Given the evidence of how surgical checklists can reduce deaths and complications, it's a mystery why nearly 10% of hospitals still don't mandate their use and why another 12% can't say for certain whether or not checklists are being used.
One week ago, the Centers for Medicare & Medicaid Services' Hospital Compare website started publically reporting which of 4,136 hospitals across the country use surgical checklists and which ones don't.
That, one would think, is a pretty big deal, introducing a level of transparency that would please Brigham & Women's Hospital surgeon Atul Gawande to no end.
After all, it's been seven years since the New Yorker published the first version of his Checklist Manifesto, in which he demonstrated that team time-outs at three intervals during the operation could prevent surgical horror stories.
Gawande's work has shown that a Safe Surgery Safety Checklist can reduce by up to one-third deaths and complications resulting from retained objects, infections, unplanned reoperations, and other procedural horrors such as wrong-site or, heaven forbid, wrong-person surgery.
Now information about which facilities are using checklists is public.
Amazingly, despite so much evidence showing the importance of using checklists in every operating room where surgeries take place, the website shows that, for the calendar year 2012 when the reports were collected, 366 hospitals said they still don't use them and 497 couldn't say whether they did or not.
Specifically, CMS is now reporting on whether hospitals use a 12-point version of the checklist, one that stops everything at three "critical points" of an operation, before anesthesia, before skin incision, and after surgical site closure but before the patient leaves the operating room.
There are much more complicated adaptations in use, for example Gawande's is a 19-point checklist, so the CMS version seems like a no-brainer.
Does Gawande feel validated, delighted, disappointed, or angry? When I asked him on Wednesday, he surprised me. He seems pleased, but with some important caveats. It turns out that seven years on, the story of the checklists' success is a little bit longer and more complicated than a simple yes or no.
Gawande says he's "glad to see the surgery checklist is getting recognized as important. When it is implemented well and surgical teams actually use it, multiple trials show it reduces complications and deaths."
He notes, however, that recent studies have shown, that "virtually all hospitals will report they are following the checklist but… just because they adopted the checklist doesn't mean that their teams are actually using [it]."
In Ontario, Canada, the Ministry of Health and Long-Term Care mandated public reporting of adherence to surgical safety checklists in 2010. But according to a paper published in the New England Journal of Medicine, during a period three months after adoption of that policy, there was no significant reduction in operative mortality or complications.
Mandating checklists doesn't do the job, Gawande says. Changing the culture does.
Checklists Need Follow-through
"The CMS metric won't improve care by itself," Gawande says. "It only documents a hospital's promise to use the checklist. Whether their teams actually use the checklist will remain to be seen."
Lucian Leape, MD, chairman of the Boston institute that carries his name and an author of the Institute of Medicine landmark report, To Err Is Human, also believes that just saying your organization's doctors use a checklist isn't the end of the story.
In an editorial in the same issue of the New England Journal of Medicine, Leape noted that:
"…It is not the act of ticking off a checklist that reduces complications, but performance of the actions it calls for." These actions do not merely include confirming the identity of the patient, operation, and site and ensuring that the necessary instruments, fluids, blood and equipment are available; they also include having all team members introduce themselves and having the surgeon brief the team on the critical steps of the operation and address any concerns of the anesthetist and nursing team. The checklist is merely a tool for ensuring that team communication happens."
Tejal Gandhi, MD, president of the National Patient Safety Foundation, adds, "You can't just put in a checklist without the culture change, and leadership commitment. Otherwise it's just the thing that people do without really having any buy-in or paying attention." Having it mandated by the government, as happened in Ontario, "is probably not what is needed to get the impact you want."
It's still a mystery to me, however, why 366 hospitals didn't think the checklist is important enough to at least say their doctors use one, even if they don't.
Asked what she thought of that, Leah Binder, President and CEO of the Leapfrog Group, quickly replied: "The leadership of those 366 hospitals should be fired for not putting patients first. There's no excuse for this egregious failure."
I placed a call to about 10 of those 366 hospitals at random, leaving messages with public affairs representatives or administrative offices, but only two replied. One said that the CMS listing for them was incorrect.
"I am not sure how that information got on that site," wrote Gregory Rouleau, vice president and chief nursing officer for Mercy Medical Center of Merced, CA. "We do use a surgical checklist in our Electronic Medical Record in the OR."
At another hospital, a woman who identified herself as an assistant in the administrative office said surgeries are not even performed at her hospital. So maybe some of those 366 hospitals don't even do surgery. That's sloppy work by CMS, if true.
So I'm not sure what went wrong. I can't believe that surgical teams in nearly 1 in 10 U.S. hospitals today still fail to do something so basic, such as checking the anesthesia machine and medications, communicating with surgical team members about any anticipated critical events, or taking a complete count of surgical instruments. It really boggles the mind.
Maybe some hospitals don't require their surgeons to adhere to the checklist because they can't verify that they did. Or maybe they don't bother to acknowledge the checklist because they know they'll never be able to tell surgeons what to do.
For others, there might be a concern that the checklist itself becomes rote, with surgical team members saying "check," to get through the case and on to the next.
The story of the checklist, and at long last the reporting of its use by hospitals throughout the country, is not a simple one. But it makes sense that these time outs to check patients, equipment, and procedures down to the last critical detail, can and do reduce the terrible things that can happen when a patient goes under the knife.