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The WakeWings Journey: Creating a Patient Safety Program
PATIENT SAFETY FIRST
The WakeWings Journey: Creating a Patient Safety Program ELIZABETH MILLS, MSN, RN, CNOR, CSSM
I
nnovations in the OR may arise from new policies, changes in practice, new technologies, improved procedures, and new surgical techniques. At times, the impetus for change occurs because of inadequate outcomes or what are called sentinel events and near misses. Research confirms that sentinel events (eg, wrong-site surgery, retained surgical items) are uncommon, but when they happen, it is tragic for everyone involved.1-4 The Joint Commission defines a sentinel event as a “patient safety event that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm and intervention required to sustain life.”5 Wrong-site surgery or retained surgical items may occur for several reasons, but The Joint Commission and research cites communication errors in the OR as the main contributing factor to such events.3,4 To prevent sentinel events, The Joint Commission mandated the use of the
Universal Protocol in 2003. The Universal Protocol requires verification of the patient’s identity and the planned procedure, surgical site marking, and the performance of a time out in the OR.6
THE WAKEWINGS PROGRAM Perioperative personnel at our facility, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, implement many policies and procedures to help ensure compliance with The Joint Commission’s Universal Protocol; however, even with these steps in place, sentinel events were still occurring here. From July 2009 to June 2010, six sentinel events occurred in our OR. In the subsequent six months, an additional three sentinel events occurred. These incidents emphasized the need to consult with outside sources to determine how our processes could be improved. http://dx.doi.org/10.1016/j.aorn.2016.04.004 ª AORN, Inc, 2016
636 j AORN Journal
www.aornjournal.org
June 2016, Vol. 103, No. 6
LifeWings is a collection of physicians, nurses, astronauts, pilots, and risk managers who teach medical personnel how to implement the same teamwork behaviors used by highreliability organizations in commercial aviation and the National Aeronautics and Space Administration. At our facility, personnel in the divisions of Surgical Services and Surgery and the Department of Anesthesiology adopted the LifeWings program on December 6, 2010, and the program was officially implemented July 5, 2011. We created a steering committee to devise and oversee the implementation of the program by ensuring the consistency of the tools and evaluating the evolving needs of the program. This committee meets monthly under the leadership of two cochairpersons and has a diverse membership that includes surgical executive leaders. The committee’s charge is to monitor the progress of the LifeWings program by meeting monthly to review concerns and plan for future safety initiatives. In January 2011, a team of aviation leaders presented their LifeWings program at our hospital. Afterwards, the steering committee conducted many meetings and discussions to help transition the perioperative personnel to a culture of safety via a team approach. After receiving training, we decided to name our program WakeWings. WakeWings is our patient safety and teamwork program designed to implement checklists and standardized communication. The purpose of WakeWings is to create a culture of open communication among team members and to provide a standardized framework for operative or other invasive procedures that promotes the ultimate goal of an optimally safe environment. The WakeWings philosophy statement is: Every patient at Wake Forest Baptist Medical Center reliably receives patient-centered, safe, and compassionate care of the highest quality. We provide this care by holding ourselves accountable for expert teamwork, technical excellence and adherence to policy, procedures and checklists, and by continuous data-driven improvements to our knowledge and skill. Perioperative personnel spent months developing more than 20 customized patient safety tools (eg, checklists, hand overs, report outs) that they now use daily throughout a patient’s continuum of care in the OR, endoscopy unit, and the postoperative care unit. Personnel in the surgical clinics also adopted WakeWings principles, and other groups throughout our medical center (eg, the pediatric intensive care unit, the radiation oncology department) have inquired about how to become involved. The patient safety tools are under periodic review and are optimized on a regular basis and as needed (eg, as personnel become more familiar with terminology, as new regulations require additional oversight). WakeWings is a
www.aornjournal.org
The WakeWings Program
Table 1. Goals and Outcome Measures for the WakeWings Program Goal
Outcome Measure
Safety
Decrease in sentinel events and patient harm Decrease in perioperative events filed with risk managers Decrease in number of times the root-cause analysis teams are needed
Teamwork
Improvement in employee satisfaction on survey questions relating to teamwork and communication Increase in number of staff members commenting or speaking up during OR team debriefing Decrease in staff turnover Activation of escalation algorithm policy Increase in number of staff suggestions for improvement
Quality outcomes Decrease in surgical site infections Decrease in unplanned patient returns to OR Decrease in morbidity and mortality Improvement in patient satisfaction Improvement in National Surgical Quality Improvement Program and Surgical Care Improvement Program measures Efficiency and reliability
Decrease in OR turnover times Increase in on-time procedure starts 100% compliance with use of safety tools (OR Team Checklist, other hand-over checklists) Reduction in procedure times Decrease in number of Concern Reports generated Decrease in average discharge cost per surgical procedure type
Editor’s note: National Surgical Quality Improvement Program (NSQIP) is a registered trademark of the American College of Surgeons, Chicago, IL.
highly flexible system, and this program is changing the facility’s culture. A safety culture consists of many factors; shared beliefs, practices, and attitudes focused on safety exist in an atmosphere that has a safety culture. We believe we have a safety culture because we are experiencing fewer safety incidents, lower staff turnover, lower absenteeism, positive and motivating staff stories, and higher productivity. We believe our efforts are successful because of our commitments to reassessment and continuous improvement. AORN Journal j 637
Mills
June 2016, Vol. 103, No. 6
Figure 1. The Wake Forest Baptist Health OR Team Checklist. DNR ¼ do not resuscitate order; H&P ¼ history and physical; MR# ¼ medical record number; DVT ¼ deep vein thrombosis; SCD ¼ sequential compression device; ICU ¼ intensive care unit; ASA ¼ American Society of Anesthesiologists (ASA) Physical Status classification; ID ¼ identification; O2 ¼ oxygen. Reprinted with permission from Wake Forest Baptist Health, Winston-Salem, NC.
WakeWings Training The medical center’s chief patient safety officer is one of 11 internal WakeWings trainers. From February to June 2011, she provided four-hour training sessions to educate the current 1,300 surgical services employees before the launch of the program in July 2011. These training programs included surgeons, anesthesia providers, nursing personnel, and ancillary staff members. The WakeWings trainers now hold these training sessions monthly for all new surgical services personnel. As of April 2016, a total of 2,601 employees have attended a four-hour Team Skills Workshop training session. Anyone working in the OR, the postanesthesia care unit, the preoperative holding rooms, or the endoscopy service is required to be WakeWings certified by attending this class and completing an online module to reinforce important concepts. Surgical executive leaders view this program as “the way we do business,” and they have committed to ensuring that all personnel are WakeWings certified or are in the process of certification. As part of our commitment to the WakeWings
638 j AORN Journal
initiative, trainers created a self-study module to reinforce the four-hour Teamwork Skills Workshop. This module contains information regarding the patient safety tools and the policy and procedures regarding the use of those tools. Table 1 describes the program’s goals.
WakeWings Tools One of our most frequently used patient safety tools is the OR Team Checklist (Figure 1) that hangs in every OR suite. It is 3 ft by 5 ft, and it is our version of the Universal Protocol. Staff members use it as a read-and-verify tool during time outs. Two other tools are the Concern Report and the Success and Praise Report. A Concern Report is a safety tool that alerts WakeWings leaders to any nonemergent issues (eg, procedures with incorrect supplies, broken instruments, delays as a result of current processes) and can be submitted by any team member. Each report is evaluated by department leaders, who provide a response to all involved
www.aornjournal.org
June 2016, Vol. 103, No. 6
personnel. The Concern Report is the appropriate venue for issues involving the day-to-day functionality of the WakeWings program. Such a report does not substitute for an assertive statement or an escalation. Assertive statements are made using approved code words, such as “I’m concerned.” These words should be used when necessary to convey important and time-sensitive information. The assertive statements have a standard structure to provide team members ease and confidence to speak up in the interest of patient safety. Whenever there is professional and respectful disagreement among team members (particularly in the immediate management of an assertive statement) and a team member is not satisfied that the patient’s best interests are being served, that person must escalate action on the issue in the interest of patient safety and without fear of retaliation. The escalation mechanism can be activated by any member of the surgical team. As of April 2016, a total of 2,984 Concern Reports have been submitted. Success and Praise Reports are mechanisms by which to praise teammates and to ensure they are recognized by WakeWings leaders. These reports can be submitted by any team member to the person being recognized and to his or her direct manager. We designed this tool to document instances of a staff member successfully affecting a patient safety outcome using a WakeWings process. Success and Praise Reports also are appropriate for recognizing occasions when culture change is apparent or when a team member speaks up in the interest of patient safety or is a model coworker. As of April 2016, a total of 1,154 Success and Praise Reports have been submitted. Additionally, the frequency of safety events has decreased.
CONCLUSION Personnel in the surgical services department at Wake Forest Baptist Medical Center have improved safety through dedication to the WakeWings Patient Safety Program. The program was instituted to rigorously implement The Joint Commission’s Universal Protocol and to reduce the number of sentinel events. Safety is a continuous journey. When nurses stop learning, focusing, pursuing, reaching, and engaging, apathy sets in and can become contagious. Perioperative nurses
www.aornjournal.org
The WakeWings Program
should consistently and continuously strive for lifelong learning and quality improvements. Editor’s note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
References 1. Crane M. Wrong-site surgery occurs 40 times a week: Joint Commission announces preliminary results of project to prevent “never happen” events [news release]. New York, NY: Medscape; June 29, 2011. http://www.medscape.com/viewarticle/745581. Accessed March 1, 2016. 2. Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. October 17, 2013;51. http://www.jointcommission .org/assets/1/6/sea_51_urfos_10_17_13_final.pdf. Accessed March 1, 2016. 3. Hempel S, Maggard MA, Nguyen D, et al. Prevention of wrong site surgery, retained surgical items, and surgical fires: a systematic review. Department of Veterans Affairs, Health Services Research & Development Service. VA-ESP Project 05-226. http://www.hsrd .research.va.gov/publications/esp/wrong-site.pdf. Published September 2013. Accessed February 29, 2016. 4. Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg. 2015;150(8): 796-805. 5. Joint Commission. Sentinel event policy and procedures [web page]. http://www.jointcommission.org/sentinel_event_policy_and_ procedures. Published January 6, 2016. Accessed February 29, 2016. 6. Joint Commission. National Patient Safety Goals effective January 1, 2015. http://www.jointcommission.org/assets/1/6/2015_npsg_hap .pdf. Published January 6, 2015. Accessed March 25, 2016.
Elizabeth Mills, MSN, RN, CNOR, CSSM, is a perioperative clinical educator/quality and resource manager at Wake Forest Baptist Medical Center, Winston-Salem, NC. Ms Mills has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 639
The WakeWings Journey: Creating a Patient Safety Program ELIZABETH MILLS, MSN, RN, CNOR, CSSM
I
nnovations in the OR may arise from new policies, changes in practice, new technologies, improved procedures, and new surgical techniques. At times, the impetus for change occurs because of inadequate outcomes or what are called sentinel events and near misses. Research confirms that sentinel events (eg, wrong-site surgery, retained surgical items) are uncommon, but when they happen, it is tragic for everyone involved.1-4 The Joint Commission defines a sentinel event as a “patient safety event that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm and intervention required to sustain life.”5 Wrong-site surgery or retained surgical items may occur for several reasons, but The Joint Commission and research cites communication errors in the OR as the main contributing factor to such events.3,4 To prevent sentinel events, The Joint Commission mandated the use of the
Universal Protocol in 2003. The Universal Protocol requires verification of the patient’s identity and the planned procedure, surgical site marking, and the performance of a time out in the OR.6
THE WAKEWINGS PROGRAM Perioperative personnel at our facility, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, implement many policies and procedures to help ensure compliance with The Joint Commission’s Universal Protocol; however, even with these steps in place, sentinel events were still occurring here. From July 2009 to June 2010, six sentinel events occurred in our OR. In the subsequent six months, an additional three sentinel events occurred. These incidents emphasized the need to consult with outside sources to determine how our processes could be improved. http://dx.doi.org/10.1016/j.aorn.2016.04.004 ª AORN, Inc, 2016
636 j AORN Journal
www.aornjournal.org
June 2016, Vol. 103, No. 6
LifeWings is a collection of physicians, nurses, astronauts, pilots, and risk managers who teach medical personnel how to implement the same teamwork behaviors used by highreliability organizations in commercial aviation and the National Aeronautics and Space Administration. At our facility, personnel in the divisions of Surgical Services and Surgery and the Department of Anesthesiology adopted the LifeWings program on December 6, 2010, and the program was officially implemented July 5, 2011. We created a steering committee to devise and oversee the implementation of the program by ensuring the consistency of the tools and evaluating the evolving needs of the program. This committee meets monthly under the leadership of two cochairpersons and has a diverse membership that includes surgical executive leaders. The committee’s charge is to monitor the progress of the LifeWings program by meeting monthly to review concerns and plan for future safety initiatives. In January 2011, a team of aviation leaders presented their LifeWings program at our hospital. Afterwards, the steering committee conducted many meetings and discussions to help transition the perioperative personnel to a culture of safety via a team approach. After receiving training, we decided to name our program WakeWings. WakeWings is our patient safety and teamwork program designed to implement checklists and standardized communication. The purpose of WakeWings is to create a culture of open communication among team members and to provide a standardized framework for operative or other invasive procedures that promotes the ultimate goal of an optimally safe environment. The WakeWings philosophy statement is: Every patient at Wake Forest Baptist Medical Center reliably receives patient-centered, safe, and compassionate care of the highest quality. We provide this care by holding ourselves accountable for expert teamwork, technical excellence and adherence to policy, procedures and checklists, and by continuous data-driven improvements to our knowledge and skill. Perioperative personnel spent months developing more than 20 customized patient safety tools (eg, checklists, hand overs, report outs) that they now use daily throughout a patient’s continuum of care in the OR, endoscopy unit, and the postoperative care unit. Personnel in the surgical clinics also adopted WakeWings principles, and other groups throughout our medical center (eg, the pediatric intensive care unit, the radiation oncology department) have inquired about how to become involved. The patient safety tools are under periodic review and are optimized on a regular basis and as needed (eg, as personnel become more familiar with terminology, as new regulations require additional oversight). WakeWings is a
www.aornjournal.org
The WakeWings Program
Table 1. Goals and Outcome Measures for the WakeWings Program Goal
Outcome Measure
Safety
Decrease in sentinel events and patient harm Decrease in perioperative events filed with risk managers Decrease in number of times the root-cause analysis teams are needed
Teamwork
Improvement in employee satisfaction on survey questions relating to teamwork and communication Increase in number of staff members commenting or speaking up during OR team debriefing Decrease in staff turnover Activation of escalation algorithm policy Increase in number of staff suggestions for improvement
Quality outcomes Decrease in surgical site infections Decrease in unplanned patient returns to OR Decrease in morbidity and mortality Improvement in patient satisfaction Improvement in National Surgical Quality Improvement Program and Surgical Care Improvement Program measures Efficiency and reliability
Decrease in OR turnover times Increase in on-time procedure starts 100% compliance with use of safety tools (OR Team Checklist, other hand-over checklists) Reduction in procedure times Decrease in number of Concern Reports generated Decrease in average discharge cost per surgical procedure type
Editor’s note: National Surgical Quality Improvement Program (NSQIP) is a registered trademark of the American College of Surgeons, Chicago, IL.
highly flexible system, and this program is changing the facility’s culture. A safety culture consists of many factors; shared beliefs, practices, and attitudes focused on safety exist in an atmosphere that has a safety culture. We believe we have a safety culture because we are experiencing fewer safety incidents, lower staff turnover, lower absenteeism, positive and motivating staff stories, and higher productivity. We believe our efforts are successful because of our commitments to reassessment and continuous improvement. AORN Journal j 637
Mills
June 2016, Vol. 103, No. 6
Figure 1. The Wake Forest Baptist Health OR Team Checklist. DNR ¼ do not resuscitate order; H&P ¼ history and physical; MR# ¼ medical record number; DVT ¼ deep vein thrombosis; SCD ¼ sequential compression device; ICU ¼ intensive care unit; ASA ¼ American Society of Anesthesiologists (ASA) Physical Status classification; ID ¼ identification; O2 ¼ oxygen. Reprinted with permission from Wake Forest Baptist Health, Winston-Salem, NC.
WakeWings Training The medical center’s chief patient safety officer is one of 11 internal WakeWings trainers. From February to June 2011, she provided four-hour training sessions to educate the current 1,300 surgical services employees before the launch of the program in July 2011. These training programs included surgeons, anesthesia providers, nursing personnel, and ancillary staff members. The WakeWings trainers now hold these training sessions monthly for all new surgical services personnel. As of April 2016, a total of 2,601 employees have attended a four-hour Team Skills Workshop training session. Anyone working in the OR, the postanesthesia care unit, the preoperative holding rooms, or the endoscopy service is required to be WakeWings certified by attending this class and completing an online module to reinforce important concepts. Surgical executive leaders view this program as “the way we do business,” and they have committed to ensuring that all personnel are WakeWings certified or are in the process of certification. As part of our commitment to the WakeWings
638 j AORN Journal
initiative, trainers created a self-study module to reinforce the four-hour Teamwork Skills Workshop. This module contains information regarding the patient safety tools and the policy and procedures regarding the use of those tools. Table 1 describes the program’s goals.
WakeWings Tools One of our most frequently used patient safety tools is the OR Team Checklist (Figure 1) that hangs in every OR suite. It is 3 ft by 5 ft, and it is our version of the Universal Protocol. Staff members use it as a read-and-verify tool during time outs. Two other tools are the Concern Report and the Success and Praise Report. A Concern Report is a safety tool that alerts WakeWings leaders to any nonemergent issues (eg, procedures with incorrect supplies, broken instruments, delays as a result of current processes) and can be submitted by any team member. Each report is evaluated by department leaders, who provide a response to all involved
www.aornjournal.org
June 2016, Vol. 103, No. 6
personnel. The Concern Report is the appropriate venue for issues involving the day-to-day functionality of the WakeWings program. Such a report does not substitute for an assertive statement or an escalation. Assertive statements are made using approved code words, such as “I’m concerned.” These words should be used when necessary to convey important and time-sensitive information. The assertive statements have a standard structure to provide team members ease and confidence to speak up in the interest of patient safety. Whenever there is professional and respectful disagreement among team members (particularly in the immediate management of an assertive statement) and a team member is not satisfied that the patient’s best interests are being served, that person must escalate action on the issue in the interest of patient safety and without fear of retaliation. The escalation mechanism can be activated by any member of the surgical team. As of April 2016, a total of 2,984 Concern Reports have been submitted. Success and Praise Reports are mechanisms by which to praise teammates and to ensure they are recognized by WakeWings leaders. These reports can be submitted by any team member to the person being recognized and to his or her direct manager. We designed this tool to document instances of a staff member successfully affecting a patient safety outcome using a WakeWings process. Success and Praise Reports also are appropriate for recognizing occasions when culture change is apparent or when a team member speaks up in the interest of patient safety or is a model coworker. As of April 2016, a total of 1,154 Success and Praise Reports have been submitted. Additionally, the frequency of safety events has decreased.
CONCLUSION Personnel in the surgical services department at Wake Forest Baptist Medical Center have improved safety through dedication to the WakeWings Patient Safety Program. The program was instituted to rigorously implement The Joint Commission’s Universal Protocol and to reduce the number of sentinel events. Safety is a continuous journey. When nurses stop learning, focusing, pursuing, reaching, and engaging, apathy sets in and can become contagious. Perioperative nurses
www.aornjournal.org
The WakeWings Program
should consistently and continuously strive for lifelong learning and quality improvements. Editor’s note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
References 1. Crane M. Wrong-site surgery occurs 40 times a week: Joint Commission announces preliminary results of project to prevent “never happen” events [news release]. New York, NY: Medscape; June 29, 2011. http://www.medscape.com/viewarticle/745581. Accessed March 1, 2016. 2. Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. October 17, 2013;51. http://www.jointcommission .org/assets/1/6/sea_51_urfos_10_17_13_final.pdf. Accessed March 1, 2016. 3. Hempel S, Maggard MA, Nguyen D, et al. Prevention of wrong site surgery, retained surgical items, and surgical fires: a systematic review. Department of Veterans Affairs, Health Services Research & Development Service. VA-ESP Project 05-226. http://www.hsrd .research.va.gov/publications/esp/wrong-site.pdf. Published September 2013. Accessed February 29, 2016. 4. Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg. 2015;150(8): 796-805. 5. Joint Commission. Sentinel event policy and procedures [web page]. http://www.jointcommission.org/sentinel_event_policy_and_ procedures. Published January 6, 2016. Accessed February 29, 2016. 6. Joint Commission. National Patient Safety Goals effective January 1, 2015. http://www.jointcommission.org/assets/1/6/2015_npsg_hap .pdf. Published January 6, 2015. Accessed March 25, 2016.
Elizabeth Mills, MSN, RN, CNOR, CSSM, is a perioperative clinical educator/quality and resource manager at Wake Forest Baptist Medical Center, Winston-Salem, NC. Ms Mills has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 639