Checklists: Moving from Procedures to Clinical Care Workflow

I am a big fan of the Checklist philosophy (see past post reviewing this), as espoused by docs like Atul Gawande and Peter Provonost. And I like to combine that with the writings of Dr. Richard Bohmer (Designing Care) who talks about "Islands of Standardization" that stand out in a sea of unstructured medical thinking (those areas where docs need to take in a lot of info and make a decision). In other words, we should use checklists for those areas of clinical care that should be standardized... and be careful not to overuse them in places where the care cannot be as structured.

For example, as part of the Szollosi Healthcare Innovation Program , we have studied some "inflection points" in healthcare (i.e. A new and important finding that can have a large impact). Whereas traditional checklists focus on procedures, we have started adopting the concept to parts of the clinical care process. To help understand this, it's important to understand that the clinical care process has three basic phases:

1. The Initial Diagnosis Phase: : An "unstructured" time where the doctor takes in all history, physical exam, and test elements and decides on a "final diagnosis". To date, we have explored (in order of increasing complexity): Hematuria, Atrial fibrillation, and Cancer.

2. The "Workup" Phase: Once one of these "Diagnoses" has been decided by the physician, there is usually an "island of standardization" that often involves further testing and a consult to a specialist. For Atrial fibrillation, it involves getting a stress ECHO and a Holter monitor, and then seeing a Cardiologist after those tests are completed. We therefore created a "Checklist" within an EMR message that allows the doctor to send a note to our Care Coordination team. The doctor needs to choose the message type (called "PATHWAY - Atrial Fibrillation"), answer one question within the message (which helps decide how acute the problem is), and then send it to a coordinator who follows the directions of the message (e.g. set up the tests, and then the consult).

3. The Management Plan Phase: This is another unstructured time where the PCP or specialist reviews all the information and decides on the treatment plan. But note, depending on certain issues, it is possible to make this part somewhat standardized as well.

4. The Stable Follow-Up Phase: This is a very structured time where the patient is stable on their treatment plan and just needs routine follow-up care, such as checking some blood tests and vital signs every 6 months. This can often be done by an NP or even an RN, and the doctor is only notified if a patient's findings veer off course. This area is particularly ripe for Checklists.

In other words, we do not want to try and create checklists for the unstructured thinking part of the physician's job- that part is critical and is very hard to replicate or standardize- but the time it takes is relatively small. Unfortunately, physicians instead waste their valuable time on trying to remember the exact protocol for the workup phase, and helping their patients complete them as quickly as possible and make sure they do so in the right order. THAT is where a checklist helps, and even better if we can hand it off to a "lower level" person on our team! As the saying goes, make sure each team member is working to the top of their ability and licensure!

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Since we are on the topic of using Checklists appropriately... you should read this new article from HealthLeaders magazine: "Use Medical Checklists as Tools, Not Cure-Alls, for Patient Safety Problems". Three great quotes from this article point to how we need to be careful in further understanding how to be successful with Checklists:

However, in reality, these checklists need to be accompanied by a "change in the culture"—where nurses, for instance, are empowered to question doctors who don't follow the steps properly or where members of a healthcare team toss out long held beliefs that infections are an inevitable cost of being in the hospital. "Just having a checklist on a piece of paper isn't going to be enough," Pronovost said in a statement.

"Everyone wants to do a checklist. The message becomes that . . . checklists are the simple solution for solving an adaptive problem with a technical solution," he says. "It needs to be embedded in a broader effort to evaluate and address local context. It needs to add value. If providers don't believe in the value of the checklist, they'll just check a box." (Sean Berenholtz, MD, an associate professor with the departments of anesthesiology, critical care medicine, and health policy and management at Hopkins)

The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."


UPDATES
Medical Personnel Taking a Page Out of the Pilot Handbook
Dec, 2009: Medical personnel who used procedural checklists modeled after preflight checklists used by pilots were more likely to report safety-related incidents and feel empowered to address safety issues, according to an online report in the December 21, 2009 Archives of Surgery (PDF).  After preoperative checklists were introduced to certain medical teams, their use rose from 75 percent in 2003 to 100 percent in 2007, the study found.  The introduction of checklist-based programs, known in the aviation industry as "crew resource management programs," or CRMs, was accompanied by an increase in self-initiated reports of safety breaches among medical staff, from 709 per quarter in 2002 to 1,481 per quarter in 2008 among teams using the checklists.

The Inflection Navigator Project

A lot of my effort in the past 1-2 years with the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org) has focused on making the experience easier and better for patients dealing with an "acute inflection point" in their healthcare, such as the new diagnosis of cancer or a heart problem. Working with a great team at Northwestern University and Northwestern Memorial Hospital, we created "The Inflection Navigator" project, which brings together physician-friendly ordering workflows, system level protocols, care coordinators ("Navigators") and a web-based tool we developed to tie it all together.

We went live in April with a Hematuria Pathway, and then launched the Atrial Fibrillation Pathway in June, and finally the Cancer Pathway in September. We believe this combination of people, process and technology improves both the quality and efficiency of these situations, and does so in a cost-effective manner.

This recent article further explains our system and how we developed a web tool called "iNav", working with Northwestern University Biomedical Informatics Center (NUBIC):
http://cabig.cancer.gov/resources/newsletter/issueXXV/action.asp

Mike Gurley led the software development of iNav. Since it as based on open source code already developed for the cancer Biomedical Informatics Grid (caBIG), he posted the code and architecture online: http://github.com/mgurley/inav
Enjoy!

"What health care needs is process innovation, not product innovation."

Wow- I love it, this is a simple but great explanation of where we should focus on innovation in healthcare (from Dr. Devi Shetty, a cardiac surgeon and efficiency expert in India). To clarify further: we actually know how to do a lot of things very well (e.g. prevent infections, manage diabetes, cure many cancers)... but instead of trying to make sure we follow these processes 100% of the time, we seem more intent on coming up with the newest product or service that will only be incrementally better than the last one (and which may actually be used by less patients because it is more expensive)!

As it turns out, much of the time, all we need to do are create some easy and cheap process improvements which simply enforce the standards of care we all accept- and we would get much better bang for our buck than any new medication or device! This was highlighted by Dr. Atul Gawande in "The Checklist", an article about Dr. Peter Provonost's simple checklist procedure to prevent line infections in the ICU - which saved a significant amount of lives and money... and yet which has not yet been widely accepted because that is not how American's like their innovations! As Dr. Gawande describes:

The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them.

A more recent WSJ article reviews Dr. Shetty's experience and philosophy about how increasing volume can save money and improve quality:

The approach has transformed health care in India through a simple premise that works in other industries: economies of scale. By driving huge volumes, even of procedures as sophisticated, delicate and dangerous as heart surgery, Dr. Shetty has managed to drive down the cost of health care in his nation of one billion.

His model offers insights for countries worldwide that are struggling with soaring medical costs, including the U.S. as it debates major health-care overhaul. "Japanese companies reinvented the process of making cars. That's what we're doing in health care," Dr. Shetty says. "What health care needs is process innovation, not product innovation."

In the healthcare innovation program I help lead (the Szollosi Healthcare Innovation Program), we have used a similar philosophy to come up with some simple process improvements which have started making a difference. The ExpectED project created a web-based tool which formalized the hand-off from outpatient physician to the Emergency Department. Further evolutions of this project have moved this formalization into our EMR system.

Meanwhile, the Inflection Navigator system allows physicians to send a single order which then triggers a cascade of processes related to one of the defined "inflection points" we are studying (Cancer, Hematuria, Atrial Fibrillation). These processes (including radiology orders, specialist consults and patient education) are carried out by a team of people knowledgeable about each of their separate duties. The result is a more efficient and more consistent process for both patients and physicians.

So as Thanksgiving rolls around, let's rejoice in the fact that there is plenty of innovation left to do in healthcare... much of it right before our eyes!

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes

The California Healthcare Foundation (CHCF) just put out a new paper on Innovation Centers- it’s a nice overview of what is happening out there formally, and ideas on how they can be expanded. The paper highlights 9 innovation centers/organizations across the nation:
- Kaiser's Garfield Health Care Innovation Center
- Vanderbilt's Center for Better Health
- Mass General's Stoeckle Center for Primary Care Innovation
- Mayo Clinic's Center for Innovation
- Johns Hopkins Center for Innovation in Quality Patient Care
- Ascension Health
- Alegent Health
- Geisinger/Geisinger Ventures
...and the one I help lead: The Szollosi Healthcare Innovation Program (www.TheSHIPHome.org).

Intro is below, full paper is online: http://www.chcf.org/topics/view.cfm?itemid=134067

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes
by Bonar Menninger
September 2009

Hamstrung by an increasingly complex, costly, and disorganized system of care, health care organizations are following the lead of the corporate world and embracing innovation as a way to overcome the seemingly intractable problems that have undermined U.S. health care delivery for decades.

Today's innovation centers — most of which are affiliated with large hospitals or health systems — range in scope from modest internal programs to large, formalized organizations with dedicated physical space, sizable staffs, and external clients. Key areas of emphasis include facility design, operational efficiency, optimized information technologies, improvements in the patient experience, and care quality.

Leaders at health care innovation organizations nationwide were interviewed to learn more about how the centers operate, the objectives they are pursuing, and some of the challenges they face.

The complete issue brief is available under Document Downloads below. Also available is a video presentation on the Garfield Health Care Innovation Center at Kaiser through the External Link below.