New Targeted Solutions Tool to prevent wrong site surgery

On February 14, the Center for Transforming Healthcare released its newest solution in the ongoing challenge to reduce the risk of wrong site surgery. The center’s new Targeted Solutions Tool (TST) guides health care organizations through a step-by-step process to identify, measure, and reduce risks in key processes that can contribute to a wrong site surgery. The focus on eliminating defects is important because a single operative case has multiple opportunities for problems from the time a procedure is scheduled to the time when the first incision is made. Research has shown that there is usually no one root cause of failure, as it is frequently the result of a cascade of small errors.* While wrong site surgery rarely occurs, health care professionals who perform invasive procedures, who ignore that they are at some degree of risk, or who rely on the absence of such events in the past as a guarantee of future safety, may be doing so at their own risk.

The TST for Wrong Site Surgery provides organizations with a process to evaluate risks across their surgical system, including scheduling, preoperative, and operating room (OR) areas. Because incidents of wrong site surgery are rare, the TST helps an organization efficiently monitor its surgical cases and focus on the specific areas of potential weakness that might result in a wrong site surgery. Surgeons and all other health care professionals at Joint Commission-accredited organizations have free access to the new wrong site surgery TST via their secure Joint Commission Connect extranet. Once accessed, the TST works as a Web-based tool that walks the user through the wrong site surgery performance improvement project from start to finish.

The TST for Wrong Site Surgery is designed so that it can be clearly understood and used by an organization’s current staff without requiring any additional resources to implement the tool’s steps. There are six basic steps that will help guide staff through the project, and each step includes a list of action items to complete before proceeding. By using the TST to identify specific causes that could lead, or have led, to a defect at an organization, and then implementing targeted solutions that address those causes, the TST takes the process improvement that could have been overwhelming and simplifies it.

The Center for Transforming Healthcare’s Wrong Site Surgery Project began in July 2009. Eight U.S. hospitals and ambulatory surgical centers teamed up with the center to address the problem and develop the solutions. The organizations that participated in the project used Robust Process Improvement™ (RPI) methods. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates tools, concepts, and methods from Lean Six Sigma and change management methodologies to discover the causes of and put a stop to these preventable breakdowns in patient care. The participants identified 29 main causes of wrong site surgeries that occurred during scheduling, preop/holding, or in the OR, or those causes that stemmed from the organizational culture. The TST was then pilot tested by six hospitals and ambulatory surgical centers.

Over the course of the project, the original eight project organizations were able to reduce the number of surgical cases with risks by 46 percent in the scheduling area, by 63 percent in preop, and by 51 percent in the OR. The hospitals and ambulatory surgical centers that pilot tested the TST experienced gains similar to those of the original participants.

Although invasive surgical procedures occur in many settings, the scope of this project included all procedures performed in the OR and regional blocks performed by anesthesia either in the preoperative area or in the OR. Within the project scope, the time frame begins at the time a procedure is scheduled for surgery and ends with incision.

The first set of targeted solutions, created by eight of the country’s leading hospitals and health care systems working in collaboration with the center, focuses on improving hand hygiene. Solutions for hand-off communications, another center project, are expected to be added to the TST in summer 2012. In addition, the center is working to reduce surgical site infections following colorectal surgery through a project that was launched in August 2010 in collaboration with the American College of Surgeons. The solutions for this project are expected to be published later this year. Other center projects include preventing avoidable heart failure hospitalizations, preventing falls with injury, and safety culture.

For more information on the Center for Transforming Healthcare’s Wrong Site Surgery Project and other center projects, visit the following links:

* Joint Commission Center for Transforming Healthcare. Reducing the risk of wrong site surgery. Available at: Accessed February 28, 2012.

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