1 | P a g e

Health System: Los Angeles County- Department of Health Services 313 N. Figueroa St., Room 703 Los Angeles, CA 90012 http://dhs.lacounty.gov/wps/portal/dhs Primary Contact (Submitter) Arun Patel, MD, JD, MBe DHS Risk Management and Patient Safety Director Apatel3@dhs.lacounty.gov 213-240-8283 Secondary Contact Marife P. Mendoza, RN, MBA-HCM DHS Patient Safety Coordinator Mamendoza@dhs.lacounty.gov 213-240-8283 Title: LAC-DHS Standardized Time out Checklists (for ORs and Non-ORs) Identified Topical Area of focus in this application Patient Safety Brief Statement by an executive leader in support of the application To respond to an increasing number of reported events and near misses reflecting problems in the pre-operative and pre-procedural “Time Out” process across DHS, the DHS-wide Patient Safety Committee led a formation of a Time Out Project workgroup that develop tools to ensure that surgical (OR), and Non-OR time-outs are done properly and consistently across all of DHS operating rooms, ambulatory care surgical centers, inpatient & outpatient procedural areas, outpatient clinical areas, and patient’s bedside where procedures are performed. This standardized OR and Non-OR Time Out checklists will prevent DHS surgical and procedural patients from harm and injury; improve DHS ORs and Non-ORs workflow, teamwork, and culture; and prevent occurrence of peri-operative and peri-procedural errors. Executive Summary (must contain a summary of results) The DHS Patient Safety Committee along with the key stakeholders from all DHS facilities (4 hospitals, 1 regional medical center, 1 outpatient center and 6 comprehensive health centers, and 7 personal health centers) have successfully developed a standardized step by step process and time-out checklists for our staff in ORs, procedural areas, outpatient clinical areas, and other patient care areas. The standardized time-out process and checklists were instrumental in improving our staff’s

2 | P a g e

ability to speak up especially in an uncomfortable/stressful clinical situation and to communicate effectively amongst all members of the care team. In addition, the staff are more conscientious in ensuring that they have correct patient, site, and procedure. The project has also increase staff’s readiness and openness to report time-out related events in our event reporting database. The project team has also developed system-wide policy and procedure on the standardized process and checklists and aligned their time out documentation in HER with the new process and use of standardized checklists. Background and relevance of the problem being addressed and effort undertaken (3-8; 2,400 words) The project is to standardize the OR and Non-OR time out checklists and to maintain a consistent approach in conducting the time out activity in all of the DHS ORs, ambulatory care surgical center, procedural areas, outpatient clinical areas, and other patient care areas. Having a standardized checklists and consistent process in conducting the final time out activity across the system helped us ensure that the correct patient, site, and procedure are appropriately identified. It also improve the communication and teamwork of the care team. It empowers any member of the team to speak up if there is any concern or safety issue noted before starting the surgery or procedure. In addition, the standardization of the OR and Non-OR checklists and reliability of practices across all of DHS’ ORs and Non-ORs prevent variance and adopts a best practice process that help the organization prevents any type of peri-operative and peri-procedural errors and/or near miss incidents which could harm or put the safety of our surgical & procedural patients at risk. To date, since the project was implemented across DHS’ ORs and Non-ORs, there is considerable increase of event reporting related to OR and Non-OR time out activity. Description of the effort, including the scope, processes, strategies and tactics utilized, challenges encountered and how they were addressed. There was a considerable amount of effort put into the project. There were two different project teams who were involved although the core members remained the same for both time outs (OR & Non-OR). The entire project was rolled out into 2 phases. The entire implementation and roll out took almost a year in all of the DHS facilities. Please refer to the summarized table below on the detailed effort, scope, processes, strategies and tactics utilized, challenges encountered and actions taken to resolve the challenges faced.

Project Efforts Scope & Processes Strategies and tactics utilized

Challenges encountered

Actions taken to resolve challenges

*Standardized Surgical Time Out *Standardized Non-OR Time Out

Formed a project team composed of DHS Patient Safety Officers, facilities stakeholders:

1.Obtain facilities time out policies and verified facilities current surgical & procedural time out

1. Raise awareness -Inform all staff about the project via DHS Director Newsletter, time out

1. In the early stages, there was some push back for the standardization.

1. Provide event reporting data and med mal cases related to time out to support the need for

3 | P a g e

OR Timeout --chiefs/designees in surgery, anesthesia, nursing team, QI, and IT Non-OR Time Out – Chairs/designees of various specialty groups. Implemented the project in 2 phases. 1st phase – Standardized Surgical Time Out 2nd phase – Standardized Procedural Time Out

processes and checklists (if any) 2. Compare and identify variance of time out checklists and processes (as reported and observed during site visits) with facilities’ existing policy and procedure (if any) 3. Organize a project team (OR & Non-OR Time out) 4. State the problem, define objectives, set goals, identify tasks and accountable persons/discipline, set timeline and deliverables. 5. Do 1 hour weekly conference calls with the project team. Assign call facilitator. 5. Obtain OR & Non-OR time out best practices and recommendations, develop own checklists and create a standardized process/workflow applicable to all facilities. 6. Conduct PDSAs, tweak draft checklists and process (es) per PDSAs results. 7. Finalize standardized checklists and process (es). 8. Make technical changes in the time documentation in EHR (to align with the new process and checklists) 8. Implement project in all facilities.

screen savers, and soft/hard copy flyers 2. Education and Training – Create a 6-minute fun-filled educational OR and Non-OR time out video utilizing our own facility staff as actors and animated cartoons. Reenact the standardized time out process in the videos. Show the step by step process on how to use of standardized OR and Non-OR time out checklists. 4. Conduct the facility training and education. Facilities patient safety officers (PSOs) conduct in-service and trainings using timeout videos and ppt presentation in all care units involved. 5. Adequate Resources - Provide laminated checklists in all of the OR suites, procedural areas, outpatient clinical areas and others. 6. Marketing - Advertise the new time out process and checklists through electronic posting of time out screen savers. 7. Audits & Monitoring Facilities PSOs or QI staff perform direct observation audits in the ORs, procedural areas, outpatient clinical areas, and other patient areas.

2. Some disagreements between project team members on the core items included in the checklist. 3. difficult to compromise on a standardized time out process that applies to all facilities regardless of the care setting.

standardization of process and checklists. 2. Get facility exec leaders to be involved in the conversation to get more buy in from middle management from each facility to support the project. 3. Present evidence-based effective practices, WHO guidelines, and AORN recommendations, on items needed to be included in the checklist. 4. Reevaluate DHS resources and practices. 5. Come up with a unanimous list of items to be included in the list which are applicable to all facilities. 5. Ensure that all members of the project team are heard and empowered to make the decision for their facility.

4 | P a g e

9. Develop system-wide Surgical and Non-Procedural Time Out policies. 10. Get facility leadership’s final sign offs with the system-wide policies. 11. Disseminate policy to all facilities.

8. Incorporate the new process and checklist in the staff annual competency testing and Annual Patient Safety and Risk Management Handbook

Description of the results of the effort. The efforts instituted were all well-received and respected by all members of the project team; corporate executive leadership; and facility C-suite, mid management, and front line staff. Discussion of the significance of the results. How do the results demonstrate outstanding achievement? The results obtained were extremely significant especially for patient safety and risk management. The project team successfully met their goals and objectives, were able to gained buy in and support from all stakeholders, and successfully resolved all challenges faced along the way. At present, all DHS facilities perform OR and Non-OR time out in a consistent manner and use a standardized checklist for all OR and Non-OR procedures. Everyone in OR and other patient care areas speak the same language when it comes to time outs and feel safe to speak up regardless of who is doing the surgery or where the procedure is perform. The results demonstrate outstanding achievement as evidenced by the improved safety and speaking up culture in the operating and procedural rooms and any patient care units where procedures are done. There is also an increase of event reporting related to time out after the project was rolled out –most if not all are aware of the standardized time out process and checklists, any deviation from the process or verification from the items included in the checklist are reported openly. Before the standardization, most facilities are doing their own thing so there was no clear expectation. The project gainfully established a clear expectation from staff during the conduction of a time out. Finally, it is also noted that there has been a decline of the time-out related reporting this year compared to last year and there have not been a major time-out related med mal case discussed in the DHS Executive Peer Review this year. The decline of time out event reporting may be seen as an outstanding achievement driven from the implementation of standardized OR and Non-OR Time Out process and checklists across all the DHS facilities. Description of sustainability and scaling of the achievements.

5 | P a g e

Most of the quality improvement or patient safety department from each facility does random monthly direct observation audits in their surgical and procedural areas. In case of a drift, the particular case (if reported) will be discussed in the executive peer review, investigated, and corrected (if necessary) by the facility leadership and patient safety officer. In terms of scaling the achievements obtained, all our hospitals except one are currently implementing TeamSTEPPS strategies (specifically teamwork, communication, and debrief components) to further enhance their safety and speak up culture, teamwork, and effective communication. To date, DHS central Risk Management and Patient Safety Department continue to monitor time-out related reporting for trending. Description of key lessons learned and any advice to colleagues who might try to undertake a similar effort. Key lessons learned are: importance of establishing an absolute need of a particular project, identifying the right people in the project team which should include individuals who will be utilizing the “project” in a daily basis, the value of doing site visits to evaluate and see what normally happens in the care areas and comparing observation results to existing policies (if any). Secondly, Researching on evidence-based effective practices and presenting data that support the project need is highly important. Provide a project environment with psychological safety at all times (regardless if it is a conference call or physical meeting with the project team) where all members are free to speak up and be heard. Get consensus of the project team members that would best benefit and meet the project goals and objectives. If there are any challenges, deal each of them professionally and with an open mind. Stick to the timeline set other than if there is a “valid” and “acceptable” reason to delay project tasks, deliverables, and implementation date. Be creative and institute fun learning if there is a need for staff training and education related to the newly implemented project. Finally, seek status updates from the facilities project owner post implementation at least for the next 6 months (at a minimum). My sole advice to colleagues who might try to undertake similar effort is to take note of the lessons learned provided (above paragraph).