IHI ID 16 Moving from parallel to serial preoperative process flow utilizing multidisciplinary bedside handoffs improves preoperative task completion

• Published in: BMJ open quality 2018-12, Vol.7 (Suppl 1), p.A20
• Main Authors: Josephs, Sean, Raleigh, Jennifer, Wooten, Leslie, Adams, Frank, Chadwell, Jamie, Trammell, Alison, O’Brien, Lynne, Merkel, Andrea, Osborne, Todd, Wallmann, Ron, Topala, Alex, Bertsch, Stuart
• Format: Article
• Language: English
• Subjects: Communication; Control charts; Documentation; Interdisciplinary aspects; Medical errors; Medical records; Medical-surgical nursing; Nurses; Patient safety; Surgery; Teams
• ISSN: 2399-6641
• DOI: 10.1136/ihisciabs.16

BackgroundIncident reports suggested that patients were reaching the operating room (OR) without completion of necessary preparatory tasks. Incidents included Near Misses with potential for harm. Parallel processing and inadequate communication among preoperative nurses, anesthesia providers, and OR nurses were determined to be root causes of many of these failures.ObjectivesSignificantly increase the number of days-between preoperative task-completion (PTC) failures.MethodsIncident reports were analyzed for root causes. Preoperative process flow was mapped. Process flow at other institutions was observed. Multidisciplinary bedside handoffs utilizing a task-completion checklist were tested, adapted, and adopted as a new preoperative process (figure 1). Days-between PTC failures were plotted on an XMR chart as the primary metric. First case procedure start times were plotted on XMR charts as a balancing measure. Qualitative data were collected about process issues identified by the handoff process.Abstract IHI ID 16 Figure 1Process flow chart and bedside handoff checklistResultsAfter introduction of bedside handoffs days-between PTC failures reaching the OR increased from every 5 days to >40 days (figure 2). The average procedure start time was delayed by 8 min (figure 3). A majority of PTC failures that were stopped from reaching the OR were surgeon-specific (figure 4A). Unavailability of nurses was a reported barrier to process success. (figure 4B).Abstract IHI ID 16 Figure 2Days-between preoperative task completion failuresIndividuals (XMR) chart depicting the days between preoperative task-completion failures that resulted in incident reports. The chart is annotated for important time points in the study. Special cause is illustrated by points/connectors in red and by points above the upper control limit. Dashed red line = upper control limit; Light blue line = Centerline depicting the mean for each valueAbstract IHI ID 16 Figure 3First-case start timesIndividuals (XMR) chart depicting the average start time for first cases in the operating room. The chart is annotated for important time points in the study. Special cause is illustrated by points / connectors in red and by points above the upper control limit. The shift upward of the centerline after special cause was met in the upper chart illustrates the average start time becoming significantly later after ‘Go-Live’ of the new handoff process. The widening control limits illustrate increased variatio