Successful applicants to the ASGE Endoscopy Unit Recognition Program submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The quality assurance and performance improvement (QAPI) project in the spotlight this month looked at looked at the “time-out” process.

DEFINE

The universal protocol was developed to prevent wrong site, wrong procedure and wrong person incidents. Two of the topics covered in the 2019 Ambulatory Health Care National Patient Safety Goals are:

1. Identifying patients correctly
2. Preventing mistakes in surgeries/procedures
   

An important part of the universal protocol is the "time-out" prior to the start of a procedure. According to our center's policy, prior to the start of the endoscopic procedure, the team stops all activity and identifies the patient by name and date of birth and identifies the procedure to be performed by reading the consent signed by the patient.

Although we have been documenting the time-out process on our procedure record, a study of the quality of this process has not been done. Therefore, this study will focus on the observation of the time-out process, noting that all steps have been followed and all participants are solely focused on the process.

MEASURE

Our study ran for four weeks: two weeks in February and one week each in March and April during the weeks of February 4, February 18, March 11 and April 1. On a spreadsheet, we recorded our data with a "1" for yes and a "0" for no. The following data were observed and collected:

Time-Out Components

• Correct patient (staff member states patient's name from name bracelet to staff in room)
• Correct date of birth (DOB) (staff member states patient's DOB from name bracelet to staff in room)
• Correct procedure (staff member reads procedure from the electronic chart to staff in room)
  

Quality of the Time-Out

• All members of the team were present at the start of the time-out
• One person led the time-out procedure
• All members of the team participated/acknowledged the time-out
• No member of the team was doing any other activity during the time-out
  

Each day, two patients were chosen at random to be part of the study.

ANALYZE

During the study, 40 patient procedures were randomly chosen to observe the time-out procedure. For the time-out components of correct patient, DOB and procedure, 100 percent of the 40 patients were identified by viewing the patient's name bracelet for the correct patient and DOB. However, the correct procedure was identified properly (staff member reads procedure from electronic chart to staff in room) only 90 percent of the time.

For the quality of time-out, all team members were present at the start of the time-out and one person led the time-out procedure in 100 percent of the 40 cases. However, in only 14 of the 40 cases, or 35 percent, members of the team participated/acknowledged the time-out. Finally, in eight of the 40 cases, or only 20 percent, was no team member doing any other activity during the time-out process.

IMPROVE

This was a good study for our center because it showed that we need improvement in our time-out process. Although everyone was present during the time-out, many team members were busy doing other tasks, and acknowledgement of the time-out was not consistently present. The importance of this process must be stressed to all members of the staff, with an emphasis on total compliance. After discussion by our quality improvement committee, we decided that all staff will be provided with reeducation on our time-out protocol to include everyone in the room stopping all activity and verbally acknowledging the full time-out. In addition, starting immediately, the time-out process will be added to the monthly tracer round worksheet used to monitor staff compliance with things like hand hygiene, universal precautions and proper labeling of medications, to name a few.

CONTROL

The outcome of this project proved that we did not meet two of the three performance goals we set. For example:

• Goal 1: To determine if the steps of the time-out process are completed 100 percent of the time. We met this goal on two of the three elements. Only 90 percent of the time did the staff member leading the time-out read the procedure from the patient's electronic record.
• Goal 2: To discover if all team members acknowledge the results of the time-out process by either a verbal or nonverbal (nod) response at least 95 percent of the time. We did not reach this goal, as only 35 percent of the time, the entire team participated/acknowledged the time-out.
• Goal 3: To find out if all activity ceases in the procedure room during the time-out at least 80 percent of the time. We did not meet this goal, as only 20 percent of the time was no team member doing another activity during the time-out.

The results of this study were shared with the quality improvement committee, board of directors and staff. We will immediately add the time-out process to our monthly tracer rounds and look to the future for reevaluating our time-out process in another quality improvement study to compare to our first one. Our goal in a restudy would be to increase our percentage for goal #2 from 35 percent to 95 percent and for goal #3 from 20 percent to 80 percent.

REMEASUREMENT

The remeasurement of the time-out study ran for four weeks during the weeks of May 2, May 10, June 6 and July 11.

RESULTS

For the remeasure, 40 patient procedures were randomly chosen to observe the time-out procedure. The results were as follows:

Time-Out Components

• Correct patient: 40 patients, or 100 percent
• Correct DOB: 40 patients, or 100 percent
• Correct procedure: 40 patients, or 100 percent

Quality of Time-Out

• All members are present at the start of time-out: 40 patient procedures, or 100 percent of the time.
• One person leads the time-out: 40 procedures, or 100 percent of the time.
• All team members participated/acknowledged the time-out: 40 procedures, or 100 percent of the time.
• No team member was doing any other activity during the time-out: 40 procedures, or 100 percent of the time.

By reeducating all our staff and adding the time-out process to our monthly tracer rounds, we were able to meet all goals at 100 percent. Following are the results:

• Goal 1: To determine if the steps of the time-out process are completed 100 percent of the time. Originally, we met this goal on two of the three elements. Only 90 percent of the time, did the staff member leading the time-out read the procedure from the patient's electronic record. During remeasurement, we met this goal with 100 percent compliance.
• Goal 2: To discover if all team members acknowledge the results of the time out process by either a verbal or nonverbal (nod) response at least 95 percent of the time. Originally, we did not reach this goal, as only 35 percent of the time, the entire team participated/acknowledged the time-out. During remeasurement, we met this goal with 100 percent compliance.
• Goal 3: To find out if all activity ceases in the procedure room during the time out at least 80 percent of the time. Originally, we did not meet this goal, as only 20 percent of the time was no team member doing another activity during the time-out. During remeasurement, we met this goal with 100 percent compliance.

Going forward, we will continue to monitor the time-out process during our monthly tracer rounds, and should we begin to notice a trend in noncompliance, we will consider another study of this process.

We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the ASGE Endoscopy Unit Recognition Program. EURP honoree units may use the ASGE Quality Star logo in promotion of their units, receive premium educational content bimonthly via an exclusive e-newsletter The Huddle, and enjoy a range of additional benefits. Questions should be directed to eurp@asge.org.