The Institute for Healthcare Improvement, which has been in the vanguard of the patient safety movement for many years, is trying to get all U.S. hospitals to test the World Health Organization's surgical checklist in at least one OR between now and April 1. While IHI doesn't believe that a government mandate is required, it hopes that peer pressure from hospitals and national organizations that endorse the checklist will lead to universal adoption.
According to an international study of hospitals in eight cities in advanced and developing countries, use of the checklist reduced surgical mortality rates by nearly half, and inpatient complications, by 38 percent. While the checklist probably wouldn't reduce the death rate as much in the U.S. as in the less developed nations (Indian, Jordan, Philippines, Tanzania) where the protocol was tested, the study found that "all sites had a reduction in the rate of major postoperative complications."
The 19-point checklist, analogous to the one that airline pilots go over before taking off, includes items that surgical teams should check before anesthesia, before skin incision, and before the patient leaves the operating room. They include seemingly minor actions that can have a major impact, such as having team members introduce themselves to each other by name. This step, rare in American ORs, could facilitate communication when something goes wrong in the middle of a case, notes Fran Griffin, IHI's project director for the checklist deployment.
Some items are already standard operating procedure, such as having a pulse oximeter attached to the patient. But, even in hospitals where many of the other steps are performed as well, Griffin tells BNET, they're not done for every patient. "Because they're not built into the way the work is done for every case every time, they're just not occurring at the highest level of reliability that we'd like to see."
IHI has posted the checklist and supporting materials on its website. It's also promoting the "sprint" to test the checklist by April 1 in its e-newsletter, which goes to most hospitals. More than 4,000 facilities participated in IHI's 5 Million Lives safety campaign, and IHI is using the same network of 70 field offices that organized that campaign to get this one off the ground. Most of these offices use the resources of local organizations, such as state hospital associations and Medicare-contracted quality improvement organizations. According to Griffin, groups in 13 states have pledged to get every hospital in their state to try the checklist.
Implementing the checklist involves some workflow changes, says Griffin, but it requires minimal additional resources. The real obstacles to using the checklist to protect patients from harm are complacency and physician culture, she says. Some hospitals think they're already doing a good job on the checklist steps, but aren't doing as well as they think, she points out. And some surgeons--who have to be involved in the checklist process--don't want to be told what to do. If they are major admitters, their hospitals may be afraid to hold their feet to the fire, she points out.
For a very instructive discussion of why hospitals and doctors are often at loggerheads over patient safety issues, read Paul Levy's blog about running a hospital--in his case, Beth Israel Deaconess Medical Center in Boston. Or, if you don't have time to read the whole thread, my colleague David Hamilton has artfully arranged some excerpts. The main point is, many surgeons don't see why they should listen to anyone but themselves. Perhaps that attitude will change if CMS stops paying them--as it's doing with hospitals--when their patients suffer avoidable complications.