SDS Accreditation Update

New tool addresses wrong-site surgeries

A new targeted solutions tool (TST) from The Joint Commission's Center for Transforming Healthcare to address wrong-site surgeries cut those surgeries by 63% in the preoperative area, 51% in the OR, and 46% in the scheduling area during the testing period. These reductions are significant, considering that there are as many as 40 wrong-site surgeries each week.

The Center for Transforming Healthcare tested the safety tool at eight hospitals and ambulatory surgery centers. The tool is meant to be used in addition to the Universal Protocol. It is free to all accredited organizations and can be accessed through the Joint Commission Connect extranet. The tool includes training modules, and videos show good and bad practices. Interactive training materials assess staff learning. The TST provides detailed implementation guides and checklists.

At a recent webinar held about the tool, representatives of Algonquin Road Surgery Center, Lake in the Hills, IL, discussed their experience.

The tool helps facilities identify and measure risks in their processes that can contribute to wrong-site surgery, then reduce them, says Andrew Ward, MD, medical director at the center. "You don't want to have the event occur, and then figure out what you can do to keep it from happening," Ward says. "You'd rather do something more while you can, and never have it happen."

Since the tool focuses on scheduling, preoperative, and the OR, facilities can address one area at a time, or all three at once, says Lori Callahan, CASC, director of the Algonquin Road facility. "So it was very easy. It didn't take too much on our part," Callahan says.

The TST provides training tools and resources to prepare select staff members to collect observation data. Observations can be collected on paper or input directly into the tool using a tablet device, such as an iPad. Ward says, "Data collection is critical to the project since your focus of improvement stems from the data," he says.

The tool allows advanced data analysis and automatically generated charts and graphs. You can easily share this data with your leaders and staff, Ward says. "After having implemented the tool, we've gained the acceptance and the buy-in from the surgeons, the staff, and the anesthesiologists to increase our percentage and get close to 100% compliance in the operating room, and to drastically improve the compliance in the holding room," he says.

The data helps you zero in on any problem areas, Callahan says. They tell you the rate of defective cases per day, the percent of those cases that contain more than one defect, and a breakdown of results by specialty or surgeon. This data analysis can lead you to the top three or four solutions for your key risk areas, Callahan says. "Why spend time implementing solutions that may not — and probably don't — address your risk areas?" she says. "What we think in leadership is working effectively may not always be working the way we think it's working until you actually have some data that is measurable, and you can print out and actually review with staff."

You'll see improvements as soon as eight weeks, say leaders from Algonquin Road, and most facilities finish the project in 14-16 weeks. "By utilizing the TST, it allowed our employees to become empowered," Callahan says. "It gave them a chance to stand up to the surgeon and actually stop them in a situation that may not be following policies."

The center's biggest improvement? Buy-in from the staff and surgeons at the beginning of cases, Ward says. "Previous to using the tool we would have people working on the Mayo stand, checking gauges, writing things down, and not really paying attention to the timeouts," he says. "Now, however, everybody does stop, everyone listens, and everyone agrees."

Hospital shares its success

Holy Spirit Hospital, in Camp Hill, PA, realized improvement opportunities after testing the TST.

The timeout has been expanded so everyone, including the surgeon, anesthesiologist, and surgical technician, actively participates, according to Susan McQuade, RN, associate director of surgical services.

"We are proud of how we handle patient safety, but we wanted to be proactive and develop protocols so we never have a wrong-site surgery," says Joseph A. Torchia, MD, senior vice president and chief medical officer at Holy Spirit. "We joined the Center for Transforming Healthcare project because we wanted to put into place an evidence-based best practice that eliminates the possibility of having a wrong site surgery."

For more information on the tool, go to