Checklist culture to reduce risk

Tina Rosenberg of the New York Times follows up her ‘machines that go ping’ piece about hi-tech handwashing compliance techniques with a low-tech approach that seems ridiculously successful: checklists.

“In 2003, the Michigan Health and Hospital Association began an experiment to see if its members could bring down the rate of infection in central line catheters — one of the deadliest types of hospital-acquired infections.

“The intensive care units at nearly every hospital in Michigan participated — 103 I.C.U.’s. What they had to do was use a five-point checklist to prevent infection when inserting the catheters. The steps were: Wash hands. Cover the patient with sterile drapes. Clean the skin with chlorhexidine antiseptic. Do not insert catheters into the groin area. Remove catheters as soon as they are no longer needed.

“A paper in the New England Journal of Medicine by Peter Pronovost, the Johns Hopkins University doctor who designed the checklist, set out the results.

“’Within 3 months after implementation, the median rate of infection was 0, a rate sustained throughout the remaining 15 months of follow-up. All types of participating hospitals realized a similar improvement.’”

“Atul Gawande wrote about the checklist in The New Yorker, and went on to write a book called “The Checklist Manifesto.” In his article, he talks about how the checklist makes each step explicit and helps harried doctors and nurses to remember all of them. …

“The checklist itself probably isn’t useful for routine hand-washing — there would be only one item on it. What is useful is borrowing the way the checklist replaces a culture of “no questions” with a culture of “patient safety comes first and it is part of my job to speak up.”

“One very valuable source for ways to improve hand-washing rates comes from the health care industry’s Joint Commission Center for Transforming Healthcare Hand Hygiene Project. The project worked with eight hospitals to implement pilot programs designed to raise hand-washing rates in different ways. A solution that helped almost everywhere was to streamline workflow to make it easier and more automatic to wash hands: for example, to put sinks in the same place in every room, with a table to put down items the nurse might be carrying. Keep supplies in every room so nurses don’t have to go in and out to get them.

But the project also found, as many readers suggested, that hospital managers needed to elevate hand-washing as a priority, stress its importance, and hold all hospital workers accountable. Accountability requires knowing the hand-washing rates of different units and people, which is why the technological systems I wrote about on Tuesday can be important. But data only matters if it is used. Once hospitals can know their workers’ hand-washing rates, they need to use the information for coaching and to create incentives — both negative and positive.”