We are consistently inconsistent in the delivery of health care. While we know what to do to reduce errors, we don’t always use all the available tools, or we allow individuals to decide whether or not to follow best practices. You may think I’m a broken record with my recurring themes of evidence-based practice, safety, and quality, but I can’t help myself. It’s inconceivable that smart, educated professionals refuse help or ignore proven interventions in deference to personal preference. Sometimes we collude and step aside because of cantankerous colleagues who think they don’t need to follow the rules because of their status as experts. But here’s the upshot: What we permit, we promote. Our job is to prevent avoidable errors.
Fortunately, help is on the way via a simple tool—the checklist. The care we provide is complex, and committing everything to memory isn’t reliable. Studies have shown repeatedly that even when clinicians know the right thing to do, they omit steps. Healthcare checklists aren’t new, but they need more traction.
In the past few years, evidence-based approaches to reducing infections and enhancing safety in the surgical suite have been shared across the world. The central-line “bundle” interventions developed by Peter Pronovost, a critical care specialist physician at Johns Hopkins Hospital, combine five practical but proven approaches to ensuring safe intravascular central catheters for inpatients and outpatients. The premise is that all five interventions implemented together as a bundle achieve the best outcomes. The interventions include hand hygiene, maximal barrier precautions (draping the entire patient as well as use of a mask, hat, gown, and gloves by caregivers during line insertion), use of chlorhexidine for skin antisepsis, optimal site selection, and daily review of the need to retain each line followed by prompt removal of any unnecessary lines. A checklist guides these steps and empowers the nurse to ensure compliance. Another checklist for patients on ventilators promotes elevating the head of the bed 30 degrees to prevent oral secretions from draining into the lungs and giving antacids to prevent stomach ulcers, leading to a decrease in ventilator-associated pneumonia and mortality.
Prominent Harvard surgeon Atul Gawande helped develop a “safe-surgery checklist” for the World Health Organization. Believed to reduce complications by one-third and deaths by almost one-half, the checklist contains three sections assessing activities that reduce risks before, during, and after the procedure. The nurse is a key participant and informant in this process. Moreover, the study in eight sites worldwide also saw a decrease in postoperative infections and unplanned returns to the operating room.
So with these results, why do only 20% to 50% of U.S. hospitals use the checklist? What’s holding us back?
Experts at our academic medical centers have been schooled to compete and become the best individual stars—coming up with the latest discovery, the most promising invention, or the first-of-its-kind technique. The concepts of conformity and standardization are contrary to those raised on a diet of rugged individualism. But this outlook does little to support organization-wide success in reducing variations in care. Today’s public report cards on hospitals are revealing the results, and the negative headlines they generate (“America’s least deadly hospitals”) do little to instill confidence.
The power of precedent as programmed behavior (“We’ve always done it that way”) can be an immobilizing threat to change. It can interfere with translating new knowledge into action and can widen the knowing-doing gap. Repeating the approaches of the past in the face of new evidence is just plain wrong. Breaking out of the mold requires a culture that encourages questioning behavior and an atmosphere of trust and safety.
The nurse is a pivotal player in the use of checklists, following evidence, and preventing deviation from desired behavior. Consistent with the wisdom of W. Edwards Deming, a professor and consultant who became known as an icon of quality, we must drive out fear and distrust to create enlightened work environments, thereby empowering the nurse. By doing so, we can achieve the best outcomes for every patient every time.
How do we influence others to change their behaviors and thereby reach the goal of doing no harm and improving outcomes? Give feedback. Pronovost suggests we use the “four Es”: Engage teams with stories and their baseline performance data, educate them on what they need to do, execute action locally accounting for the culture, and evaluate. Having a good design for what you want to do is important, too, and checklists can create consistent, measurable approaches. They have the power to save lives.