Communication, coordination among hospital leaders and physicians improve surgical outcomes

In October 2010, some hospitals in South Carolina began implementing a customized surgical safety checklist patterned after a checklist that the World Health Organization developed. Hospitals implemented the 12-step process that focused on teamwork, training and monitoring progress.

So far, the early results are promising. Researchers last month published an article in the Annals of Surgery that found hospitals using the checklist had a 22 percent reduction in 30-day mortality rates compared with hospitals that did not use it.

Ariadne Labs, a joint center between Brigham and Women’s Hospital in Boston and the Harvard T.H. Chan School of Public Health, partnered with the South Carolina Hospital Association on the voluntary, statewide program.

“We are honored to be a learning lab for the rest of the country,” Thornton Kirby, President and CEO of the South Carolina Hospital Association, said in a news release. “The study validates what we hoped and believed from the outset—if you change the operating room culture of how you communicate and coordinate your efforts, you can produce better outcomes.”

The program had a statewide leadership team to champion the program, support hospitals and provide implementation strategies and checklist performance improvement. Each hospital also had a leadership team devoted to the program, but they did not hire additional staff and did not receive financial support for this work, according to the researchers. The hospitals convened on a semi-annual basis, received training and shared their experiences. They also had a webinar-based educational series available.

By December 2013, 14 hospitals completed the program. The researchers found no significant difference in mortality trends between the groups from 2008 to 2010, which was before the collaborative formed. However, from 2011 to 2013, there was a statistically significant trend of decreasing postoperative mortality among hospitals that completed the program.

“The specific attributes leading to completion of the program within this group are important to understand to inform other hospitals and large-scale initiatives,” the researchers wrote. “There were no significant structural differences identified; hospitals completing the program included large and small, rural and urban, and also teaching and nonteaching hospitals, but there are likely unmeasured differences that led the completion group to be primed for improvement.”

Among hospitals that completed the program, the 30-day postoperative mortality rate was 3.38 percent in 2010 and 2.84 percent in 2013, which was a statistically significant decline. Meanwhile, the 30-day postoperative mortality rates in hospitals that did not complete the program were 3.5 percent and 3.71 percent, respectively, which was not a significant difference. In addition, the overall state-wide 30-day postoperative mortality rate did not significantly change from 2010 to 2013.

The researchers acknowledged a few limitations of their analysis, including that it was not a research trial and did not include a formal control group. They also did not know which elements of the intervention led to changes in perioperative practice and outcomes. In addition, they could not measure checklist use in the operating room. Further, they only considered inpatient surgery, which they defined as having spent at least two midnights in the hospital following the procedure.

“The findings indicate that the institutional engagement necessary to create the requisite behavioral changes among teams of surgical professionals is unlikely to occur without broad, sustained participation of both frontline clinicians and hospital leadership,” the researchers wrote. “The checklist was specifically designed to better enable team communication and a culture of safety; implementation is unlikely to affect patient outcomes without fostering acceptance of change in attitudes toward patient safety and team behaviors in the operating room. Participants in the program moved at different paces, and implementation efforts continue beyond the timeframe reported here in many hospitals within the state.”