1045 - Safety First: A Multidisciplinary Approach to Standardizing Universal Protocol

Overview/Abstract: Following review of reported safety events and observed variability in safety checks and communication across surgical areas, our goals for this project were to standardize and improve universal protocol practices and communication in all ORs across seven hospitals and six ambulatory surgical centers.

We will share our systematic approach of engaging with a multidisciplinary team representing the perioperative areas across the system, including practicing surgeons, anesthesiologists, nurses, quality and safety leaders, IT partners, and patient advocates to develop the redesigned protocol. This team was also involved in simulation and pilot testing events, receiving feedback, and providing training and support for the implementation of the revised protocol. Additionally, we established a system framework of leadership, for oversight, communication, support and accountability to the changes, which included system leaders in quality, patient safety, nursing, anesthesia, surgeons and proceduralists.

Key change included the required use of a tool within the EHR to communicate readiness amongst the team (SOAP- representing Surgeon, OR, anesthesia, and preop readiness), collaborative completion of the pre-procedure checklist, full team engagement during timeouts and debrief, and integrating patient and procedure information into each of the checklists.

Following the implementation, we noted improved compliance with the communication tool (SOAP), reductions in patient safety events, including wrong site/procedure/patient events. and improved staff perception post-implementation regarding pre-procedure readiness (+19%) and the effectiveness of debriefs (+23%).

Attendees will learn the key strategies and tools used to align practices, address variation, and sustain compliance to improve team communication, collaboration, and patient safety.