Author Archives: Philip D. Authier

Reducing Variation in Time-Outs

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Time-outs were put into place several years ago by JCAHO due to the alarming number of wrong site surgeries taking place. Wrong-site surgeries are considered “never events,” which are obviously events that should never happen.

Time-outs occur right before a procedure, during which the procedure team is supposed to go through a check list to make sure all is ready. Verras was asked to examine a hospital’s compliance with its time-out policies in the wake of three never events occurring in the space of 10 months. Here is what we discovered, based upon a review of hundreds of procedures in 18 procedure locations.

  • While time-outs were being conducted (and had been since 2002), the process was not being done consistently. Not all items on the checklist were always being reviewed
  • There would frequently be distractions during the time-out, such as music playing

Our analysis began in the fall of 2011. This analysis included gathering data on non-compliance. In the four months from the time we initiated the analysis, there were 31 procedures where there was some type of non-compliance to the time-out policy, for a non-compliance rate of 2.5%. While that number may seem small, it is not. Also, while compliance data was not recorded prior to our beginning the analysis, we believe the fact that since clinicians knew they were being monitored, compliance went up, and that non-compliance prior to our analyzing the processes was even higher than 2.5%.

After examining the data and working collaboratively with the medical staff, the following physician-directed best practice protocol was implemented.

  1. The procedure and tracking form were revised.
  2. Concentrated education was done for staff and physicians.
  3. Ongoing monitoring was put into place in the OR and throughout the facility to monitor every location where time-outs were being done.
  4. A process was put into place which called for the CMO, chief of staff, and/or chief of OR to meet individually with any physician or staff not following the procedure.

In the two months after the new process was formally introduced, there were two incidents of non-compliance out of a total of 661 procedures, for a non-compliance rate of 0.3%. Neither incident resulted in a never event. In addition, there were two (2) potential wrong site procedures caught and avoided with the revised time-out process.

There is a new energy and effort around this process. It is now being taken very seriously and all members of the team are feeling more empowered to speak out.

Non-Compliance with Time-Out Process

Click on the graphic to enlarge

We welcome your insight on time-outs. Please feel free to comment. And remember…June 16 is National Time-Out Day.

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Reducing Variation in Treatment of Sepsis

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Sepsis strikes 750,000 Americans1 annually, and between 28% and 50% of those people die2. It is estimated that $17 billion is spent annually to treat sepsis2, or a cost per patient of more than $22,000. Early identification and aggressive treatment is essential in improving outcomes and reducing costs.

We recently examined more than 500 cases of sepsis at one hospital and observed the following:

  1. Charges per discharge had increased by more than 46%.
  2. Mortality was significantly higher than expected – with the variance between expected and actual increasing (see Chart I).
  3. On a per-patient, severity adjusted basis, there was significant variation in both length of stay and charges, indicating a variation in practice patterns (see Charts II and III).
  4. The majority of the variation was due to not identifying the patient early in the hospitalization, getting them into the ICU, and beginning early aggressive treatment. Therefore, patients were in the hospital longer than expected, utilizing many more resources, and having poorer outcomes.

Click on the graphic to enlarge

Click on the graphic to enlarge

Note: BP is best practice; LLQ is length of stay significantly higher than the mean

Click on the graphic to enlarge

Note: BP is best practice; LLQ is charges significantly higher than the mean

After examining the data and working collaboratively with the medical staff, the following physician-directed best practice protocol was implemented.

  1. Monitors and criteria were put in place to track treatment bundle compliance, mortality, and charges per discharge.
  2. ED protocols were implemented to complement the in-patient order sets.
  3. Data on treatment bundle usage, order sets and outcomes was shared with targeted hospitalists and appropriate physicians.
  4. Physician champions and ED leadership were added to the sepsis team.
  5. A work group was established to work on timeliness and availability of central line placement.
  6. Ongoing education was initiated.

Much of this work was done in the first quarter of 2012. We are eagerly anticipating results, and will keep you informed.

We welcome your insight on sepsis. Please feel free to comment.

  1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine. 2001 Jul;29(7):1303-10.
  2. Wood KA, Angus DC. Pharmacoeconomic implications of new therapies in sepsis. PharmacoEconomics. 2004;22(14):895-906.
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