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June HCI Editor's Notes: Got a Surgical Checklist? Guess What—It’s More Complicated Than That

May 27, 2014
by Mark Hagland
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Healthcare IT vendors are working to respond to the growing needs for IT facilitation of so many healthcare processes

The March 16 issue of the New England Journal of Medicine offered the results of a fascinating study on the impact of the mandatory use of surgical checklists in hospitals in Ontario, Canada.  As the introduction to the article put it, “Evidence from observational studies that the use of surgical safety checklists results in striking improvements in surgical outcomes led to the rapid adoption of such chcecklists worldwide. However, the effect of mandatory adoption of surgical safety checklists is unclear. A policy encouraging the universal adoption of checklists by hospitals in Ontario, Canada, provided a natural experiment to assess the effectiveness of checklists in typical practice settings.”

Indeed, it turns out that, “During three-month periods before and after adoption of a surgical safety checklist… the adjusted risk of surgical complications was 3.86 percent before implementation and 3.82 percent afterward,” wrote the team of authors, led by David R. Urbach, M.D. In other words, as the authors wrote, “Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications.”

What’s more, Dr. Urbach, the lead researcher and author, also spoke extensively to HealthDay regarding the findings of the Ontario study. In an interview published in a March 12 article for that publication, Urbach said, “It’s one thing if hospitals develop these things on their own, where people are motivated and engaged. That can transform a culture and make it more safety-conscious. If it is mandated, it may not achieve the same result.” What’s more, he said, referring to early studies that found cuts in mortality as high as 50 percent based on the use of checklists in surgery, “That’s a really big effect. Very few things reduce something by 50 percent.”

Still, Dr. Urbach told HealthDay that he still believes in the value of checklists as a way of bringing the surgical team together to talk about the patient. “There is probably a value in checklists, even if it can’t be measured in terms of reducing the risk of bad outcomes.”

There are so many examples of situations like this one in healthcare these days. From barcode-facilitated medication administration to electronic health record-embedded clinical decision support, including evidence-based order sets, to adverse diagnostic test-reporting alert systems, there are tools embedded in clinical information systems now that have tremendous potential. But how those tools are designed, and how they’re used—and particularly how they’re leveraged within the cultures of individual patient care organizations—makes all the difference.

What’s heartening is how creative some healthcare IT vendors are becoming as they try to respond to growing needs for IT facilitation of so many processes in patient care delivery and healthcare operations.  Many vendors on the Healthcare Informatics 100 list, our annual compendium of the largest vendor companies in U.S. healthcare IT, are working forward intensively to meet the emerging needs in healthcare. But so are many smaller vendors, six of whom are represented in our Up and Comers stories. Please peruse both the HCI 100 compendium and enjoy our Up and Comers report, as well as Ben Rooks’s annual mergers and acquisitions analysis.

As we move forward as an industry in the development of new tools and solutions, though, we need always to keep in mind, as the NEJM study found, that it’s not just the capability of any tool or process that is of value, but also very much how it’s used. One would hope that all the smart people developing emerging solutions now in healthcare will keep end-user use processes in mind going forward, as we collectively move into the new healthcare.