staff about the advantages, and in ensuring that it is used for each patient. Nursing staff have reported that the ‘time out’ stage of the checklist in particular has been enthusiastically received, as the team introductions have created a more open environment where even junior members of staff feel engaged and part of the team.
Hurdles
While the reception from the majority of staff has been very positive, it was inevitable that not all staff would be immediately enthusiastic about such a comprehensive change. Any teething problems were dealt with by members of the working group, who:
• provided training sessions to staff
• led trust-wide publicity campaigns
• worked with individuals to identify any gaps or issues with implementation.
Without a doubt the checklist works best when all staff members are engaged so encouraging an open culture has been vital. Taking time to emphasise the ways that the checklist can improve patient safety and theatre processes has been key.
Outcomes
At Guy’s and St Thomas’ we have benefited from both the help and guidance available from the Patient Safety First website and useful events that have been held where we’ve had the opportunity to share and compare ideas with other trusts.
We have monitored our implementation of the checklist via a number of mechanisms including:
- Observational audits of the checklist in use
- A notes review to ensure use of the checklist was being recorded appropriately in the patient record
- A staff survey to collect feedback on how effectively it is being used and to gather suggestions for improvement.
Communication and staff morale have definitely improved since the checklist was introduced. Staff have found that talking things through involves everyone in theatre and can encourage everyone to take responsibility for a patient’s safety.
Introducing the checklist has been a major work programme for us due to the size and complexity of the organisation. However, it has been worth it and so far our audit results have shown that it is being used as standard throughout theatres.
Implementation is not a static process. We will continue to monitor staff feedback and adapt the process wherever necessary.
AUTHORS Dr Rachel Bell [MS FRCS] is Consultant Vascular Surgeon and Clinical Lead for the Surgical Safety checklist at Guy’s and St Thomas’ Foundation Trust, London and Linnie Pontin [BA Hons] is Senior Clinical Governance Manager at Guy’s and St Thomas’ Foundation Trust, London.