Overlapping Surgery Checklist















The Big Picture





Has your organization as a whole adequately discussed the concept of overlapping surgery and agreed it should be allowed?







Definition of overlapping surgery





Have you defined “concurrent” surgery?




Have you banned “concurrent” surgery?




Have you defined “overlapping” surgery?




Do your definitions meet those of the American College of Surgeons?







Audit of scope at your facility





Have you collected data on how often overlapping or concurrent surgery is done at your facility?




By department?




By surgeon?







Credentialing and privileging





Do you require specific privileges for your surgeons to do overlapping surgery?




Do you have criteria for granting such privileges?




Do you periodically assess surgeons for continuation of such privilege to perform overlapping surgery?







Definition of “critical portion” for overlapping surgery





For each type of surgery that you allow to be overlapping, do you have a definition of what is the “critical portion” that is hospital-wide (or system-wide)?




Have those definitions been developed and approved by department chairs?




Have those definitions included recommendations by specialty societies?




Are you sure that definitions are the same for procedures performed by more than one specialty?




Have you defined which surgical procedures may be eligible for overlapping and which ones should never be allowed for overlapping?







Designation of “backup” surgeon





Is a “backup” surgeon specifically designated for all cases of overlapping surgery?




Are the duties and responsibilities of that “backup” surgeon clearly spelled out?




Does the “backup” surgeon have privileges to perform the surgery for which he/she is backup?




If a fellow is allowed to be designated as the “backup” surgeon, is he/she appropriately trained to serve in that role?




Have you defined “immediately available”?




Do you have a method of communicating to all parties the identity of the “backup” surgeon?

During the pre-op huddle?

During the surgical “time out”?

On the white board in the OR?

In the patient’s medical record?




Does your policy and practice make it clear that any member of the surgical team should be able to call the backup surgeon in to the surgery?







Informed consent





Does your informed consent policy and practice require the patient specifically be told that their surgeon will not be present for their entire procedure?




Is the concept of “overlapping” surgery provided in any pre-op educational materials presented to patients?




Does the verbal discussion between patient and surgeon clearly include details of what it might mean to them that their surgeon may not be present during all portions of their surgery?




Is this informed consent discussion performed sufficiently in advance of their schedule surgery for them to contemplate the implications, ask questions, and decide whether to consent to overlapping surgery?




Is the above timeframe specified?




Are your policies clear that a surgeon may not refuse to perform the surgery if the patient will not consent to overlapping surgery?




Does your informed consent form include specific wording about overlapping surgery or require the patient to sign or initial a separate section or separate document that he/she consents to overlapping surgery?







Surgical “time out”





Is it clear in your Universal Protocol or surgical “time out” policy that the attending surgeon must participate in the surgical “time out” in every case?




Does the above specify that a second “time out” must be performed any time a surgeon leaves and returns to a case?




Does your surgical safety checklist include an item for acknowledgement that a surgeon will be participating in overlapping cases?




If you use a white board in your OR, does it identify that the attending surgeon will be doing overlapping cases?

And does it specify who the “backup” surgeon will be?







Pre-op huddles or briefings





Do you have in your policy how pre-op briefings will be handled in cases of overlapping surgery?




Does your pre-op huddle include discussion of whether this is an overlapping case and, if so, who the designated “backup” surgeon will be?




Does your pre-op huddle include discussion of at what point the surgeon is expected to leave the OR?







Post-op debriefings





How do you handle the post-op debriefing when the attending surgeon has left for an overlapping case?




What mechanism do you have in place for the attending to have input after the fact when he/she could not participate in the post-op debriefing?




How do physicians in training receive feedback when no post-op debriefing occurs?







Monitoring presence or absence of the attending surgeon





Do you have a mechanism is place to document the presence or absence of the attending surgeon?




Do you record every instance when the surgeon leaves or enters the OR?




Do you record every instance when any OR personnel leave or enter the OR? (may be important to minimize unnecessary opening/closing OR doors that could be important in infection prevention)




Do your policies specify what infection prevention activities are required when moving from one OR to another? (eg. handwashing, gowning, gloving, masking, etc.)







Quality Improvement and Patient Safety









Is compliance with your overlapping surgery policy routinely or periodically audited?







Do you ask during review or RCA of cases with complications whether “overlapping” contributed to the complications or adverse outcomes?




Do you have a mechanism where any staff member can report a problem related to overlapping cases without fear of retribution?




Do you review every case in which the attending surgeon was required to return or “backup” surgeon was required to come into a case?




Do you audit all cases of overlapping surgery for case duration and time spent under anesthesia?




Do you flag cases of “outlier” case duration to see whether overlapping played a role?




Do your medical staff policies or practices make clear the penalties for violating the overlapping surgery policy?




Can your anesthesiologists reschedule, delay, or cancel surgical cases in order to ensure policy compliance and appropriate behavior?




Do you periodically or randomly assess how long it would take the “backup” surgeon to arrive at the OR after a request is made?




How are patient complaints or concerns about overlapping surgery handled?




Do you have a mechanism for assessing whether patients had a full understanding of the implications of overlapping surgery and whether they felt unwanted pressure to consent?




Do you survey your OR nursing staff and residents, fellows, etc. anonymously about their opinions on the practice of overlapping surgery at your institution?







Monitoring billing practices





Do you have in place an internal audit of whether billing practices are in compliance with the requirements of CMS or other payor for cases of overlapping surgery?




What do you do if your surgeons bill outside of your purview?




Last updated 12/9/2016









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