Moving beyond exclusively letting staff use checklists could greatly improve the NHS & make it safer

Moving beyond checklists could make the NHS safer


I read this Wired article about checklists written by Dr Cosima Gretton (a newly qualified Doctor working in the NHS) (follow her on Twitter) and wasn’t at all surprised. I may have had a mobile with me and always on for the last 20+ years but my advancing years mean I’m still a mobile immigrant and probably can’t even begin to imagine how confusing it must be for the BornMobile generation (who have always existed in a world where everyone is connected) to finish up at medical school and find themselves having to use Fax Machines and interact with 19 different software programmes to work in a ‘world class’ teaching hospital across the bridge from the Houses of Parliament:

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It’s really no wonder checklists fail to make sense when viewed from on top of such a spaghetti style mess of competing IT non-systems and priorities, the NHS may not be yet using checklists appropriately (eg. those idiotic A&E kiosks!) but let’s not let this completely cloud our perspective and let’s let Patients and Carers also use them.

mHealth Insights
Since the aviation industry improved its safety record in the 80s and 90s -in part through the use of checklists by pilots – similar methods have been attempted in healthcare In 1999, the Institute of Medicine, a non-governmental US body, published a report, To Err is Human, which was the first admission of the death and disease caused by medical error. Since then the focus across all aspects of medicine has been on imitating aviation in reporting errors in an attempt to create the “black box” of healthcare
I think it’s really important that we properly understand industries like aviation before we think we’ve any chance of learning from them because the level of understanding required to be able to properly teach something from one industry into another is much greater than most appreciate.
Checklists have been monumentally important throughout the history of aviation (eg. the B17 “Flying Fortress” was using pre-flight checklists in the 1930’s) and it’s not just because the Pilot (unlike the Doctor) has to get on the plane with the passenger/Patient. For a good backgrounder on this Dr Richard Sills of IMH UK (the developers of the clinically validated questionnaire that we have adapted as part of the 3G Doctor service) gave a great talk on the history of Computer/Patient interviewing in medicine at ICASM (a big Aviation industry conference) that was held last year in Oxford that you will find interesting. Slides here.

It’s really important to note that checklists shouldn’t just remain the preserve of Doctors. When sympathetically designed  we know Patients will communicate more honestly and they can ensure Patients get the time to tell their story and enabling Healthcare Professionals to work towards the top of their license.

In 2001, Peter Pronovost, a specialist in intensive care at Johns Hopkins Hospital in Baltimore in the US, created a five-step checklist for placing a catheter in a large vein of patients. The checklist included simple instructions such as “Wash your hands with soap” and “Wear a sterile mask, hat, gown and gloves”. It reduced infection rates from 2.7 per 1,000 patients to zero inside three months, and is estimated to have saved 1,500 lives across the Michigan hospitals in which it was implemented. Since then, checklists have proliferated in every aspect of healthcare
I think it’s important to appreciate that checklists may have proliferated but it is with exception because they have not proliferated in use by Patients. Tens of millions of NHS Patients still pick up telephones to call GP Practices (100,000 a day get turned away by receptionists making this the least safe interaction a Patient has with General Practice)to have rushed 5 min appointments for which the Doctor has no idea what the concern will be until the door swings open and ridicules them if he decides they’ve wasted his time. Let’s not even start on about the work that ‘height of their career’ Consultants are doing as they fan their faces with Patient diaries etc.
However, there’s a problem with the overuse of checklists. Checklists oversimplify medicine. They might work for carrying out procedures and remembering simple sequences of actions, but not when managing the complexity of a 95-year-old with heart failure and multiple co-morbidities who wishes to die in peace. Patients’ psychology and physiology are complex and constantly changing, and we understand too little. They require systems with flexibility and adaptation. Checklists can’t simplify the inherent complexity of medicine
The idea that a checklist output is the same as a diagnosis is such a common misunderstanding Doctors have about checklists. I’ve been working around the clock recently turning a paper based checklist developed over the last 30 years by one of the world’s most pre-eminant Consultant Paediatricians into a secure online tool that will be made available free-of-charge to help Parents the world over who have children suffering with allergies and long term conditions. From this experience let me assure you understanding the output of this checklist/questionnaire is not creating ‘paint by numbers medicine’ but helping Patients and Carers share their stories, making better use of the skills of highly qualified Doctors and helping less experienced Doctors see when they’re clearly out of their depth and struggling to manage things with too little information and not enough understanding/experience.
A good example of the problem we have when we don’t let Patients contribute to their EHR is that in my work conducting audits etc I’ve personally reviewed the electronic records of hundreds of very elderly Patients in hospitals and although advance care directive initiatives are at last happening I have yet to ever see information explaining how the Patient wishes to die listed in an electronic billing/CMA database. Most Patients don’t even get to see their EHR never mind the capacity to post their “wishes to die in peace” to that provider held record.


Related: Watch David Doherty explains Mobile Video Consulting best practice at Doctors 2.0 in Paris

About David Doherty
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