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CMS suggests that the cost of a single surgical site infection represents between $63,000 and $180,000. If one were to average the results of the four hospitals in high-income countries as reported in the NEJM article, implementation of this simple and mundane protocol represents two less infections per 1000 surgeries. Now do the same math for other complications such as retained foreign objects ($63,000), or infection after CABG ($299,000) and the picture is quite compelling. In today's austere financial climate doing the right thing is also good business.
"Regardless of whether it's a "bundle," a checklist, or a protocol, not every healthcare facility that tries to implement these standardized practices succeeds, and they seem very surprised when they don't."
Checklists often appear intuitively easy - in fact many of us used two common checklists as we prepared to feast during the holiday season. A grocery list is a great example of a "read-and-verify" checklist, while a recipe is a "read-and-do" checklist. If you want to ensure that your meal will be a success, and save time and money by avoiding additional trips to the store, you use the checklists.
Using a checklist makes sense beyond the kitchen and many clinicians have learned over time to make their own checklist. Whether it's a surgeon triple checking that she has the correct lens for the correct patient, or the nurse ensuring that all meds are administered to the patient on time, various informal checklists are used every day in hospitals across the country. With such obvious face validity, success should be simple: just find one that works somewhere else, make it policy that it be used, drop it off in the OR, and watch outcomes improve. If only it were that easy.
LifeWings Partners, LLC has been helping innovative healthcare organizations implement standardized processes for ten years. In our work from New York to California, we've learned some very important lessons about successfully implementing standardized, evidence-based, high reliability processes. Here are ten important lessons you shouldn't ignore, and while they're written for checklists they apply to any standardized process:
Everyone's responsible: Compliance is a team issue and anyone on the team from the newest OR tech to the most seasoned surgeon is responsible to hold all other team members accountable for the proper use of the tool they created and collectively agreed to use. Given that there is joint responsibility, successful implementation requires a strong endorsement, or better yet a mandate, from leadership, MEC, and others.
Someone's responsible: There must be one member of the OR team who is ultimately responsible for completion of the checklist. This person must be empowered to "stop the line," and held accountable for doing so, until the checklist is properly completed.
Physicians must lead: Aside from patients, physicians have the most to gain from the correct use of a checklist and their behavior sets the tone for the OR. Yes, getting physician buy-in is hard work - sometimes even painful. It can be done. The secret is good data, constant communication, an appeal to what matters most to physicians (their patients' well being), and strong leadership.
Physician leadership must demand that physicians lead: It's so important that it deserves mentioning again. Medical staff really can't "sit this one out."
Make it organic: "Drop In" checklists never work. There's no buy-in or investment in its success. The people that will actually use the checklist must understand the clinical need, and then create, or modify, the tool that facilitates the work here. The World Health Organization agrees, advising "The checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged." There are no shortcuts on this step, and all disciplines must be involved in thoughtful dialogue about what will keep the patient safe.
Persistence required: Checklists are NEVER perfect the first time they are used. The clinical team must know going into the checklist building process that it is an iterative process. This process is sometimes known as "kaizen," a) adopt a standard for the work, b) adhere to the standard, c) continually refine the standard, and d) repeat steps a, b, and c endlessly.
Design matters: In fact, it is extremely important if you want your checklist to be used consistently and reliably. The checklist should be: a) Simple and intuitive to use; b) Easy to see and to read, using the fonts and font sizes consistent with the best science on the design of checklists; c) Inclusive of amplifying information (expanded checklist) to clearly define expectations and roles; and d) Designed to minimize distraction from clinical priorities.
Adopt a culture of discipline: Even the perfectly constructed checklist imposes nothing - it is just a tool designed to "hardwire" the right behaviors at the right time, making it easy to do the right thing and hard to make a mistake. A checklist doesn't impose discipline, rather it flourishes in a leadership environment where compliance is rewarded and non-compliance is promptly addressed with coaching and significant negative consequences for continued non-compliance. Implementing a checklist without the proper leadership actions is a futile and frustrating experience.
A paradigm shift: Many professionals think that a checklist is "good for those who need it." This mindset springs from the idea that "a medical error hasn't happened to me (because I'm really good, and very careful), so it can never happen to me." A safer mindset is that "Use of a checklist is the hallmark of a true professional." Unfailing use of well-designed checklist becomes part of your personal ethos and to skip the use of this valuable tool would be unthinkable - just as failing to scrub your hands prior to surgery would be unthinkable in the modern era. The motivation for use is intrinsic, not extrinsic. To put things in perspective, imagine that you were sitting on an airplane and the pilot said, "Ladies and gentlemen, I'm Captain Smith and I've been flying airplanes for 27 years without an accident. Today I've decided that I don't need to use the checklist because I'm very good, and very careful." What would you feel? What would you do? As a professional pilot with twenty-seven years of accident-free flying I would urge you to get up out of your seat, calmly collect your belongings, and walk off the airplane!
The time is now: There's never a convenient time to implement a new process. The excuses, and costs to patients (preventable morbidity and mortality), for delaying implementation are increasingly unacceptable. Plan, educate, create, and implement... then do the hard work of following through with continuous measurement, refinement, and improvement.
Change is never easy. The cost of not changing is too dear. Margaret Meade provides us this assurance: "Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it's the only thing that ever has."
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