1. Can we change the checklist?
Yes. The checklist is a tool to drive improvements in communication and teamwork within the perioperative setting and to improve the reliability of care provided to patients. Local adaptation of the checklist is encouraged and supported by the WHO to fit local practice.
Learning through Patient Safety First is that implementation is more effective and sustainable, where staff have adapted the checklist through small tests of change to identify what suits their local requirements.
As an example look at the Implementing the checklist improvement methodology WebEx recording which highlights how a trust adapted the checklist.
2. Do we have to sign the checklist?
There is no requirement to have signed checklists. What you do locally should be determined by local clinical governance procedures/requirements.
3. Can we put some of the questions into a pre-list safety briefing?
Yes. The checklist contains critical prompts necessary at key points of a patient’s individual surgical pathway to assure their safety; namely prior to induction of anaesthesia, knife to skin and conclusion of the case.
The majority of hospitals in England provide list-based rather than case-based care which means that staff introductions and equipment considerations are more usefully addressed at the start of the day with regard to all patients on the list. Briefings provide an opportunity for the team to highlight actual and potential problems at the start of the day and thereafter to proactively manage them. As well as improving patient safety, briefings have been shown to reduce the number of glitches, delays and interruptions experienced on a list, contributing positively to increasing the efficiency and productivity of the list.
4. Does the surgeon have to be present for the 'Sign-in' for each patient?
It is for individual trusts to decide how the elements are implemented. There is no single or right way to do it. The Sign-in is principally a check for the anaesthetist and anaesthetic assistant to run through, before induction of anaesthesia.
Small tests of change / PDSA’s (Plan, Do, Study, Act) of each aspect of the Surgical Safety Checklist will enable you to to judge what works in real time under different settings / circumstances and across specialities. As a tool, the checklist is designed to enhance and improve how staff communicate and work together, not to burden or hinder them.
5. If we do a briefing does it have to be before we send for the first patient?
Briefings are about informing the whole team about what is going to happen during the list. It would often include a discussion about each patient and the potential problems or challenges. Whether that takes place before or after sending for the first patient should be decided locally to take account of your local geography and the distance of some wards/admissions units from the Operating Theatre.
6. Can the checklist become part of the surgical care plan documentation?
Yes. Many trusts have found this to be a way of reducing duplication of questions and ensuring a record of the checklist is filed in the notes.
7. What should we measure?
Measurement for improvement or ‘plotting the dot’ on a run chart is designed to demonstrate that what we think is happening in practice is actually happening. Recording sign-in, timeout and sign-out either in the notes or electronically can be verified by a random sample of case notes on a monthly basis to provide due assurance of the reliability of processes. Some trusts are linking existing monitoring of theatre activity via local IT systems to evidence that the checklist has been used to support the care delivered, eg: recording anaesthesia start time, is linked to a question about whether the 'Sign-in' has taken place, the time of incision to 'timeout' etc.
8. What do we measure to demonstrate a benefit?
Measurement of indicators of quality, outcomes, process and efficiency can all be used to demonstrate benefit.
Teamwork and safety attitudes assessed via staff self-report or independent observation / interview, can show improvement in the culture of theatre. Complications and deaths are clearly important measures and can be captured by the overall Hospital Standardised Mortality Rate (HSMR).
Audits of the delivery of the Surgical Site Infection bundle and VTE prophylaxis can demonstrate improvements in the reliability of processes.
Reductions in the number of cancelled procedures, over-runs and turn round times can show efficiency gains resulting from all the quality improvements.
Most importantly measurement for compliance or ‘ticking the box’ must not become an industry in ‘itself’ or the over-riding preoccupation as this will detract from the overall aim to improve teamwork and communications to deliver better care for patients.
9. Is the checklist to be used for all surgical procedures?
The immediate requirement of the NPSA Alert (January 2009) is that the checklist is used for all patients undergoing a surgical procedure on an ‘in patient’ or day case requiring general, local anesthesia or sedation. This includes therefore endoscopy, interventional radiology and dermatological procedures. Clearly the opportunity exists for improving communication in many other situations and the development of checklists to improve the reliability of local processes is encouraged. Examples already observed include oncology clinics for children, radiotherapy lists and rheumatology biologic treatments.
10. How de we handle staff who may be less open to using the checklist?
As with any change there will inevitably be reluctance to use the checklist amongst some staff members. It is often surprising who readily adopts a new process and who resists it. Start where the will is, identify your champions and early adopters but also try to understand the viewpoint of those not embracing the change so readily. Knowing the reason for their reluctance is useful information and can do much to inform you in developing your local solution.
If an individual is completely unhelpful or purposefully subversive in their actions, take account of the leadership for safety intervention principles and seek the support of your named Executive Lead.
11. Do we have to use the NPSA documentation as circulated with the Alert?
No. The core content should be included but adapt the documentation to suit what works in your trust. In many instances trusts are opting for a paperless solution or using a whiteboard or laminated sheet in the Operating Theatre; again small tests of change will help you identify what staff accept more readily and what behaviours are likely to prove sustainable and enduring.
12. How de we use it for ‘rapid turnover’ lists?
The sign-in, timeout and sign-out in ‘rapid turnover’ lists, are even more important as there is a greater risk of error and changes to the order of the list. The cross check of safety critical issues should only take a minute or so and will recoup the time invested in doing them by reducing mistakes and hold ups. Staff are reporting to Patient Safety First that together with the checklist, pre-list safety briefings have done much to reduce turn around times, because staff are alert to and sensitive to things that cause glitches or ‘lost’ time.
13. Who should do the time out?
All of the theatre staff team should do the time-out and anyone in the team can lead it. It doesn't have to be a doctor. Culturally there is much to be gained from circulating the team member leading it.
14. Who should be involved in the sign-out?
Everyone involved with the case should be part of the sign-out.
15. Who should lead the briefing / debriefing?
This can be any of the team. A surgeon or anaesthetist leading may inhibit the degree of open exchange at the outset depending up the team culture. Similarly with regard to encouraging introductions a doctor telling members of the team to introduce themselves may not be the best way to flatten a hierarchy! Encourage all team members to take an active role.
Overall the 5 steps of briefing, sign-in, time out, sign-out and debriefing are designed to enhance the teamwork and communication between team members to contribute positively to the patient experience and reliability of care delivered in the operating room.