Beth Israel Medical Center reaction to wrong-site surgery becomes class discussion at Darmouth

Yesterday I reported on Beth Israel's response to a wrong-site surgery and how we were encouraged by their frankness in addressing the problem in a very public way. That discussion prompted a Dartmouth professor to use the blog post and comments in a master's level class at Dartmouth on patient safety and quality. 

"In starting my class this fall on the intellectual underpinnings of the improvement of health care, I decided to take your blog and its responses, the Globe blog and responses and the WSJ blog and responses and give them to my Master's class ahead of our first session. I assigned a "role" of patient, family member, surgeon, anesthesiologist, nurse, payer, CEO, board member to each student and asked them to prepare a two page description of the actions they would recommend and the worries that they might have about what they were recommending."

Reviewing the conclusions from class discussion arrives at conclusions similar to my own in earlier posts.

"At the start of class, I divided them into tables of mixed roles and asked them to come up with a plan, why they thought it might work and how they might know it was.

We had a very good conversation and I'm including some of the outputs of the discussions for your interest."

Those conclusions from the various groups and included the following summary of the group presentations.

"Pay for Performance
From a financial perspective, nobody wants to pay for the cost of a medical error. Our position is that payers should reimburse based on performance. In order to measure this performance, it is beneficial to assign a quality score to each organization. This way, insurance companies and payers can choose to only contract with high quality providers.

Better Pre-Op Procedures
We recognize that miscommunications and errors happen, and so it is important to devise a standard protocol for making those errors less likely. Before surgery, the surgical site is usually marked. However, those markings can be ambiguous. By color coding a "yes" on the correct side and a "no" on the wrong side, there is less likelihood of error due to misinterpretation. We also suggest allowing the patient to be involved in the marking. The patient (if able), pre-op nurse, and the surgeon should all sign the surgical site in an effort to further reduce error.

Better Time-Out Procedure
Time-outs are already "implemented," but the key is making sure that they are actually being carried out. In an operating room, there is often a superiority issue that may cause a nurse or assistant not to speak up if the surgeon goes through the time-out incorrectly or skips it altogether. To remedy this, we suggest assigning a "time out captain" who will always initiate the time out. This may be the surgical nurse, or a tech in the OR who is prepping the tools. By assigning a role, it is more likely to be done. We also recommend having some sort of written time-out. By forcing the people in the OR to write out the right person, right place, and correct site rather than just quickly checking it off, it ensures that this step will not get skipped. Finally, a visual projection on the wall of the operating room may be a good tool to reinforce the time out. By projecting a picture of the patient (or outline of a patient) and highlighting the correct area to be operated on, surgeons will have a visual check before they begin."

I find the discussion about paying for performance very interesting, although I suspect that will go nowhere with third-party payers.  Although it's an interesting idea it's not one people can get used to; since we all are paying expecting the surgeon and staff to do their job right the first time. If not one has to ask, then what are we paying for?

Again I say, well done!