A recent survey of pediatric surgeons regarding
surgical safety checklists (SSCs) revealed some disturbing, but not really surprising, results (Roybal 2018). While 93.6% of respondents use SSCs
and 62.6% would want one used in their own childs operation, only 54.7% felt
that checklists improve patient safety.
Reasons for
checklist skepticism included the length of the checklist process, a
distraction from thoughtful patient care, and lack of data supporting use.
Literature review shows that checklists improve communication, promote
teamwork, and identify errors, but do not necessarily decrease morbidity. Staff
perception is a major barrier to implementation.
Checklists are
incredibly valuable safety tools in healthcare and many other industries. But their
implementation encounters all the barriers that implementation of any change
project encounters. Like almost any change project, things that are imposed
from the outside are doomed to failure. And, when you dont encounter some noise
early during implementation, you are also likely
doomed.
Some of the comments
in the Roybal pediatric study are particularly insightful.
Checklists
only work if they are short. That is a point weve made several times. In
our recent October 30, 2018 Patient
Safety Tip of the Week Interhospital
Transfers, we broke down a long checklist into
several shorter checklists to facilitate use.
There
are generic elements to all surgical procedures that have some applications in
the generic checklists currently available. What would be far more effective would be computer generated checklists SPECIFIC for the
procedure scheduled. A good point. You wouldnt want a checklist designed
for a 747 if you were flying an airbus. So why would you want to use a
checklist designed for a cholecystectomy when you are doing a total hip
replacement? But some checklists may apply to all types of surgery. For
example, malignant hyperthermia might occur in almost any surgical procedure,
so a checklist specific for malignant hyperthermia could be used during any surgical
procedure if malignant hyperthermia were suspected.
All
this devotion to checklists and process has become a form of fetishism, and
often is a distraction from the task at hand. In our May 2015 What's New in the Patient
Safety World column The
Great Checklist Debate we
discussed checklist fatigue.
There may be one case in 10,000 in which it
makes a difference. I personally havent seen it. Failure to make a compelling case as to why a particular
checklist is needed is one of the biggest barriers to checklist adoption.
The
surgical checklist is highly ineffective in modern Western hospitals. This was
shown, but ignored, in the original paper. It is a meme, a trend, and a fad. It
does not actually improve real mindfulness, and often distracts from it.
Perhaps a little bit of truth and a lot of chutzpah in that statement! See our What's
New in the Patient Safety World columns for April 2014 Checklists Dont Always Lead to Improvement
and May 2015 The
Great Checklist Debate.
Fortunately, there
is now a terrific resource available to help with meaningful implementation of
checklists. The OR Emergency Checklist Implementation Toolkit,
from Ariadne Labs, Emergency Manuals Implementation Collaborative (EMIC), and
Stanford University School of Medicine, takes you through all the steps
necessary in successful checklist implementation.
Researchers
involved in development of that toolkit used data gathered through a Web-based
survey to examine factors that might be related to success in implementing OR
cognitive aids (Alidina 2018).
Completing more
implementation steps was significantly associated with more successful
implementation. In fact, each implementation step completed was associated with
just over 50% higher odds of more successful implementation. Leadership support
and dedicated time to train staff were other factors associated with successful
implementation. Small facility size was also associated with a fourfold
increase in the odds of a facility reporting more successful implementation. Previous
quality improvement experience was associated with success in OR cognitive aid
implementation: the greater its number of quality improvement initiatives, the
more likely a facility was to successfully implement OR cognitive aids. More
successful implementation was associated with the use of the tool in emergency
drills, in preparation for complex cases, and in debriefing after a critical
event.
Factors associated
with less successful implementation were resistance among clinical providers to
using cognitive aids, absence of an implementation champion, and unsatisfactory
content or design of the cognitive aid,
The following were
associated with more successful implementations:
So
the OR Emergency Checklist Implementation
Toolkit, recommends the following strategies:
The toolkit tells
you to expect to spend 6-12 months or more for implementation and training.
The need for a clinical champion speaks for itself. In getting
buy-in, its important to get support of clinical and administrative leadership.
Early communication and outreach to staff is essential. Key hospital leaders need
to be engaged in a multidisciplinary implementation team. Get the word out
about the project at department meetings and joint conferences.
A key feature of any successful change
project is also to identify key people who are likely to resist the change and
meet with them 1-on-1 and invest time in educating them about project. In-house
marketing (videos, other promotional materials, periodic announcements and
updates, etc.) can be helpful.
Since this toolkit
is specifically about OR checklists, you need to establish a multidisciplinary
team that is representative of all perioperative personnel. Best team members
are thoughtful, respected, reliable, collaborative, able to participate, and
experienced in quality improvement. They dont have to be titled leaders.
Phase in your
checklists. Dont roll them out to all areas at once. Get them up and running
in a few key areas, learn from them, tweak them, and test them again.
Monitor the use of
the checklists. Which ones are being used? Encourage their use and provide
feedback on both their use and usefulness.
Youve heard us over and over use the phrase
stories, not statistics. At each
stage where you are training or promoting a checklist, try to give a personal
story of how a use of a checklist was important. If, for example, you just say something
like we have not had a wrong site surgery since we implemented
you wont get
the same enthusiasm as if you tell a story about how, in a specific case, the
checklist actually helped avert a near-miss.
When weve seen
successful projects using checklists, we always wonder whether success was due
to the checklist itself or to the teamwork and culture changes that were involved
in implementing the checklist. We suspect the latter are probably as or more
important than the checklist. So never be hasty in pushing out checklists.
Follow the steps outlined in the toolkit and youll likely find that your
checklists result in the improvements you were looking for.
Some of our
prior columns on checklists:
References:
Roybal
J, Tsao K, Rangel S, et al. Surgical Safety Checklists in Childrens Surgery:
Surgeons Attitudes and Review of the Literature. Pediatr
Qual Saf 2018; 3: e108; Published online October 16,
2018
Ariadne
Labs/EMIC/Stanford. The Operating Room Emergency Checklist Implementation
Toolkit. 2018
https://www.implementingemergencychecklists.org/
Alidina
S, Goldhaber-Fiebert SN, Hannenberg
AA, et al. Factors associated with the use of cognitive aids in operating room
crises: a cross-sectional study of US hospitals and ambulatory surgical
centers. Implement Sci 2018; 13(1): 50
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-018-0739-4
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