Ximedica Leverages Human-Centered Approach to Redefine the Surgical Site Identification Process

Wrong site surgeries continue to occur with no consistent evidence of slowing. The Universal Protocol has not proven successful in reducing the risk to acceptable tolerances, much less to the goal of zero. Surgeries continue to be performed on the wrong side, the wrong digit, even the wrong patient. Research names several contributing factors. Among them are: 

• Heavy workload
• Fatigue
• Pressure to move quickly
• Changing team members
• Patient draping method
• Communications

Despite a five sigma compliance with Universal Protocol, a sentinel event at a regional community hospital triggered a search for solutions to lower the risk of wrong site surgery. Tasked with this critical clinical process improvement, Ximedica went to work.

Our Approach

Deconstructing the touchpoints and path by which patient information arrives at the OR was fundamental. Through contextual observations and interviews, Ximedica’s multi-disciplinary team observed over 100 procedures and spent 200 hours mapping the journey from surgical diagnosis to OR entry. These comprehensive task maps accurately depict how people think and perform critical tasks in relation to workflows and patient journeys. Maps like these allow the client to align and agree on a system’s real versus perceived risk-prone elements.

The example map above reflects the complexitites of a surgical patient's journey from the time the need for surgery is identified through completion of the procedure and all the opportunities for site and side identification error that begin early in the process. 

A single document with six critical pieces of patient procedure information, including site and side, begins the patient paper trail. More than 32 redundant, manual information transfers of this information occur throughout the patient hospital journey.

A staff of 21 professionals collectively create and share this patient procedure information to verify and move the patient through the hospital.

Ultimately, more than 60 paper and digital documents carry six pieces of critical patient information in and out of the hospital leading up to the day of the surgery - 60+ opportunities for error before the site and side are even marked.

Ximedica collaborated with the staff to create an eight-part integrated solution program that consisted of a series of natural build-on initiatives, including a revised universal protocol, improved patient education, digital information package, software enhancements, and task-shifting. The result is a system that is more seamless, intuitive, and user-friendly and most importantly, a process that has fewer opportunities to introduce error.
 
To learn more about how Ximedica can join with your team to achieve adoptable and sustainable workflow improvement resulting in enhanced patient flow and safety, please contact Ximedica’s Director of Healthcare Delivery Solutions, Kristin Simoens, at ksimoens@ximedica.com.