Re­al­ity check on sur­gi­cal check­lists

Modern Healthcare - - NEWS - By Sabriya Rice

Hospi­tal sur­gi­cal check­lists have taken off since their in­tro­duc­tion more than a decade ago. Bor­rowed from the avi­a­tion in­dus­try and pop­u­lar­ized by sur­geon and New Yorker writer Dr. Atul Gawande, check­lists have been hailed glob­ally as a huge leap for­ward for pa­tient safety.

But now, with sev­eral coun­tries and U.S. states mov­ing to man­date their use, some safety pi­o­neers say it’s time to step back and check in with check­lists. “It’s not a magic bul­let,” said Dr. Peter Pronovost, se­nior vice pres­i­dent for pa­tient safety and qual­ity at the Johns Hop­kins Univer­sity School of Medicine in Bal­ti­more and also a pioneer in the use of clin­i­cal check­lists. While check­lists of­fer vast po­ten­tial to im­prove out­comes, broad im­ple­men­ta­tion with­out proper train­ing and co­or­di­na­tion with staff who will use them could pos­si­bly have the op­po­site ef­fect, he said.

The re­assess­ment comes in the wake of a study re­ported last week in the New Eng­land Jour­nal of Medicine that found sur­gi­cal safety check­lists im­ple­mented in more than 100 hos­pi­tals in On­tario, Canada, failed to re­duce com­pli­ca­tions or deaths. The On­tario Min­istry of Health and Long-Term Care re­quired its hos­pi­tals to in­cor­po­rate safety check­lists by July 2010.

Thou­sands of hos­pi­tals across the globe have up­dated their stan­dard op­er­at­ing pro­ce­dures to in­clude check­lists de­signed to help clin­i­cians pre­vent sur­gi­cal er­rors, re­duce in­fec­tion rates and lower read­mis­sions. More than 30 coun­tries have ei­ther adopted or con­sid­ered re­quir­ing use of the World Health Or­ga­ni­za­tion’s sur­gi­cal safety check­list, the or­ga­ni­za­tion re­ports. In 2011, Ne­vada be­came the first U.S. state to re­quire med­i­cal fa­cil­i­ties to adopt pa­tient safety check­lists to im­prove health out­comes.

But safety ad­vo­cates worry that hasty im­ple­men­ta­tion through govern­ment reg­u­la­tion, though well-in­ten­tioned, may not gen­er­ate in­tended re­sults. “Reg­u­la­tion is too slow to keep up with the changes in ev­i­dence-based prac­tices,” Pronovost said. “I fear that reg­u­lat­ing (check­lists) may ac­tu­ally an­chor you into bad prac­tices.”

What’s miss­ing in govern­ment re­quire­ments are hospi­tal-spe­cific cus­tomiza­tions needed to make check­lists work for spe­cific set­tings. In an ac­com­pa­ny­ing ed­i­to­rial in the NEJM, Dr. Lu­cian Leape, ad­junct pro­fes­sor of health pol­icy with the Har­vard School of Pub­lic Health in Bos­ton and a leading ad­vo­cate on pa­tient safety, wrote, “What should be man­dated, and na­tion­ally funded, are large-scale state and sys­temwide col­lab­o­ra­tions to mo­ti­vate, train, and sup­port lo­cal ef­forts to im­ple­ment check­lists.”

Stan­ford Univer­sity, for ex­am­ple, en­hanced the WHO-is­sued sur­gi­cal safety check­list in 2008 by in­clud­ing more spe­cific in­struc­tions for anes­the­si­ol­o­gists, nurses and surgeons. Of­fi­cials also added a ver­bally dic­tated time­out be­tween pro­ce­dures and a post-surgery dis­cus­sion for team mem­bers. “Af­ter the check­list was im­ple­mented, mor­tal­ity de­clined,” a hospi­tal spokesper­son said.

While work­ing on a qual­ity-im­prove­ment pro­gram with hos­pi­tals in Michi­gan, Pronovost en­cour­aged par­tic­i­pants to mod­ify the Johns Hop­kins’ check­list to en­sure the fi­nal prod­uct ad­dressed their sys­tems’ spe­cific needs. “Now ev­ery one of them thinks that their check­list is the best,” he said, “and it is, for their cul­ture.”

One of the ma­jor chal­lenges, and what may have gone wrong in Canada, is that reg­u­la­tors failed to get all the key play­ers com­mit­ted to the process. “Just check­ing boxes is not ap­ply­ing the check­list in the way it is meant to be ap­plied,” said Dr. Don Gold­mann, chief med­i­cal and sci­en­tific of­fi­cer at the In­sti­tute for Health­care Im­prove­ment.

Govern­ment man­dates also don’t pro­vide what Gold­mann called the “coura­geous lead­er­ship” needed for a check­list pro­gram to suc­ceed. For in­stance, af­ter hospi­tal lead­ers in Wash­ing­ton state failed to ex­plain the ra­tio­nale be­hind check­lists, sur­gi­cal staff grew frus­trated with them and some even­tu­ally aban­doned their use, de­spite the hos­pi­tal­wide man­date, ac­cord­ing to a study of five hos­pi­tals.

Pronovost sug­gests it’s time to move away from paper check­lists, at least as cur­rently con­fig­ured and con­sider them as just one com­po­nent of what will help re­duce harm. He is now in­ves­ti­gat­ing how to de­sign safety into the tech­no­log­i­cal pro­cesses used in op­er­at­ing rooms.

Hos­pi­tals world­wide have up­dated stan­dard­ized op­er­at­ing pro­ce­dures to in­clude safety check­lists.

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