Today we heard from Kathy Masters about the basics of Six Sigma, a statistical system designed to improve efficiency of outputs by minimizing errors. We focused on measuring these outputs, the “M” in the DMAIC. One of the principal ways to measure is the use of checklists in medicine. Dr. Tsai, a pediatric cardiothoracic surgeon, talked about how checklists in the OR have helped to decrease the rate of surgical site infections.
- However, why haven’t checklists been adopted in medicine as they have in the automobile construction industry and world of aviation? What are ways for them to gain widespread acceptance?
Checklists also have drawbacks, as Dr. Tsai alluded to in his comment about having so many checklists that you need checklists to remember all the checklists. Many of the interpersonal aspects of healthcare, like establishing a rapport with a patient, being considerate of cultural and religious concerns and caring for a person’s emotional needs are not readily exportable to a checklist. It is important to recognize that checklists have both benefits and limitations and they must be executed appropriately.
Kathy Luther also mentioned how checklists can be adopted in primary care in the treatment of diabetes. Measuring HbA1c, HDL, and LDL should be done annually for diabetic patients, yet this is not being done. Does a checklist solve this problem? Blue Cross Blue Shield recently started a program called Bridges to Excellence, where physicians are financially rewarded for following guidelines for diabetic and cardiac care.
- Are checklists an effective, accurate, and fair way to measure quality improvement in the primary care clinic?
We also discussed the proper implementation of a checklist in an operating room setting. Dr. Tsai mentioned that in Memorial Hermann ER’s the checklist is done by the surgeon, while other operating rooms throughout the country will use residents, fellows, and nurses to run the checklist.
- Who should be in charge of the checklist? Also, continuing on yesterday’s post on technologies involved in process maps, what technologies could be implemented to improve usage? Are there ways to integrate the checklist with the electronic health records?
We should also remember that in addition to being a great tool for improving adherence to a protocol, checklists can also be a very effective tool for data collection in a QI project. I've been working on a QI project with Dr. Sara Miller in the ED for about a year now, and within the last few months we have finally gotten to the stage of gathering prospective data. We're using a data collection form that is filled out mostly by the resident, and then has a few places that must be completed by the attending. Most of the form consists of checklists that can be very quickly completed by both the resident and the attending, and ease of use must be a primary concern when designing such data collection tools (especially if the form is to be completed by someone *other* than the person who designed it!).
ReplyDeleteOne nice thing about a checklist as a data collection tool is that it can be easily converted into binary data, which can then be manipulated easily. For instance, our data forms are transcribed into an Excel spreadsheet where each column corresponds to a checkbox on the form. The study is about chest pain, so there are check boxes for each of the types/qualities of pain that are commonly seen. Once our data is entered into the Excel sheet, it becomes very easy to use the basic tools built into Excel to see what percentage of patients presented with a certain type of pain and how many of those actually ended up with a diagnosis of Acute MI, for instance. More detailed statistical analysis of the data can be performed, as well.
But that gets back to the point about technologies used in quality improvement: it would be fantastic if there were readily-available technologies to allow the data collection to happen electronically and be logged directly into a database. An app for the smartphone that nearly every physican carries nowadays? There are security and compatibility issues, to be sure, but it would be nice to avoid the tedium of entering all that checklist data by hand. Of course, such technologies would cost money... and the labor of medical students is free. :)
In response to your second question, Zane, I think that checklists will not only be an excellent way to measure improvement, but also to help bring about the improvement itself. I think it's worth considering this from the patient's perspective, too. Could checklists be modified for patients so that they could take a more active role in their own care? For example getting those HDL, A1c readings yearly could be part of the patient's as well as the physician's checklist. Maybe that would help ensure the success of some of these goals.
ReplyDelete@Meghan: A physician I shadowed always provided patients with a form for blood work which they would need to complete for their next visit.
ReplyDeleteTo capture activity like you describe, challenges us to map processes which extend outside the confines of our hospital to small town clinics and into patient's homes. To achieve that seamlessly requires not only EMR but interoperability.
There's nostalgia for the doctor who made house calls. How can those warm feelings transfer to digitally entering our patients' lives?
I would hope that an insurer would see the value in your suggestion and consider how to incorporate patient compliance with their pricing of insurance premiums. The first steps could use positive incentive. For example, while working I got paid to continue to not smoke.