Case study
Communicating for success – Royal Bolton Hospital NHS Foundation Trust introduces the Surgical Safety Checklist
As part of their commitment to improving patient safety Royal Bolton Hospital NHS Foundation Trust has recently introduced the WHO Surgical Safety Checklist. Since learning that 66% of the incidents during surgery reported at the trust between April 08 and April 09 were avoidable the surgical team has worked tirelessly to implement the checklist to ensure a safer environment for patients. It is now part of the operating standard within the trust and has been positively embraced by staff.
Royal Bolton signed up to the voluntary Patient Safety First campaign in 2008. With their own plans in place to improve patient safety, they saw it as an ideal way to help them put their plans into practice. One of the Patient Safety First interventions that Royal Bolton focused on was Reducing Harm in Perioperative Care, which aims to improve care for patients undergoing surgical procedures in a hospital setting. Part of this intervention is the implementation of the Surgical Safety Checklist which was created to improve patient safety through enhancing teamwork and communication.
Introducing the Checklist
Prior to the trust’s focus on the checklist, Royal Bolton had already brought together a core group of experts to begin work on implementing the Perioperative intervention. The core group consisted of a theatre manager, an improvement lead and consultant orthopaedic surgeon and associate director, Steve Hodgson. This group began to work across the trust on how to introduce the checklist, how to test its use and how to measure the improvement from using it. Steve says “As a first step we were keen to benchmark what we were already doing against the various measures in the intervention. This gave us a clear idea of our current performance allowing us to determine when a change becomes an improvement.”
The importance of communicating with and involving people beyond this core group was recognised straight away. Steve says: “We spent May and June (2009) spreading word of our intentions throughout the trust and getting feedback from different teams. 120 members of staff took advantage of the drop-in sessions that we held where we presented research supporting the checklist. We also held further information sessions and departmental meetings. “The feedback we received from staff was very positive. Most people were keen to introduce the checklist as quickly as possible.”
To understand the need for the checklist they looked at the level and detail of incidents from April 2008 to April 2009. Steve says “We found that over the 12-month period there were 41 incidents reported. These ranged from incorrect equipment, missing items and patients being anaesthetised without correct consent. All 41 incidents were reviewed and 27 were found to be avoidable had the checklist been in use.”
The trust also looked at whether they would benefit from any adaptation of the checklist. They concluded to implement it without adaptation and made sure that every staff member had a copy of the checklist, and time to discuss it, well before it was introduced.
A pilot was implemented in two theatres before it was put into practice trust-wide. This one-month learning-focused pilot immediately highlighted the effectiveness of the checklist in improving patient safety, as Steve says “Over the month, the checklist was used on 62 patients and we identified nine potential incidents that were avoided as a result. During the same period, staff from other theatres where the checklist wasn’t being used came forward and admitted to two very near misses.”
Patient Safety First week
The trust used September’s Patient Safety First week as the springboard to fully promote and accelerate use of the checklist. All theatres used it during the week and following an audit, they found that 33% of patients undergoing surgical treatment were reached. This jumped to 72% of patients in October 2009.
All eight theatres are now using the checklist, covering all patients all times of the day. “We know that in the last few weeks we’ve improved even further,” adds Steve. “Recording how we’re doing is really important to see if we’re improving, so we’re relying on theatres to complete their audit forms to measure for improvement.”
Changes to implementation
While the trust is happy with how the checklist is going, Steve admits that he should have had a wider core group from the start: “In hindsight, it would have been nice to have an anaesthetist on board and have more theatre staff involved earlier on. However, having said this, having a smaller group did enable us to get up and running very quickly.
“Every trust is different but implementating the checklist across the trust worked for us rather than a prolonged pilot period. Essentially it is all about changing the culture, which can be a long process, but it’s well worth it.”
Looking ahead
At Royal Bolton, as with many trusts, the biggest challenge remains changing the culture. Steve says “I’m thoroughly enthusiastic about the checklist. It’s about engineering a system that means the operation can’t go ahead without it happening first; for example, the blade not being mounted onto the scalpel until the checklist sign-in and time-out has been done.”
David Fillingham, Chief Executive at Royal Bolton adds “However much we win staff’s hearts and minds, people are people and there will still be times when the best and most experienced forget to do the checklist or don’t do it fully. As a result we need to redesign the system so that it is absolutely impossible to start until all the checks have been done.”
Steve says “So where do we go from here? Our operating standard now includes the checklist; it is now part of theatre practice just the same as equipment and swab checks are at the end of an operation. It will be documented for all patients and we’ll continue to audit until we reach a tipping point where it becomes part of standard practice.”
Steve concludes “The information and guidance from Patient Safety First has been instrumental to us in making patients at Bolton safer. I would recommend other trusts to fully take advantage of this opportunity.”