Checklists, teamwork minimizing mistakes in medicine

You might not see much in common between a hospital admission and bungee jumping, but Dr. Scott Ellner does.

“Anytime somebody comes in to have a procedure done or just have some sort of hospital admission, there’s a 1 in 500 chance during that encounter that that person may not survive,” said Ellner, a trauma surgeon and director of surgical quality at St. Francis Hospital and Medical Center. “That’s on the same level as mountain climbing or bungee jumping.”

Driving to the hospital on a highway? Closer to a 1 in 20,000 chance of a fatality.

“Health care is hazardous,” Ellner said. “We have to put systems in place to protect our patients.”

Ellner described the risks shortly before his first surgery of the day on a recent morning. He’d already visited the patient, written his initials on the area where there would soon be an incision to remove her gallbladder, and discussed the plans for the procedure with the team that would be with him in the operating room.

Some of what goes into Ellner’s preparations for surgery is routine, and some of it is part of a larger cultural change that he and others are pushing for in operating rooms across the country. It’s aimed at preventing errors using techniques as complex as data analysis and as seemingly simple as teamwork and calling colleagues by their first names.

The use of checklists to ensure that the proper steps are taken before and after surgery has become commonplace, inspired in part by the use of similar methods in fields like aviation. But Dr. Alison Hong, interim vice president of quality and patient safety at the Connecticut Hospital Association, said researchers have found that even with checklists, preventable errors like leaving foreign objects in a patient or operating on the wrong body part were still happening.

Now, she said, experts are increasingly focusing on going beyond the checklist itself, making sure the steps necessary for safety are being done “with intent” — a harder-to-measure shift in operating room culture that emphasizes the patient, teamwork and minimizing interruptions.

Or, as Ellner put it, “The checklist is just a piece of paper unless it’s used correctly.”

He’s working with other surgeons, the hospital association and the health care consulting firm Qualidigm on educational programs aimed at improving patient safety at hospitals across the state.

“It comes down to communication and respect,” Ellner said.

First names, role playing and data

At St. Francis, much of the work has been shaped by the use of data. The hospital participates in a database that compiles information on rates of urinary tract infections, pneumonia and other hospital-acquired complications that can occur after surgery.

“We looked at those and we realized we’re not as good as we can be,” Ellner said.

Data also offer a starting point for diagnosing the root of problems. If a hospital has a high rate of a certain type of infection, for example, staff can examine each case for commonalities.

The data on St. Francis’ cases offered one clue: The more times a nurse had to leave the operating room to get something, Ellner said, the higher the infection rate. That led to a new emphasis on preparing for surgery by making sure everything that could be needed was in the operating room beforehand.

Then there’s teamwork, something experts say is key to improving patient outcomes. Operating room personnel at St. Francis went through training aimed at addressing how to communicate in high-stress situations, particularly among people who respond to pressure differently. What happens if a sponge is missing after a long surgery? People in the operating room are likely tired. The surgeon might already be closing the patient. How do you encourage people to speak up and make clear that everyone must stop and find the sponge?

Part of that includes “leveling the authority gradient” — that is, making sure everyone in the room, regardless of role, feels comfortable speaking up on behalf of the patient. Doctors get called by their first names, not their titles. The training also included role-playing that required doctors to take on the roles of other professionals while simulating scenarios. In one, Ellner played a nurse while the nurse took on the role of a surgeon.

“I could see the surgeon was treating me as I wouldn’t want to be treated,” he said.

The idea of emphasizing a physician’s role as part of a team represents a shift from how doctors have historically been taught, said Dr. Gerald Healy, a senior fellow at the Institute for Healthcare Improvement and a professor at Harvard Medical School. In the past, medical school students were taught that health care involved the physician and the patient; the other staff involved was peripheral.

“That was fine when doctors made house calls and had pretty much only aspirin and a few different things to give people for their illness,” Healy said. “We’re in a different era now.”

Some older physicians need to be re-educated, to understand that teamwork will be more critical in the future of medicine, but Healy said the concept has been widely embraced. “People, especially younger surgeons, understand that it takes a team to have a good outcome on a patient event,” he said.

Jean Rexford, executive director of the Connecticut Center for Patient Safety, said a critical change in health care has been the recognition of the importance of teamwork and making sure everybody involved in patient care has the power to speak up for the patient.

“It’s cultural transformation,” she said.

A growing movement

When Rexford began advocating for patient safety a decade ago, it was a lonely job. Ten years later, the topic has become far more prominent. She attributes the change to a growing network of consumer advocates, media attention, and federal policies, including health reform, that have forced hospitals to pay more attention to errors and poor outcomes. Medicare no longer pays for “never events” like surgery performed on the wrong body part, and hospitals will soon be penalized if patients who get discharged are readmitted for preventable reasons within 30 days.

Healy, too, has seen a growing focus on patient safety and medical errors.

“I can’t go to a medical meeting now where you don’t hear these terms mentioned,” Healy said. “And five years ago, it was kind of a rarity.”

He thinks the change has come from a variety of factors, including the inclusion of an emphasis on quality and safety among national medical organizations and in training programs for new doctors, as well as payment systems in which insurance companies focus on quality parameters and won’t pay for errors.

“If you want to be a cynic and say, ‘Well, this is all coming about because it’s bottom line driven and people don’t want to lose money,’ well, that’s fine,” he said. “At the end of the day, whatever drives it, frankly, I don’t really care as long as it gets done, because the people that are going to benefit at the end of the day are the patients.”

More than words

Culture change isn’t easy. At St. Francis, some of the changes in surgery made certain staffers uneasy, Ellner said. One nurse told him she felt uncomfortable because she couldn’t leave the operating room.

“I said, ‘Well, that’s the whole point, we don’t want you to leave the room because that creates opportunities for infection,’” he said. “‘She says, ‘I know, but I’m not used to it.’”

It turned out that part of nurses’ daily routines involved interacting with other people whenever they left the operating room during surgery to get something and getting to see what was happening in other rooms.

Some people won’t be comfortable with changes and won’t move forward with the organization, Ellner said. But for others, seeing someone like him who’s in the operating room adopting the new practices can make a difference. So can results. Ellner said the hospital’s infection rates began dropping, as did the use of blood products and complication rates.

The changes also made some procedures faster. That day’s gallbladder removal, for example, took about 25 minutes less than it might have in the past, in part because everyone knew their roles and no one had to leave the room, Ellner said. In the past, someone might have had to exit to get a clip, or a tool might not have been working and wouldn’t have been checked beforehand, wasting time while they replaced it.

“It’s not an overnight thing,” Healy said of culture changes. “There are going to be naysayers,” particularly those who say they’ve been doing surgery for 35 years and never operated on the wrong body part, so why change things now?

It’s important for hospital leadership to buy into the changes, and to not tolerate those who resist them, even if they’re busy surgeons who bring in a lot of revenue, Healy said.

Rexford said every hospital she’s visited has touted the importance of patient safety. But if leadership isn’t on board with efforts to really improve it, she said, things won’t change; the pledges will be little more than words.

Once people begin making changes, she said, seeing improvements can help push the cause.

On a recent visit to Bristol Hospital, Rexford said, one of the first things the staff told her was that they hadn’t had a central line infection in the intensive care until for 18 months. She could tell they were proud of it.

“When they bite the bullet, when they decide, ‘Ok, we’re going to change and we’re going to improve the quality of care,’ everybody gets excited and people get on board,” she said. “But it takes that leadership.”