Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol.

Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.

Medicare payment trends compared to inflation for anesthesia services.

STUDY OBJECTIVE: Identify changes and trends in the real value of Medicare payments for anesthesia services between 2000 and 2020 and how it may affect practices. DESIGN: Retrospective analysis. SETTING: We utilized the Physician/Supplier Procedure Summary (PSPS) datasets of Medicare Part B claims to identify high volume anesthesia services in 2020 with 20 years of data. The Consumer Price Index was used as a measure of inflation to adjust prices. PATIENTS: The PSPS datasets contain summaries of all annual Medicare Part B claims and payment amounts by carrier and locality. INTERVENTIONS: Patients receiving anesthesia services. MEASUREMENTS: For each service, identified by Current Procedural Terminology (CPT) codes, we trended the average Medicare payment per procedure from 2000 to 2020 and calculated year to year changes and compound annual growth rate (CAGR). We also evaluated base and time units for each CPT code and the national Medicare anesthesia conversion factor (CF) for the same years. MAIN RESULTS: The average Medicare payment in the study sample increased 20.1% from 2000 to 2020. After adjusting for inflation, the average Medicare payment per anesthesia service decreased by 20.8% over that period. The Medicare anesthesia CF increased 24.9% in the same period, and after adjusting for inflation, the real value of the CF decreased 16.9%. Average CAGR across the 20 anesthesia services was 0.88%, compared to the average annual inflation at 2.06%. CONCLUSIONS: Average Medicare payment for common anesthesia services after adjusting for inflation have decreased from 2000 to 2020, consistent with findings in other physician specialties. Understanding these trends is important for practice viability and suggests significant financial implications for anesthesia practices and hospitals if the trend were to continue.

Perspectives on Perioperative Team-Based Morbidity and Mortality Conferences: A Mixed Methods Study.

BACKGROUND: Morbidity and mortality conferences (MMCs) are quality improvement mechanisms during which adverse events are reviewed, often by physicians within a single discipline. There is a growing desire to include nonphysicians and physicians from other disciplines in team-based morbidity and mortality conferences (TBMMs). This mixed methods study investigates perioperative perspectives on MMCs generally and TBMMs specifically. METHODS: A national survey of perioperative health care professionals, including surgeons, anesthesiologists, and nurses, was used to explore opinions about MMCs and TBMMs. Semistructured qualitative interviews and focus groups were conducted with health care professionals and leaders at a single study site. Quantitative data were compared using a Kruskal-Wallis test. Interview transcripts were inductively analyzed. Data were analyzed using a concurrent mixed methods approach, triangulating both sources of data. RESULTS: Survey respondents (N = 1,466) were generally positive about both MMCs and TBMMs, agreeing that conferences were respectful, affected practice, and were educational. Nurses, compared to surgeons and anesthesiologists, were more likely to find conferences educational (p = 0.004) and were less comfortable speaking up in conferences (p < 0.001). Attendees who had more experience with TBMMs rated conferences as having significantly higher utility in achieving educational and safety goals. Qualitative data from 14 participants identified barriers and facilitators at the micro, meso, and macro level. Barriers include negative personal interactions, unsupportive leadership, and legal and regulatory issues. Facilitators include interpersonal relationships between professionals, buy-in from leadership, and external motivators. CONCLUSION: Perceptions of TBMMs were overall positive, but significant barriers to implementation remain. Team members may be invited to the table, but more effort is needed to make the entire team feel included in the discussion and optimize the value of these conferences. Strategies for overcoming identified barriers remains an open area of research.

Perioperative Team-Based Morbidity and Mortality Conferences: A Systematic Review of the Literature.

Objective: This systematic review aimed to identify key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety, education, and quality improvement outcomes. Background: Patient safety in the perioperative period is influenced by system, team, and individual behaviors. However, despite this recognition, single-discipline morbidity and mortality conferences remain a mainstay of educational and quality improvement efforts. Methods: A structured search was conducted in MEDLINE Complete, Embase, Web of Science, ClinicalTrials.gov, Cochrane CENTRAL, and ProQuest Dissertations and Theses Global in July 2022. Search results were screened, and the articles meeting inclusion criteria were abstracted. Results: Seven studies were identified. Key TBMM elements were identified, including activities done before the conference-case selection and case investigation; during the conference-standardized presentation formats and formal moderators; and after the conference-follow-up emails and quality improvement projects. The impacts of TBMMs on educational, safety, and quality improvement outcomes were heterogeneous, and no meta-analysis could be conducted; however, improvement was typically shown in each of these domains where comparisons were made. Conclusions: Recommendations for key TBMM elements can be drawn from the reports of successful perioperative TBMMs. Possible benefits of structured TBMMs over single-discipline conferences were identified for further exploration, including opportunities for rich educational contributions for trainees, improved patient safety, and the potential for system-wide quality improvement. Design and implementation of TBMM should address meticulous preparation of cases, standardized presentation format, and effective facilitation to increase the likelihood of realizing the potential benefits.

Institution-Specific Perinatal Emergency Checklists: Multicenter Report on Development, Implementation, and Sustainability.

OBJECTIVE: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse checklist use to improve obstetric care. However, there is limited research into development, implementation, and sustained use of perinatal emergency checklists to inform individual institutions. This study aimed to investigate the development and implementation of perinatal emergency checklists in diverse hospital settings in the United States. STUDY DESIGN: A qualitative study was conducted individually with clinicians from three health care systems. The participants developed and implemented institution-tailored perinatal emergency checklists. Interview transcriptions were coded using the Consolidated Framework for Implementation Research. RESULTS: The study sites included two health care systems and one individual hospital. Delivery volumes ranged from 3,500 to 48,000 deliveries a year. Interviews were conducted with all 10 participants approached. Checklists for 19 perinatal emergencies were developed at the three health care systems. Ten of the checklist topics were the same at all three institutions. Participants described the checklists as improving patient care during crises. The tools were viewed as opportunities to promote a shared mental model across clinical roles, to reduce redundancy and coordinate obstetric crisis management. Checklist were developed in small groups. Implementation was facilitated by those who developed the checklists. Participants agreed that simulation was essential for checklist refinement and effective use by response teams. Barriers to implementation included limited clinician availability. There was also an opportunity to strengthen integration of checklists workflow early in perinatal emergencies. Participants articulated that culture change took time, active practice, persistence, reinforcement, and process measurement. CONCLUSION: This study outlines processes to develop, implement, and sustain perinatal emergency checklists at three institutions. Participants agreed that multiple, parallel implementation tactics created the culture shift for integration. The overview and specific Consolidated Framework for Implementation Research components may be used to inform adaptation and sustainability for others considering implementing perinatal emergency checklists. KEY POINTS: · Perinatal emergency checklists reduce redundancy and coordinate obstetric crisis management.. · Perinatal emergency simulation is essential for checklist refinement and effective team use.. · Integrations of perinatal emergency checklists requires culture change and process measurement..

Redeployment of Health Care Workers in the COVID-19 Pandemic: A Qualitative Study of Health System Leaders' Strategies.

OBJECTIVES: This study aimed to determine the strategies used and critical considerations among an international sample of hospital leaders when mobilizing human resources in response to the clinical demands associated with the COVID-19 pandemic surge. METHODS: This was a cross-sectional, qualitative research study designed to investigate strategies used by health system leaders from around the world when mobilizing human resources in response to the global COVD-19 pandemic. Prospective interviewees were identified through nonprobability and purposive sampling methods from May to July 2020. The primary outcomes were the critical considerations, as perceived by health system leaders, when redeploying health care workers during the COVID-19 pandemic determined through thematic analysis of transcribed notes. Redeployment was defined as reassigning personnel to a different location or retraining personnel for a different task. RESULTS: Nine hospital leaders from 9 hospitals in 8 health systems located in 5 countries (United States, United Kingdom, New Zealand, Singapore, and South Korea) were interviewed. Six hospitals in 5 health systems experienced a surge of critically ill patients with COVID-19, and the remaining 3 hospitals anticipated, but did not experience, a similar surge. Seven of 8 hospitals redeployed their health care workforce, and 1 had a redeployment plan in place but did not need to use it. Thematic analysis of the interview notes identified 3 themes representing effective practices and lessons learned when preparing and executing workforce redeployment: process, leadership, and communication. Critical considerations within each theme were identified. Because of the various expertise of redeployed personnel, retraining had to be customized and a decentralized flexible strategy was implemented. There were 3 concerns regarding redeployed personnel. These included the fear of becoming infected, the concern over their skills and patient safety, and concerns regarding professional loss (such as loss of education opportunities in their chosen profession). Transparency via multiple different types of communications is important to prevent the development of doubt and rumors. CONCLUSIONS: Redeployment strategies should critically consider the process of redeploying and supporting the health care workforce, decentralized leadership that encourages and supports local implementation of system-wide plans, and communication that is transparent, regular, consistent, and informed by data.

Development of a Novel and Scalable Simulation-Based Teamwork Training Model Using Within-Group Debriefing of Observed Video Simulation.

THE CHALLENGE: Effective teamwork and communication skills are essential for safe and reliable health care. These skills require training and practice. Experiential learning is optimal for training adults, and the industry has recognized simulation training as an exemplar of this approach. Yet despite decades of investment, this training is inaccessible and underutilized for most of the more than 12 million health care professionals in the United States. DESIGNING A SOLUTION: This report describes the design process of an adapted simulation training created to overcome the key barriers to scaling simulation-based teamwork training: access to technology, time away from clinical work, and availability of trained simulation educators. The prototype training is designed for delivery in one-hour segments and relies on observation of video simulation scenarios and within-group debriefing, which are promising variations on traditional simulation training. To our knowledge, these two simulation approaches have not been previously combined. The resulting prototype minimizes the need for an on-site trained simulation educator. This report details the development of a training model, its subsequent modification based on pilot testing, and the evaluation of the resulting redesigned prototype. PRELIMINARY EVALUATION: Participant evaluations of the redesigned prototype were highly positive, with 92% reporting that they would like to participate in additional, similar training sessions. Positive results were also found in assessment of feasibility, acceptability, psychological safety, and behavioral intention (reported intention to alter behavior).

Surgical Teams' Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years: A Multinational Survey.

To assess health care professionals' attitudes on the Surgical Safety Checklist ("the Checklist") in resource-rich health systems and provide insights on strategies for optimizing Checklist use. Background: In use for over a decade, the Checklist is a safety instrument aimed at improving operating room communication, teamwork, and evidence-based safety practices. Methods: An online survey was sent to surgeons, nurses, and anesthesiologists in 5 high-income countries (Canada, the United States, the United Kingdom, Australia, and New Zealand). Survey results were analyzed using SPSS. Results: A total of 2032 health care professionals completed the survey. Of these respondents, 47.6% were nurses, 70.5% were women, 65.1% were from the United States, and 50.0% had 20 years of experience or more in their role. Most respondents felt the Checklist positively impacted patient safety (70.9%), team communication (73.1%), and teamwork (58.9%). Only 50.3% of respondents were satisfied their team's use of the Checklist, and only 47.5% reported team members stopping to fully participate in the process. More nurses lacked confidence regarding their role in the Checklist process than surgeons and anesthesiologists combined (8.9% vs 4.3%). Fewer surgeons and anesthesiologists than nurses felt they received adequate training on the Checklist's use (57.8% vs 76.7%). Conclusions: While most respondents perceive the Checklist as enhancing patient safety, not all surgical team members are actively engaging with its use. To enhance buy-in and meaningful use of the Checklist, health systems should provide more training on the Checklist with respect to its purpose and strengthening teamwork.

Alternatives to High-Fidelity Simulation.

Simulation-based education improves health care professionals' performance in managing critical events. Limitations to widespread uptake of high-fidelity simulation include barriers related to training, technology, and time. Alternatives to high-fidelity simulation that overcome these barriers include in situ simulation, classroom-based simulation, telesimulation, observed simulation, screen-based simulation, and game-based simulation. Some settings have limited access to onsite expert facilitation to design, implement, and guide participants through simulation-based education. Alternatives to onsite expert debriefing in these settings include teledebriefing, scripted debriefing, and within-group debriefing. A combination of these alternatives promotes successful implementation and maintenance of simulation-based education for managing critical health care events.

Cognitive Aids in the Management of Critical Events.

Critical events are rare and stressful. These properties make reliance on memory for clinical management highly susceptible to failure. In the past 10 to 20 years, health care has begun to accept the experience of aviation and other high-reliability organizations in addressing failure to rescue from these events through a combination of practice through simulation and the introduction of cognitive aids, known as checklists or emergency manuals. Cognitive aids have a persuasive body of evidence from simulation studies to establish their value in improving clinician performance. However, their introduction to practice is more complex than distribution of the tools.

Comparing the Learning Effectiveness of Healthcare Simulation in the Observer Versus Active Role: Systematic Review and Meta-Analysis.

STATEMENT: The benefits of observation in simulation-based education in healthcare are increasingly recognized. However, how it compares with active participation remains unclear. We aimed to compare effectiveness of observation versus active participation through a systematic review and meta-analysis. Effectiveness was defined using Kirkpatrick's 4-level model, namely, participants' reactions, learning outcomes, behavior changes, and patient outcomes. The peer-reviewed search strategy included 8 major databases and gray literature. Only randomized controlled trials were included. A total of 13 trials were included (426 active participants and 374 observers). There was no significant difference in reactions (Kirkpatrick level 1) to training between groups, but active participants learned (Kirkpatrick level 2) significantly better than observers (standardized mean difference = -0.2, 95% confidence interval = -0.37 to -0.02, P = 0.03). Only one study reported behavior change (Kirkpatrick level 3) and found no significant difference. No studies reported effects on patient outcomes (Kirkpatrick level 4). Further research is needed to understand how to effectively integrate and leverage the benefits of observation in simulation-based education in healthcare.

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.

BACKGROUND: Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises. METHODS: We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises. RESULTS: In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112). CONCLUSIONS: Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.