IHI ID 16 Moving from parallel to serial preoperative process flow utilizing multidisciplinary bedside handoffs improves preoperative task completion. (December 2018) - Josephs, Sean
Abstract : Background: Incident reports suggested that patients were reaching the operating room (OR) without completion of necessary preparatory tasks. Incidents included Near Misses with potential for harm. Parallel processing and inadequate communication among preoperative nurses, anesthesia providers, and OR nurses were determined to be root causes of many of these failures. Objectives: Significantly increase the number of days-between preoperative task-completion (PTC) failures. Methods: Incident reports were analyzed for root causes. Preoperative process flow was mapped. Process flow at other institutions was observed. Multidisciplinary bedside handoffs utilizing a task-completion checklist were tested, adapted, and adopted as a new preoperative process (figure 1 ). Days-between PTC failures were plotted on an XMR chart as the primary metric. First case procedure start times were plotted on XMR charts as a balancing measure. Qualitative data were collected about process issues identified by the handoff process. Results: After introduction of bedside handoffs days-between PTC failures reaching the OR increased from every 5 days to >40 days (figure 2 ). The average procedure start time was delayed by 8 min (figure 3 ). A majority of PTC failures that were stopped from reaching the OR were surgeon-specific (figure 4A ). Unavailability of nurses was a reported barrier to process success. (figure 4B ). Conclusions: Bedside handoffs inclusive of preoperative nurses, anesthesia providers, and OR nurses increased the days between PTC incidents reaching the OR. This safety intervention had the tradeoff of a slight decrease in efficiency as measured by procedure start times. Interventions targeting nurse availability and earlier surgeon task completion are still necessary to optimize efficiency.