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Overview

Updated on April 18, 2013

Issue

The Safe Surgical Checklist (SSCL) compliance indicator refers to the percentage of surgeries in which a three-phase surgical safety checklist was performed correctly and appropriately for each surgical patient.1 Around the world, complications from surgery result in more than half a million deaths every year. Research shows that implementing safety checklists can significantly reduce this mortality rate.2 The World Health Organization (WHO) has initiated a safety checklist and implementation manual, to improve compliance with standards and reduce morbidity and mortality.3

In Canada surgical site infections (SSIs) continue to be an issue. Safer Healthcare Now noted that despite advances in aseptic technique, prophylaxis with antibiotics, and less invasive surgical techniques, health care associated infections continue to complicate the recovery of many surgical patients in Canada.4 According to the How Canada Performs (HCP) website, Canada ranks seventh among 15 peer countries for “medical misadventures”, including surgical complications. HCP estimates that seven percent of all patients admitted to acute care hospitals in Canada will suffer a medical misadventure, with nearly 60,000 of those cases being preventable.5 In Health Quality Ontario’s 2012/13 Quality Improvement Plans: An Analysis for Improvement the provincial average rate for compliance with the three phase surgical safety checklist was 99.2% with a goal of achieving 100%.1

 

Call to Action

Compliance with the SSCL indicator refers to the percentage of surgeries in which a three-phase surgical safety checklist was performed correctly and appropriately for each patient that undergoes surgery. All surgeries carried out in a fully equipped operating room are eligible to report the use the SSCL. The SSCL is considered performed when the designated checklist coordinator confirms that surgical team members have implemented and/or addressed all of the necessary tasks and items in each of the three phases-‘Briefing’, ‘Time Out’ and ‘Debriefing’-of the checklist, based upon the Canadian Patient Safety Institute’s (CPSI) Surgical Safety Checklist.6  Most hospitals in Ontario have already achieved 99-100% compliance; any hospital that has not yet achieved this should be aiming for full 100% compliance.1

Focusing on quality improvement can help alleviate unnecessary complications from surgery to improve care and safety for patients. While the tools and information provided in this quality improvement resource focus on the process of quality improvement for the facility, the ultimate goal is to provide patients with the best possible care.

  1. Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement.

    Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 16].
    Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf

  2. Accreditation Canada. Surgical Checklist [Internet].

    Accreditation Canada; [cited 2012 Nov 16].
    Available from: http://accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf

  3. World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual [Internet].

    World Health Organization. 2008 [cited 2012 Nov 13].
    Available from: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/

  4. Safer Healthcare Now! Prevent Surgical Site Infections Getting Started Kit.

    Safer Healthcare Now!; 2011 March [cited 2012 Nov 16].
    Available from: http://www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/SSI Getting Started Kit.pdf

  5. How Canada Performs. Mortality Due to Medical Misadventures [Internet].

    How Canada Performs; [cited 2012 Nov 16].
    Available from: http://www.conferenceboard.ca/hcp/details/health/mortality-medical-misadventure.aspx

  6. Ontario Hospital Association. Surgical Safety Checklist [Internet].

    Toronto: Ontario Hospital Association; [cited 2012 Nov 16]
    Available from: http://www.oha.com/CurrentIssues/keyinitiatives/PatientSafety/Documents/Surgical Safety Checklist_Intro.pdf

Indicators & Targets

Updated on April 18, 2013

Quality indicators are measures that describe how well something is performing. Just as a physician might measure a person’s cholesterol to find out how healthy he or she is, quality indicators are used to determine how well the Ontario health system is meeting the needs of its population.7

Most hospitals in Ontario have already achieved 99-100% compliance with the Surgical Safety Checklist; any hospital that has not yet achieved this should be aiming for full 100% compliance.1 Surgical Safety Quality indicators and targets are outlined in the table below.

Quality Indicators Target*

Surgical Safety Checklist:  Percent compliance
The percent compliance is calculated as follows:

# of times all 3 phases of the surgical safety checklist was performed x 100 = % compliance6
Total surgeries

 

Three phases include:

  • Before the patient receives any form of anesthetic (briefing)
  • Before the incision is made (time-out)
  • At the end of the operation (debriefing)
Theoretical best 100%

* Best achieved to date in Ontario 100%; Provincial average 99.2% (Q2 to Q3 2011/12)1


For more ideas and information on getting started on quality improvement to improve Surgical Safety, go to the Best Practices tab.

  1. Health Quality Ontario. Guide to Long-Term Care Public Reporting [Internet].

    Toronto: Health Quality Ontario. [cited 2012 Nov 7]
    Available from: http://www.hqontario.ca/public-reporting/long-term-care/guide-to-long-term-care-public-reporting

  2. Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement.

    Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 16].
    Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf

  3. Ontario Hospital Association. Surgical Safety Checklist [Internet].

    Toronto: Ontario Hospital Association; [cited 2012 Nov 16].
    Available from: http://www.oha.com/CurrentIssues/keyinitiatives/PatientSafety/Documents/Surgical Safety Checklist_Intro.pdf

Best Practices

Updated on April 18, 2013

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.9 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.

To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach. 

Change ideas are specific and practical changes by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

  1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care.

    Lancet. 2003 Oct 11;362(9391):1225-30.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747

Measurement

Updated on April 18, 2013

“Some is not a number, soon is not a time.”
Don Berwick, former CEO and President of IHI, December 2004, at launch of the 100,000 Lives Campaign

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Key Measurement Guidelines 
  • Choose measures that support the team’s aim statement
  • Consider qualitative and quantitative measures
  • Use existing data collection systems, whenever possible
  • Integrate measurement into the daily routine
  • Use a set of five to seven measures to track progress throughout your QI project


Suggested measures for QI initiatives in surgical safety are listed in the table below:

Process

The Safe Surgical Checklist (SSCL): Percent compliance*

The percent compliance is calculated as follows:

# of times all 3 phases of the surgical safety checklist was performed x 100 = % compliance6
    Total surgeries

 

The Three phases of the surgical safety checklist include:

  1. Before the patient receives any form of anesthetic (briefing)
  2. Before the incision is made (time-out)
  3. At the end of the operation (debriefing)
  1. Ontario Hospital Association. Surgical Safety Checklist [Internet].

    Toronto: Ontario Hospital Association; [cited 2012 Nov 16].
    Available from: http://www.oha.com/CurrentIssues/keyinitiatives/PatientSafety/Documents/Surgical Safety Checklist_Intro.pdf

Tools & Resources

Updated on April 18, 2013

Tools

Surgical Safety Tools
QI Tools

 

For a more comprehensive list of tools and resources, visit the following links on our HQO website:

 

 

Resource

Surgical Safety Resources
QI Resources