Improve the Compliance to Time-Out procedure among health care in NICU

From the 2023 HVPA National Conference

Muna Shehadeh BSN (JHAH), Lianne Harris BS

Time-Out Procedure is the first step in the World Health Organizations surgical safety check list.

Joint Commission defines the Time-Out as an immediate pause by the entire surgical team to confirm the correct patient, procedure and side/site.JCIA stipulates that all team members be actively in the process, any concern or inconsistencies must be clarified at this stage.

The checks during the Time-Out must be documented.

The compliance to Time –Out at NICU is 77.6 %. Despite its effectiveness in increasing patient safety, compliance to Time –Out remain a major problem in its implementation and gaps in its daily use still occur.

The current review of patient medical records presents patterns of wrong time-out procedures, emphasizes the problem of poor compliance.

CUSP Multidisciplinary team identified Time –Out as an opportunity for improvement as compliance to the standard will promote patient safety and minimize the risk of error during a surgical/ invasive procedure.

To improve the compliance to Time –Out procedure in NICU from (77.6) % to (100) % by the End of 10/2022; this includes: compliance to conducting Pre –procedure Time –Out, compliance to proper timing of the Time -Out, and compliance to Time –out Documentation.

A specialized multidisciplinary team was convened with representation from Nurses, Neonatologists and Pharmacist aligned with process improvement expert, Followed the PDCA methodology:

Baseline assessment included review of patient medical records for 2 months before the intervention. Data was collected for compliance to conducting Pre –procedure Time –Out, Compliance to proper timing and Compliance to Time –out Documentation.

The current practice was reviewed, and Root Cause Analysis was conducted.

Major challenges identified was due to 
• Lack of knowledge about MSP 52.
• Lack of education about EPIC documentation
• Physician not doing the Time-out
• Delay in patient registration from L&D unit

Based on the gaps identified during the RCA action plan was developed interventions:
• In-serve education sessions on how to do time-out and how to do the documentation in EPIC.
• EPIC Enhancement to add all staff names who were involved in Time-Out using staff section in Time out Navigator.
• For emergencies assign the charge nurse instead pt. primary nurse to do the documentation for time-out.
• Continuous monitoring on compliance to the interventions and performance feedback communicated through communication meeting regularly.

The result is excellent the compliance to Time –Out procedure is 100%Full compliance to Time –Out procedure according to accreditation standard will improve patient safety and prevent harm to reach patient. JHAH EMS Assessment 2023


What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog