About the Safe Surgery NZ programme
Safe Surgery New Zealand (SSNZ) is a national quality improvement programme aimed at improving teamwork and communication among surgical teams, to reduce surgical harm. The programme supports all district health boards (DHBs), and several private surgical hospitals, which have implemented key interventions in operating theatres to improve teamwork and communication, including:
- a briefing among the surgical team at the start of each day’s list of procedures
- a poster checklist in theatres based on the World Health Organization (WHO) surgical safety checklist
- a debriefing at the end of the day’s list of procedures
- other communication tools.
The programme is now managed by local DHB and private surgical hospital project teams.
Surgical safety briefing checklist, and debriefing
Surgical safety briefing checklist, and debriefing
A briefing is a standardised communication tool that aims to create an environment in which individuals can speak up, express concerns and alert team members to unsafe situations in a timely manner.
Briefings include all members of a surgical team, are held at the start of a day’s list of procedures and cover all planned procedures.
When a meaningful briefing is used at the start of each list (ie, with all team members present and each case covered), and becomes the habit of how people work, it takes less and less time. In fact, it can save time because teams are better prepared to work together.
By doing a briefing and sharing information proactively at the start of the list, delays can be prevented from things such as missing equipment or unexpected positioning. Briefings create a shared understanding of how the list should progress and full team engagement, both of which make the list run better even where there wouldn’t have been delays. Therefore, briefings are valuable for complex and non-complex cases and lists alike.
The Health Quality & Safety Commission worked with the sector and an advisory group to develop a ‘gold standard’, generic (ie, non-specialty-specific) paperless checklist. Local teams can review and build on it to meet the particular needs of the local theatre/environment/specialty (eg, moving queries regarding blood loss from ‘sign in’ to ‘time out’ for paediatric surgeries).
We expect local adaptations will include all the items from the ‘gold standard’ version at a minimum – these have been included as important safety checks. Local checklists can be regularly reviewed for ongoing suitability.
Proper use of the checklist with full team engagement will focus the team on their understanding of the tasks expected of them. The checklist is one or two minutes of making sure everyone’s focus is on the same plan and in the same direction. This will bring about the best outcome, in terms of both efficiency and safety for the patient.
This is an assumption and won’t always be true. Also, where patient safety is concerned it’s better to be sure than to assume. We know, from international and local research, and adverse event reporting, that when things don’t go well, it will often turn out that someone on the team had information that may have helped prevent harm but that they didn’t have an opportunity to share that information with others. The briefings and the checklist give everyone an opportunity to share information with the team as a whole.
There is a growing body of evidence that briefings, debriefings and the checklist make a difference in preventing harm and adverse events. Even in surgeries that are short or where the risk related to a procedure is low, the risk is still not zero and the potential exists to harm patients. Please see our evidence summary for a useful overview of recent research.
The safe surgery project is focused on full surgical procedures where anaesthesia is required. However, the checklist can support safety for a wider range of procedures, again, with adaptation to the needs of the environment. We encourage the use of an appropriate checklist for all procedures.
We recommend posters are laminated and easy to remove, so they can be wiped down on both sides when theatre walls are cleaned. Each DHB will need to be aware of their local infection control guidelines and work with their local experts to find solutions.
Alternatives, such as hand-held laminated prompt cards and electronic display screens, are being used by some DHBs.
Quality and safety markers (QSMs) are sets of related indicators concentrating on specific areas of harm that show whether desired changes in practice have occurred at a local level.
The SSNZ programme has process and outcome QSMs. The process markers are that all three parts (sign in, time out and sign out) of the surgical safety checklist are used in 100 percent of surgical procedures, with levels of team engagement with the checklist at 5 or above, as measured by the seven-point Likert scale, 95 percent of the time. The outcome markers are the rates of postoperative sepsis and deep vein thrombosis/pulmonary embolism (DVT/PE).
Our fact sheet about data collection requirements covers:
- what the safe surgery process QSM is
- QSM collection and reporting schedule
- QSM data needs for each quarter
- the method used to report the QSM data
- the rationale for collecting 50 moments (for each of sign in, time out, sign out)
- the rationale for needing 50 moments from both smaller and larger DHBs
- spread of data collection within one DHB
- private surgical hospital participation in the programme data collection
- observational auditor training and development.
What is a briefing and when do you do it?
A briefing is a standardised communication tool that aims to create an environment in which individuals can speak up, express concerns and alert team members to unsafe situations in a timely manner.
Briefings include all members of a surgical team, are held at the start of a day’s list of procedures and cover all planned procedures.
What if there isn’t time to do a briefing?
When a meaningful briefing is used at the start of each list (ie, with all team members present and each case covered), and becomes the habit of how people work, it takes less and less time. In fact, it can save time because teams are better prepared to work together.
By doing a briefing and sharing information proactively at the start of the list, delays can be prevented from things such as missing equipment or unexpected positioning. Briefings create a shared understanding of how the list should progress and full team engagement, both of which make the list run better even where there wouldn’t have been delays. Therefore, briefings are valuable for complex and non-complex cases and lists alike.
Can our team change the checklist before implementing?
The Health Quality & Safety Commission worked with the sector and an advisory group to develop a ‘gold standard’, generic (ie, non-specialty-specific) paperless checklist. Local teams can review and build on it to meet the particular needs of the local theatre/environment/specialty (eg, moving queries regarding blood loss from ‘sign in’ to ‘time out’ for paediatric surgeries).
We expect local adaptations will include all the items from the ‘gold standard’ version at a minimum – these have been included as important safety checks. Local checklists can be regularly reviewed for ongoing suitability.
What if the checklist is a distraction?
Proper use of the checklist with full team engagement will focus the team on their understanding of the tasks expected of them. The checklist is one or two minutes of making sure everyone’s focus is on the same plan and in the same direction. This will bring about the best outcome, in terms of both efficiency and safety for the patient.
My team knows what I want, so do I need to do the checklist or a briefing?
This is an assumption and won’t always be true. Also, where patient safety is concerned it’s better to be sure than to assume. We know, from international and local research, and adverse event reporting, that when things don’t go well, it will often turn out that someone on the team had information that may have helped prevent harm but that they didn’t have an opportunity to share that information with others. The briefings and the checklist give everyone an opportunity to share information with the team as a whole.
Where is the evidence that the checklist works in my specific environment?
There is a growing body of evidence that briefings, debriefings and the checklist make a difference in preventing harm and adverse events. Even in surgeries that are short or where the risk related to a procedure is low, the risk is still not zero and the potential exists to harm patients. Please see our evidence summary for a useful overview of recent research.
What about using the checklist in non-invasive procedures?
The safe surgery project is focused on full surgical procedures where anaesthesia is required. However, the checklist can support safety for a wider range of procedures, again, with adaptation to the needs of the environment. We encourage the use of an appropriate checklist for all procedures.
Are posters on the operating theatre wall an infection control risk?
We recommend posters are laminated and easy to remove, so they can be wiped down on both sides when theatre walls are cleaned. Each DHB will need to be aware of their local infection control guidelines and work with their local experts to find solutions.
Alternatives, such as hand-held laminated prompt cards and electronic display screens, are being used by some DHBs.
What is the safe surgery process quality and safety marker?
Quality and safety markers (QSMs) are sets of related indicators concentrating on specific areas of harm that show whether desired changes in practice have occurred at a local level.
The SSNZ programme has process and outcome QSMs. The process markers are that all three parts (sign in, time out and sign out) of the surgical safety checklist are used in 100 percent of surgical procedures, with levels of team engagement with the checklist at 5 or above, as measured by the seven-point Likert scale, 95 percent of the time. The outcome markers are the rates of postoperative sepsis and deep vein thrombosis/pulmonary embolism (DVT/PE).
When is the QSM data collected and reported on?
Our fact sheet about data collection requirements covers:
- what the safe surgery process QSM is
- QSM collection and reporting schedule
- QSM data needs for each quarter
- the method used to report the QSM data
- the rationale for collecting 50 moments (for each of sign in, time out, sign out)
- the rationale for needing 50 moments from both smaller and larger DHBs
- spread of data collection within one DHB
- private surgical hospital participation in the programme data collection
- observational auditor training and development.
For more information please email Safe.Surgery@hqsc.govt.nz.
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