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Important updates for universal protocol at Salem Health

25 Apr 2021

See new policy for standardized safety measures

By: Denise Hoover, Chief Surgical Services Officer and Matt Boles, Vice President of Medical Affairs

For the past several weeks, front-line providers and staff from surgical services have met to check and adjust the universal protocol/time-out checklist used for patients undergoing procedures at Salem Health. Using our Lean problem-solving tools, this workgroup refined the elements of the protocol and improved the ergonomics and usability of the checklist.

Using a “highly reliable system” approach, adjustments were made to ensure the protocol is completed in the same manner at the start of every procedure. This group also reinforced a culture of safety throughout their work, with a focus on reminding every team member of the need to speak up with any safety concerns. Finally, a series of annual competencies and audits were developed to ensure progress is sustained for years to come.

This updated protocol and new posters along with education specific to surgical sections and staff will be rolled out shortly. The learnings from this group will also be shared with other procedural areas (cath lab, imaging, intensive care units, etc.) for adoption into their work flows. You should expect to continue to see auditors observing time-outs who will also let the room know if any steps were missed. View the policy via this link until it is updated in the policy system after May 1.

Please join us in thanking the following individuals for their time and expertise in these efforts: Drs. Nicole VanDerHeyden, Carrie Allison, Angie Anderson, John Ellis, John Cordero, Cameron Cangolose; OR nurses Chip Dillman, Nancy Schmidt, and Ryan Yarzak; and a special thanks to Mai Dotran, our Lean consultant from the Kaisen Promotion Office who guided and coached the team on this work.