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The hospital's leadership and quality officer devel- oped action steps, which included bi-monthly leader- ship team meetings, a communication plan to relaunch the facility's safety checklist, a reassessment of the current audit tool to make sure its elements matched the safety checklist, and developing a plan for real-time data collection and analysis. They also determined the number of daily audits they wanted to perform to ensure the surgical team was properly per- forming safety time outs, and developed auditor train- ing and multifaceted education programs to support the understanding of how the Universal Protocol impacts patient safety and team collaboration. "We had IT create an iPad audit tool, and the nurs- ing quality assurance program manager provided training to two OR nurses on how to use it as secret auditors," says Ms. Platt. "The nurses record whether surgeons, nurses, anesthesia providers and surgical technicians properly complete their defined roles on the patient safety checklist." In order to get accurate data, it was extremely important for these nurses to be very honest in their assessments. "We were able to track the compli- ance of the Universal Protocol for 45 to 60 days, and then we analyzed all the data," says Ms. Platt. form, according to Ms. Platt. "We were able to see which sections of the checklist staff failed to complete routinely, which staff members were the champions of the checklist and who did not comply with using the tool prop- erly," she explains. The data was presented to the chairman of surgery, the assistant chief nursing officer of surgery, the director of nursing for the hospital's ASC and the surgical administrator. Ms. Platt says the surgical leadership team had an epiphany while reviewing the results: If staff were failing to use the checklist properly at Marymount Hospital, surgical teams across the health system likely had the same issue. The leaders developed a worksheet that outlined dialogue designed to prevent never events and pro- mote patient safety that all surgical teams must now use during every safety time out. Ms. Platt believes it's important to assign roles to specific providers in order to improve verbal communication among everyone in the room and to prevent one person from running the whole show. "Following the Universal Protocol is supposed to be a multidiscipli- nary effort," she points out. Marymount's leadership therefore created stan- dardized roles based on an individual team mem- ber's responsibility: • Anesthesia providers review antibiotic administration; • surgeons confirm the patient's name, date of birth and ask the patient what procedure they're having done; • nurses discuss surgical fire risks and confirm with the team the correct patient, procedure and position; and • surgical technicians participate in the sign-in unless it was performed in pre-op. When the sign-in occurs in pre-op, surgical tech- nicians are required to participate in confirming It was invaluable to look at the data in graph 5 0 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • D E C E M B E R 2 0 2 0 CHECKING UP Two OR nurses at Cleveland Clinic's Marymount Hospital received individualized education on how to use the newly created audit tool. Cleveland Clinic's Marymount Hospital