Improving Team Performance during the Preprocedure Time-out

PURPOSE The World Health Organization and the Joint Commission have identified key preprocedure steps as high priority topics for improving patient safety. This includes the Universal Protocol for patient identification, site marking, and procedure verifications. The Joint Commission also recommends that these steps be standardized, observable by all members of the team and audited for compliance. These recommendations are based on two fundamental tenets of performance improvement. First is that group performance depends on development of shared mental models. Second is that measurement not only allows verification but it also promotes learning through feedback. As part of opening a new pediatric interventional suite, we sought to test and continually improve the team’s ability to comply with these requirements. METHODS The guidelines developed by the Joint Commission were used to create a script for the time-out. This script contains a series of observable behaviors that are performed by the physician, nurse, technologist and anesthesiologist. These expected behaviors were incorporated into a checklist which is posted in the procedure suite and used by the nurse to document compliance with preprocedure timeout. Since our interventional suite is equipped with audio/video recording equipment, recordings of timeout performance are readily captured and these records can be audited by independent reviewers. For this study, the reviewers were instructed to simulate how a stringent Joint Commission inspector might score the preprocedure timeout. To facilitate these audits, a standardized scoring system was developed. This system awards up to 100 points for complete compliance. Since reviewing the video recordings and scoring them was time consuming, it was elected to score compliance during one to two randomly selected procedures each week. To provide feedback to the frontline team, the results of these audits are plotted as a run chart that is posted in the interventional suite for all team members to review. This graph is updated monthly. RESULTS Creating the script for the time-out identified numerous possible failure modes and these failure modes formed the basis of the scoring rubric. The resulting scoring criteria therefore became an explicit description of the desired team behaviors and how compliance might be measured. The audiovideo recording system allows independent reviewers to rigorously assess compliance. The recordings also allowed assessment of intra-observer and inter-observer variability in the scoring scheme. The results from the first 10 months of operation demonstrated room for improvement since the average score was 68+/-8 (range 56-89). During this period, it took an average of 66+/-16 seconds to perform the preprocedure timeout. The initial scoring system required assessing 17 separate criteria and while rigorous and reproducible, it proved to be cumbersome. The scoring system was simplified to include 10 separate criteria in October 2009. This change in the scoring system was not associated with a significant change in the resulting scores. Detailed analysis of the scores revealed that one of the most common failure modes was not explicitly acknowledging that prior imaging studies were reviewed. Subsequently, the technologists altered their preprocedure workflow to include locating and posting prior images on the monitor. Technologists also began directing the physician’s attention to that image during the preprocedure timeout. As a result of these small changes, there has been an increase in timeout compliance. This increase is especially apparent for teams that routinely work together in the suite. However, performance by teams that rarely use the suite continues to lag. This observable difference in performance is not evident when reviewing documentation in the medical record since all teams routinely indicated that they believed they were compliant with the timeout protocol. CONCLUSION These results suggest that while all teams might document that a time-out was completed, variation persists. Audits of the video recordings revealed lack of full compliance with every element specified in the Joint Commission’s 2009 National Patient Safety Goals. While creating a script and posting a checklist improved compliance, scripts and checklists do not guarantee that every team member exhibits the desired behaviors. Implementing a robust feedback system which includes routine audio/video recording, scoring those recordings and posting results has helped drive our improvement efforts. Developing a system that accommodates personnel with less experience in the interventional suite will require further refinements in the overall process.

SI24B

Improving Team Performance during the Preprocedure Time-out