Jewish General finds that surgical checklists have improved outcomes

In its ongoing quest to improve patient care and provide top-of-the-line surgical services, the Jewish General Hospital (JGH) was the first hospital in Quebec and only the third in Canada to join the National Surgical Quality Improvement Program (NSQIP), in 2009. Soon after, the JGH was again first in Quebec to implement the World Health Organization’s Surgical Safety Checklist.

Both NSQIP and the Checklist positively impact patient care and outcomes, identify areas to target for quality improvement, increase efficiency, and reduce costs that could then be re-invested in areas of clinical services and care.

NSQIP is an international program that compares a hospital’s surgical outcomes to those in hundreds of other hospitals. Since some hospitals are larger and more specialized than the JGH while others are considerably smaller, all participating institutions send their data to NSQIP which uses a sophisticated statistical method of adjusting for differences between hospitals.

NSQIP then provides hospitals with the tools, reports, analysis and support to make informed decisions and monitor quality improvement initiatives. A risk-adjusted report is submitted to the JGH every three months, which provides information about where there remains room for improvement, and how the hospital is doing compared to others.

General Surgery, Colorectal Surgery and Vascular Surgery were the focus from the start at the JGH. Then recently, Orthopedics, Neurology and Urology were added. The intention has been to target more complex surgical areas that could potentially benefit from NSQIP.

“The hospital’s membership in NSQIP shows our commitment to improving for the benefit of our patients, which is fantastic,” says Anna Pevreal, head nurse for the operating rooms.

“It’s a very humbling process, because you may learn you’re not quite as good in some areas as you previously thought,” explains Dr. Lawrence Rosenberg, executive director of the Jewish General. “The investment in our membership in NSQIP has already yielded impressive improvements in surgical services at the JGH.

Dr. Rosenberg was chief of surgical services when the JGH joined NSQIP and adopted the Checklist.

Surgical clinical nurse reviewers with a clinical background and unique NSQIP training coordinate the collection of data at the JGH.

After submitting this data to NSQIP, the hospital receives benchmarked results on its performance. Once a trend is flagged, the JGH puts into place a multi-disciplinary task force to address and correct the issue.

“We’re now looking at 60 cases per week,” explains Gina Ciccotosto, JGH surgical clinical reviewer. “We review each patient’s chart from one year prior to their surgery until 30 days after, which is unique. By calling patients at home and reviewing the surgeon’s follow-up charts, we are now identifying complications such as infections after discharge.”

Corrective action to reduce post-surgical complications often alleviates services across the institution. Since NSQIP was introduced at the JGH, it has become clear that it is not just a surgical improvement program; it has proven to be a hospital-wide improvement initiative.

There are reductions in patient length of stay, demand on resources, consultations and therapies such as medications and additional surgical procedures. When these hospital services are relieved by improving complications, the quality and safety of care are also improved and institutional costs come down.

“An added benefit of this post-surgical follow-up and of the improvements implemented is that it further promotes the patients’ quality of life after their surgery,” says Ms. Pevreal.

The JGH’s Department of Surgical Services has gained a deeper understanding of where improvement is needed and has achieved substantial reductions in the rates of surgical site infections and post-surgical urinary tract infections since joining.

For example, the rate of surgical site infections among patients in colorectal surgery has continuously decreased since it was flagged in 2009. Also, since Orthopedic Surgery was brought in, NSQIP revealed a trend of over-reliance on transfusions. Thanks to that flag, another multidisciplinary team has come together to research protocols and best practices in order to address and correct the issue.

Today, there are over two million cases in the NSQIP’s centralized and extensive database that can be accessed by member institutions for research purposes. As a member, the JGH can authorize any staff member to access cumulative data from other participating hospitals to conduct research and explore hypotheses.

“Accurate, ongoing measurement is essential to improving quality,” says Dr. Rosenberg. “It ultimately reduces the overall cost of treatment and care, highlights weaknesses and offers a realistic understanding of how we compare to other hospitals.”

“Ms. Ciccotosto adds, “Our goal is simply to gather the most reliable information possible to improve the quality of surgical care.”

The pursuit and culture of improvement at the JGH is continuous. As such, Surgical Services opted to join the growing ranks of leading hospitals around the world in making systematic safety checks mandatory in all types of surgery. The Checklist is a quick, simple and inexpensive, yet remarkably effective means of reducing infection rates and lowering the number of medical complications and errors.

These procedures, which usually add no more than one or two minutes to the surgical process, ensure that the surgeon and other members of the team are familiar with the patient’s health, and that every necessary precaution has been taken to protect the patient if something unexpected happens. Among the points covered are the patient’s allergies; the availability of blood products in case of blood loss; the likelihood of complications; concerns, if any, by the anesthesia team; and the need for post operative antibiotics.

Everyone in the operating room is also required to identify themselves before the first incision is made. Research has shown that the simple act of stating one’s name and job description makes each person feel like an active participant whose voice deserves to be heard.

“The process that comes along with using the Checklist promotes communication among the team and flattens the hierarchy of those in the OR,” says Ms. Pevreal, who co-chairs the committee that introduced the Checklist. “Everyone gets an equal voice for the patient, which in the end, reduces the risk for error.”

The JGH completed the last Accreditation Canada process in 2012 and was awarded Exemplary Standing. As such, the JGH met all compliance criteria for infection rates including tracking, analyzing and prevention. Additionally, all criteria were also met for the implementation of the Checklist.

The final Accreditation Canada report stated, “The JGH demonstrates a constant desire to be among the best healthcare institutions, first and foremost to provide patients with services of the highest quality. The institution never ceases to compare itself to others to keep an eye on best practices that could help them become more effective and more efficient.”

“In the end, our team is able to celebrate our successes with these initiatives in place,” says Ms. Pevreal. “We can now see progress and results, and we can be certain we are on the right track.”

Dana Frank is Communications Coordinator for Special Projects at the Jewish General Hospital, in Montreal.