Monthly ArchiveNovember 2015

A safety checklist for UK general practice: help or hindrance?

BMJ Quality No Comments

Dr Paul Bowie is programme director for safety and improvement at NHS Education for Scotland. Twitter: @pbnes

“Checking” is endemic in healthcare the world over. It is a routine everyday activity in all care settings and is fundamental to maintaining patient safety. Checking tasks go well in the great majority of cases and do contribute to a successful outcome for the patient. However, sometimes they do not, and this may lead to things going wrong that contribute to patient safety incidents – circumstances where patients could have been or were harmed. Unfortunately some of these incidents can and do have a devastating impact on the wellbeing of patients and families, as well as the care professionals involved.  

Minimising the risks of such occurrences is obviously a major safety priority. Even so, this can be very difficult to achieve given the sheer complexity of care systems and the everyday constraints that care teams often work within (eg high workloads, increasing patient demand, and limited resources). The skill and dedication of care professionals in constantly coping and adapting to these ever changing circumstances convincingly explains why things normally go well for patients, but also why sometimes they do not (see the work of Erik Hollnagel or Sidney Dekker for example).

The use of “checklists” is promoted as one approach to standardising working practices to make care systems more reliable and contribute to patient safety.[1] A checklist is a cognitive tool that may help care teams to ensure that safety critical tasks (including communicating effectively with each other) are actually carried out. Perhaps the most well known example in healthcare is the WHO Surgical Safety Checklist which is now mandated in over 150 countries worldwide.[2]  

Barriers to checklist use

The safety checklist is often seen as a simple, practical solution – even a panacea – in making sure that highly important patient care tasks are actually performed and performed on time.[3,4] The evidence base, however, shows a different reality.[3,5-9] Checklist adoption by staff groups and subsequent impacts on enhancing patient safety are fairly mixed. In some ways this is no great surprise. In the risk management world, the “hierarchy of intervention effectiveness” rates human behaviour dependent interventions such as checklists, doublechecks, and reminders towards the bottom of its scale.[10]  

A range of reasons for this are now apparent. Prime among them is that the checklist can be viewed as an inadequate “technical fix” to what is a “complex socio-cultural problem”. In other words, individual “checking” behaviours and intentions are influenced by the “social group” that people belong to, as well as local healthcare practices, values, beliefs, and traditions.  Therefore, adoption is often dependent on how seriously the issue of “checking” is taken within a team or organisation, particularly in complex and dynamic working environments. Potential users may also resist or feel threatened by checklists because they are perceived to replace their expertise or decision making, or oversimplify the complexity of work.  

Checklist success factors

On the other hand, checklist success is associated with a number of important factors in combination; it will have limited impact as a solo intervention.  Firstly it needs the commitment and the support of healthcare leaders and local promotional champions.  Success is also more likely where step by step instructions for simple or straightforward technical tasks are necessary and where staff already know that variations in checking performance exists. There is also the fact that reliance on human memory is a problem in a busy working environment.  

Importantly, any checklist should also be flexible enough to enable users to apply “common sense” judgements, otherwise it will be considered an irritation and remain unused. Checklists that are externally imposed and lack adaptability to suit local contexts can struggle to be fully accepted and implemented effectively. Ultimately, it should have a greater chance of adoption and sustainability where there is frontline consensus that checklist use is highly relevant, that it is feasible to use routinely, and is an improvement on how work is currently done.

A safety checklist for general practice?

So, given all that we know about checklists and their impacts in secondary care, why embark on such a development for the UK general practice setting?   

Well, firstly there is a potential “checking problem” in general practice. This is not at all surprising given workload pressures, the complexity and uncertainty of care, and the volume of checks that are required to be carried out on a daily, weekly, monthly, quarterly, and annual basis to help the team run the practice safely and efficiently. General practice managers and nurses in particular will all attest to that!  

Although the safety evidence base is limited in this area,[11] most who work there will be able to recall different incidents happening (and recurring) that involved a failure to check safety critical issues, or (probably more likely) when necessary checking tasks were not performed on time. Examples would include: patients with the same name being mixed up, emergency drugs being out of date when required, employing clinicians who are not currently registered to practise, emergency equipment not working or adequately calibrated, IT systems not being routinely backed up, and so on.Secondly, although numerous safety checks are always carried out, it often seems to be done in an ad hoc manner – that is, there is a lack of standardised, timely and consistent checking processes in many general practices. Again this is unsurprising.  Most practices will have limited knowledge or experience of taking a ‘systems approach’ to identifying and routinely checking safety issues of importance, measuring performance and implementing any necessary improvements.

As a starting point to understanding this issue more clearly, NHS Education for Scotland worked closely with GP managers, nurses, and doctors to identify and prioritise a comprehensive range of safety hazards across the whole working environment (box 1). This in turn informed the design of an integrated checklist; although we’ve labeled it a “checklist” it would probably be more accurately defined as a global checking system.[12] The consensus is that it would need to be applied at least every four months. Pilot testing estimated that this would take around two hours to complete, which was deemed feasible and is arguably more manageable when compared to some checking processes that are in place.  

A way forward?

It is perceived to be a very necessary intervention by those involved in the initial study, with many frontline practitioners and safety improvement decision makers, who have since attended related workshops or conference presentations, also agreeing. The RCGP clearly recognises its potential value and have included it in their recently launched national patient safety toolkit.[13]   

To some extent the most straightforward part has been achieved. The real difficulty comes in developing the checklist further to make it easier to use and implement in busy practices – this is currently under discussion with colleagues in Healthcare Improvement Scotland. The idea of using a tablet or similar device to assist users is being given serious consideration, although introducing another technology potentially raises a set of other problems.  

Importantly, how the checking process is designed, promoted, implemented, used, and supported as a patient safety intervention will largely determine its fate – we will need to understand if and how it works and why. If most GP teams believe it to be helpful and an improvement on how everyday work is currently carried out then there is hope for success.  However, if most believe it to be a hindrance then… 

Suggested reading:

  1. Catchpole K and Russ S. The problem with checklists. BMJ Qual Saf 2015;24:545-549 doi:10.1136/bmjqs-2015-004431
  2. Bosk CL, Dixon-Woods M, Goeschel CA, et al. The art of medicine: reality check for checklists. Lancet. 2009;374: 444–5.

Box 1. Selected examples of identified potential hazards in the general practice work environment which informed development of checklist content

Safety Domains

(sub-categories)

Examples of potential hazards:

Patient, GP team members, and practice organisational outcomes

(eg quality, safety, health, wellbeing, performance)

Medication management(controlled drugs; emergency drugs and equipment; prescriptions and pads; vaccinations; all other drugs)
  • Lack of in-date stock may lead to inability to treat acutely ill patient
  • Lack of necessary emergency drugs or out-of-date emergency drugs can lead to patient safety being compromised, for example, adrenaline for anaphylaxis.
  • Protects these prescription-related items from potential theft which can lead to unauthorised prescriptions of high risk drugs being dispensed to vulnerable patients or members of the public who may harm themselves as a result
  • Safe and secure keeping is necessary to prevent theft and misuse which could harm patients and members of the public
Housekeeping

(infection control; stocking of clinical rooms; confidential waste; clinical equipment maintenance)

  • Staff and patients, including children, obtaining a needle stick injury from overfilled “sharps” bins
  • Patients at risk of infection from spilled hazardous waste on clinical surfaces/equipment
  • Patients and staff at risk of cross-contamination from blood/bodily fluids
  • Risk of cross-infections from, for example, people, equipment and clinical surface areas
  • Breaches of patient confidentiality can impact on patient safety via patients’ suffering psychological harm from knowing their medical history has been disclosed publically
Information systems

(business continuity plan is up to date; verifiable back-up of all IT systems; data protection; record keeping)

  • Can impact on how safe patient care is delivered in an emergency situation e.g. electrical outage to the practice affecting IT systems and how to manage and deliver care in such a situation
Practice team

(registration checks; CPR and anaphylaxis training; induction processes; access to patient safety-related training)

  • [All clinicians are registered with professional regulators]… patient safety-critical checks which protect the local patient population and the practice as an organisation
Patient access and identification

(access information for patients; standardised patient ID verification)

  • Numerous significant events in general practice are related to mix-ups over patient identification leading to patient’s being subjected to unnecessary treatments, hospital visits and investigations, and breaches of confidentiality which can cause avoidable physical and emotional harm
Health and safety

(building safety and insurance; environmental awareness; staff health and wellbeing)

  • Hazards in the workplace which are not identified and attended to can lead to harm (e.g. a patient sustaining a head injury from walking into a low lying light)
  • Staff can be subject to abuse, anger, threatening behaviour and violence and should be trained to manage these situations to protect the safety and wellbeing of themselves and patients.

 

References

  1. Haynes AB, Weiser TG, Berry WR, et al. . A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9.
  2. World Health Organisation. Implementation of the surgical safety checklist. WHO, Geneva; 2008.
  3. Catchpole K and Russ S. The problem with checklists. BMJ Qual Saf 2015;24:545-549 doi:10.1136/bmjqs-2015-004431.
  4. Bosk CL, Dixon-Woods M, Goeschel CA, et al. The art of medicine: reality check for checklists. Lancet 2009;374: 444–5.
  5. Fourcade A, Blache J-L, Grenier C et al., Barriers to staff adoption of a surgical safety checklist.  BMJ Quality & Safety 2011 doi:10.1136/bmjqs-2011-000094.
  6. Hillgoss B & Moffat-Bruce S.  The limits of checklists: handoff and narrative thinking. BMJ Qual Saf 2013;doi:10.1136/bmjqs-2013-002705.
  7. Ko HCH, Turner TJ, Finnigan M.  Systematic review of safety checklists for use by medical care team in acute hospital settings – limited evidence of effectiveness.  BMC Health Services Research 2011;11:211.
  8. Gillespie B, Marshall A. Implementation of safety checklists in surgery: a realist synthesis of evidence. Implementation Sci 2015, 10:137.
  9. Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J, et al. A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England Lessons From the “Surgical Checklist Implementation Project”. Ann Surg 2015;261(1):81–91. doi:10.1097/SLA.0000000000000793.
  10. Caffazo JA, St-Cyr. From discovery to design: the evolution of Human Factors in healthcare.  Healthcare Quarterly 2012:(Vol.15 Special Issue);24-29.
  11. Health Foundation. Evidence scan: levels of harm in primary care (2011). Available at: http://www.health.org.uk/publications/levels-of-harm-in-primary-care/ [Accessed 25th September 2015]
  12. Bowie P, Ferguson J, Macleod M, Kennedy S, de Wet C, McNab D, Kelly M, McKay J, Atkinson S. Participatory design of a preliminary safety checklist for general practice. Brit J Gen Pract 2015; 65(634) DOI:10.3399/bjgp15X684865
  13. Royal College of General Practitioners. Patient Safety Toolkit for General Practice. http://www.rcgp.org.uk/clinical-and-research/toolkits/patient-safety.aspx [Accessed 11th November, 2015]

Measuring quality

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jean

Jean Slepian has been a community hospital librarian in the Northeastern United States for 37 years, with special interests in health policy and advocacy

I have been a medical librarian for nearly 40 years, and in that time we have seen a 180 degree turn-about in regard to healthcare “quality”. In the old days we never questioned the quality of medical care. In fact, such blasphemy might get a person fired. In the late 1990s we were shocked out of our oblivion by a scorching report on medical errors from the National Academies Institute of Medicine, To Err is Human.[1]  Thus began the long and arduous journey toward healthcare quality. Today we measure quality with objective indicators, such as the number of readmissions after acute care hospitalization and whether patients receive appropriate discharge instructions. Have we made progress?

On the road to quality nirvana we have encountered several gurus…the first was W. Edwards Deming, the “father” of total quality management. Largely credited with the revitalization of industry in post-WW II Japan, Deming had a 14 point plan to achieve quality. Point 10 is to “Eliminate slogans and exhortations.” One of our more recent quality gurus, Quinton Studer, has lots of catchy slogans and mnemonics to inspire quality, and I tend to favor Deming’s approach. He also said, “It is wrong  to suppose that if you can’t measure it, you can’t manage it – a costly myth.”[2]

In the past year several controversial studies have been published that seem to suggest that we may not be measuring what we think we’re measuring with objective quality indicators. In the Journal of the American Medical Association (JAMA) last February a study was published that found no difference in  inpatient complications and mortality between hospitals that participate in the National Surgical Quality Improvement Project, and hospitals that don’t participate.[3] Another study published in the same issue[4] found no difference in outcomes or expenditures for Medicare beneficiaries between hospitals that participate in NSQIP and those that don’t.

A study by Howell[5] published in JAMA in October 2014 found no correlation between two obstetric quality indicators and maternal/neonatal morbidity. In the same issue, a study by Neuman[6] of Medicare beneficiaries released to skilled nursing facilities after acute care hospitalization found no consistent association between skilled nursing facility quality indicators, and readmission or death.

In the “softer” medical literature I detect a growing dissatisfaction with the objectification of quality, and the depersonalization of patient contact with use of the electronic medical record.

Chi and Verghese [7] refer to the”iPatient” and state, ” …the abundance of dropdown menus on the EHR and the compulsion to leave no box unchecked often creates a neat construct of a patient that can be a meta-fiction. This construct is often at odds with the real patient…not always accurate in the sense of the patient’s story or the manifestations of illness on the patient’s body.” Wu[8] sadly characterizes himself as a “kind of virtual doctor”, prizing “efficiency over human contact, computerized data over stories, virtual reality over authentic life.” Patel[9] painfully relates an experience in the ER when he overlooked a patient in frank respiratory failure because of his pre-occupation with her electronic history.

Dr. Charlotte Yeh relates her experience[10] after being hit by a car when emergency department providers put quality metrics before her actual needs. Dr. Patricia Gabow, a former healthcare executive and chief medical officer[11], found that when her mother was injured in a fall, the standardized care she had always advocated was not appropriate.

In the medical library business these days, “quality” seems to equate to the number of online resources we make available to our patrons, but do we really know if patient outcomes are better when providers have instantaneous access to the medical literature, or is that just a logical yet possibly erroneous assumption?

Indeed, sometimes it seems that in our quest for the perfect data driven measure, we have devolved to the point where “quality” and “compassion” are mutually exclusive concepts.

However, I believe that we can manage quality without objectifying it into tiny measurable bites. I believe that there is someone out there who is smart enough to do it – please let us hear from you!

 

References

  1. Committee on Quality of Healthcare in America: To Err is Human; Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
  2. Deming, WE. The New Economics; Cambridge, Ma:  MIT Press, 2nd ed, 2000.
  3. Etzioni DA, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA 2015 Feb 3; 313(5): 505-511 .
  4. Osborne NH, et al. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA 2015 Feb 3;313(5):496-504.
  5. Howell EA , et a. Association between hospital–level obstetric quality indicators and maternal and neonatal morbidity. JAMA 2014 Oct 15;312(15):1531-41.
  6. Neuman  MD, et al. Association between Skilled Nursing Facility quality indicators and hospital re-admissions. JAMA 2014 Oct 15;312(15):1542-51.
  7. Chi J, Verghese A. Clinical education and the electronic health record: The Flipped patient. JAMA 2014 Dec 10; 312(22):2331-2.
  8. Wu D. Virtual grief. JAMA 2012 Nov 28;308(20):2095-6.
  9. Patel JJ. Writing the wrong. JAMA 2015 Aug 18;314(7):671-2.
  10. Yeh C. ‘Nothing is Broken’: For an injured  doctor, quality–focused care  misses the  mark. Health Aff (Milwood) 2014 Jun :33(6);1094–7.
  11. Gabow P. The Fall: Aligning the best care with standards of care at the end of life. Health Aff (Milwood) 2015 Jun 34(5):871-4.