Checklists work with culture change
Checklists work with culture change
Safety expert saved lives with checklist technique
When pilots prepare to take off, they follow an audible checklist. A similar strategy, adapted to health care, helped hospitals around the country reduce central-line-associated bloodstream infections.
And the same methods can reduce injuries and improve health care worker safety, says Peter Pronovost, MD, PhD, an anesthesiologist and critical care physician who has become a leading voice for checklists as a tool in health care. He proved that checklists – distilling guidelines into easily repeated steps – could have a vast impact on safety, dramatically reducing infections at Johns Hopkins Hospital and intensive care units in Michigan.
In an interview with HEH, Pronovost explained that the real transformation is the culture change. "The biggest barrier that we had in improving safety was a culture barrier that said all these bad things are inevitable. Stuff happens," says Pronovost. "When you change the mindset [and say] these are preventable, that's when you really get a lot of leverage."
Pronovost, now director of quality and safety research at the Johns Hopkins University School of Medicine in Baltimore, began by seeking simplicity. There was a 64-page federal guideline for preventing hospital-associated infections. He distilled it into a five item checklist to be used when inserting a central line. Doctors should:
1. Wash their hands with soap.
2. Clean the patient's skin with chlorhexidine antiseptic.
3. Put sterile drapes over the entire patient.
4. Wear a sterile mask, hat, gown and gloves.
5. Put a sterile dressing over the catheter site.
When the checklist was implemented across the state of Michigan, it saved an estimated 1,500 lives in 18 months. Pronovost was named one of the world's 100 most influential people in 2008 by Time magazine because of his safety work and he was the recipient of a MacArthur Foundation "genius" grant.
The checklists worked, in part, because nurses were empowered to ask doctors to follow them, says Pronovost. And they were part of an approach to safety that looked for systematic causes of problems and measured results. The ICU teams received regular feedback on their infection rates.
Hospitals that try to implement the checklist without making other changes in the safety culture will not necessarily see an improvement. "Checklists can't be the end. The end is reduced harm," says Pronovost.
Target injury, build a team
So how can you make checklists work to improve employee health? Begin by targeting a specific type of injury, such as falls due to wet floors, or back injuries from repositioning patients.
Gather an interdisciplinary team and look for systematic problems that led to the injury, Pronovost advises. "One of the lessons we learned in safety is to respect ground truth, the wisdom of the frontline workers," he says.
Conduct a literature review to see if other facilities have tackled the same problem. Ultimately, your safety effort should ask – and answer – some basic questions, he says: "What happened? Why did it happen? What did you do to reduce risk? How do you know risk was actually reduced?"
In one case, Pronovost became aware of an employee fall and several patient falls in one unit. "Most of the falls were occurring at the same corner of the floor," he says." I went up there to look and what I found is that someone had put wax on the floor inadvertently.
"The solution wasn't to tell people to be more careful. We had to get the wax off and find out how [environmental services workers] came to make the mistake. It's a systems approach [to solving problems] rather than just blaming people," he says.
The best solution is always one that removes the hazard such as needleless devices to replace sharps. "We always seek the system design changes that eliminate the need for a checklist. They don't always exist, but when they do we should use them," says Pronovost.
Checklists help prioritize
Create a checklist if there's well-established guidance that may be cumbersome to follow. The checklist is essentially a summary of its most important points, he says.
"One of the key lessons [of our project] was to prioritize. Reduce ambiguity," he says. "One of the main reasons people don't use guidelines is that the guideline is often worded vaguely and it's unclear who is to do what, when and how."
For example, the central-line insertion checklist told health care workers to wash their hands. "We assumed that the command, 'wash your hands,' was clear to staff about exactly what it meant," he says. "[Yet] there was wide interpretation of when they were supposed to wash their hands."
He urges people to be specific: "When you enter a patient room, wash your hands with alcohol gel."
The checklist needs to be easily accessible. Pronovost's central-line checklist was taped to the central-line kits.
As with any safety initiative, it's important to follow up by measuring compliance and monitoring the impact. For example, hospitals have used observers to monitor hand hygiene or appropriate use of lift equipment.
"Don't think of the checklist as an independent intervention. Couple it with measurement and feedback and culture change," he says.
Can there be too many checklists? Pronovost readily concedes that there can be. Wrong-site surgery has continued to occur despite the widespread use of verification protocols. Perhaps surgical teams are too often just going through the motions, he says.
"Checklists aren't Harry Potter's wand," Pronovost is fond of saying. It's what you do with them that counts.When pilots prepare to take off, they follow an audible checklist. A similar strategy, adapted to health care, helped hospitals around the country reduce central-line-associated bloodstream infections.
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