(Thanks Aria! I can get in now!)
A. What evidence are you proposing to translate into practice?
Reduction in mortality, surgical errors, and post-op complications through implementation of a post-operative debrief on all neurosurgical patients.
1. Justify that this evidence is “ready for translation.”
In 2003 and 2004, the Joint Commission established the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ as a part of a series of requirements of their National Patient Safety Goals.
The timeout prior to first incision is required for accreditation by the Joint Commission. This strong delivery system incentive has resulted in near 100% uptake of the pre-incision timeout, but the post-op debrief is not specifically required by JACHO, has not been standardized, is inconsistently implemented, and has not been fully embraced by the operating room culture.
In 2008, the World Health Organization (WHO) as a part of their Safe Surgeries Saves Lives global challenge revised their Surgical Safety Checklist that includes multi-disciplinary timeouts at three time-points: before the induction of anesthesia, before the first incision, and before the patient leaves the operating room.
The Center for Medicare and Medicaid Services (CMS) is implementing new quality reporting requirements that, beginning in 2014 will include implementation of
a Surgical Safety Checklist and effect payment in 2015.
2. Identify a single, key behavior change target for your translational activity.
Targeting neurosurgical attendings and residents to initiate the debrief process and become champions of the effort, including creating space for all members of the surgical team to voice concerns and process improvements. The buy-in from surgeons is based upon closing the process improvement loop; generating a mechanism for concerns, malfunctions, and inefficiencies to be documented at debrief and triaged to appropriate channels for resolution.
3. Conduct a “gap analysis” of your target behavior. Look to diverse sources for “best guess” estimates if specific measures are not available.
B. What is the quality (performance) gap?
In 2012 and 2013, UCSF Neurosurgical services launched a pilot post-operative debrief program that included a "secret Shopper" data collection method to monitor compliance with the debrief. Although compliance was achieved up to 75% in the first few months, it waned slowly over the year, and was allowed to taper off naturally when funding was secured for a broad neurosurgical safety initiative that included a debrief (allowed to return to baseline before relaunch). Compliance with the debrief was less than 25% of neurosurgical cases at the end of 2013.
C. What is the outcome gap?
Neurosurgical cases often result in higher than institutional average for several key quality outcome measures such as SSIs. The UC Office of the President and the Office of Risk Management assessed the most costly services in the UC system and found these to be consistently Ortho- and Neurosurgery. This was the impetus for selecting Neurosurgery for a targeted quality intervention. Preventable errors such as retained objects, missing or mislabeled specimens, forgotten procedures, inadequate communication of post-operative instructions, operating room inefficiencies,
and delays in OR turnover that directly effect patient outcomes, revenue, and the patient experience.
D. Is there evidence that changing performance will improve health (clinical outcomes)?
There is strong evidence that Surgical Safety Checklists reduce complications and mortality, though specific evidence of improved clinical outcomes from just the post-operative debrief component are less demonstrated. There is strong evidence the debrief component results in improvement of the safety culture of the OR teams,
increased communication, and increased teamwork.