103 - Time Out Standardization: "It Only Takes a Minute"

Description: Time-Out Standardization: It Only Takes a Minute

Standardization of the "Time Out" Performance Improvement Project at PIH Health Downey Hospital (PHDH) Operating Room (OR) was led by the Surgery Partnership Council. The Partnership Council included the clinical director, perioperative registered nurses (RNs), surgical technicians (STs), and OR educator. We also included the chiefs of surgery and anesthesia in the implementation of action plans based on monthly compliance data. The team decided to use the Plan-Do-Check method to implement change.

Planning included a literature review on the "Time-Out" process, reviewing AORN best practice recommendations and The Joint Commission (TJC) time out criteria. In January of 2024, a gap analysis was performed, and data revealed a 23% overall Time-Out standardization compliance. While time outs were taken prior to the start of every procedure, there was a lack of standardization in time-out elements and the way the time-out was conducted. In addition, there was a lack of team member engagement during the time-out. This revealed a need for time-out standardization, staff and physician education, and team buy in to standardize the time-out process.

The team collaborated and implemented practices to improve the time-out standardization, compliance, and engagement. To engage staff, a slogan was created for the project, "It only takes a minute" and staff were empowered to speak up to promote compliance. Daily huddles and staff meetings were used to educate staff on time-out elements, process, and compliance rates. The team created magnets listing standardized time out elements and placed them on the white board in every OR. An education board delineating the Time out initiative, updates and compliance was created in the OR lounge. Anesthesiologists and Surgeons were educated and updated at monthly committee meetings and the anesthesiologists acted as time-out champions when noncompliance was encountered. A key component in the project was collaborating with anesthesiologists and surgeons to promote active participation during the time out. This was achieved by including the chiefs of anesthesia and surgery in project implementation.

In September of 2024, seven months post-implementation, the overall timeout standardization compliance rate increased from 23% to 97%. There were two elements that fell short of 100% compliance (everyone stopping during the timeout & verbalization of the fire risk score), which led to an overall compliance rate of 97%. Team member engagement improved, and team members were empowered to speak up if required elements were not addressed during the time-out. A big success was getting the surgeons to actively participate and read the surgical consent during the time-out. Standardization of the Time-Out process sets the stage for patient safety by improving communication, strengthening the team, verbalizing expectations, and most importantly, improving patient outcomes (Kooiker,2023).

The standardization of the Time-Out process is key to promoting positive patient outcomes in our department. It has also increased the confidence of the OR team to speak up and actively participate to promote patient safety. A post project staff survey revealed that 100% of those surveyed, agreed that we accomplished the goal of standardizing the Time-Out process and improved active participation during the Time-Out.