Why It Matters
"If you think of a person who is about to train for a marathon, their preparation happens well ahead of race time . . . Yet, historically in health care we say, 'Don’t worry about anything. Just show up on the day of surgery,' and that doesn’t make sense.
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Avoiding Checklist Fatigue: Interview with Dr. Thomas Varghese

By Frank Federico | Friday, November 1, 2013

Dr. Thomas Varghese is the Medical Director of Strong for Surgery, an initiative aimed at identifying and evaluating evidence-based practices to optimize the health of patients prior to surgery. In this interview with IHI Communications Specialist Jo Ann Endo, Dr. Varghese talks about engaging patients in “training” for surgery and how to fend off “checklist fatigue.”

Q: How was the Strong for Surgery concept first developed?

A: About 10 years ago in Washington State we started developing a platform for improvement in surgical outcomes. The first concept for this came with SCOAP, the Surgical Care Outcomes and Assessment Program. SCOAP was launched in 2003 as a physician-led volunteer collaborative which creates a surveillance and response system for surgical quality. Through SCOAP we incorporated benchmarking of evidence-based best practices, standardized orders, and utilizing checklists.

SCOAP is now active in 55 hospitals in the state of Washington. The lessons we learned helped to create CERTAIN, in response to the growing need for a health care system that is able to monitor the risks, benefits, and value of new treatments and technology to determine whether or not these interventions actually improve the quality of care and the health of patients. CERTAIN was built on the clinician and hospital relationship that created SCOAP. This type of system—a learning health care system—engages other stakeholders, including policy makers, payers, patients, and providers. One example of this was the creation of the Patient Voices Project. The Patient Voices Project has surveyed over 20,000 patients to date. Patients are asked questions like, “What was your experience with the surgery? What could have been done better at the time of your surgical intervention?” This led to the creation of a platform we can use to generate evidence and opportunities to improve care.

Strong for Surgery is an example of how you translate evidence back into practice. If you think about the journey of a patient, we first engage with them for elective surgery at the time of the clinic visit. We talk to them about the risks and benefits of their surgical intervention. Then the next time we typically see the patient is when they show up for the procedure in the hospital. What happens if you shift to engaging patients with evidenced-based best practice from the first time we see them in the clinic? That is where the concept for Strong for Surgery came about.

Q: The Strong for Surgery website states that, “A patient’s risk of negative outcomes from surgery is often both predetermined and modifiable before entering the operating room.” Would you explain how you see patient risks as “modifiable”?

A: The goals of Strong for Surgery included creating a program that could be used in any type of surgery, the ability to link to any and all existing surgical QI programs that you already have in place at a site, and the use of evidence-based best practices that can optimize patient’s health prior to elective surgical intervention. You can’t change the age of an 80-year-old patient, for example, but the question we kept asking was, “Are there opportunities or interventions that can be done to improve surgical outcomes by engaging with patients in the preoperative setting?

The evidence-based interventions we found were in the fields of nutritional optimization, smoking cessation, blood sugar control, and medication. These four areas seemed to have the most robust evidence for opportunities to help optimize patient’s health. We then elected to use the checklist as the vehicle to deliver change, mainly as the result of the experience we had in both SCOAP and CERTAIN. 

Q: Would you say that the evidence for ways to optimize outcomes was established, but it wasn’t necessarily being implemented reliably and the checklist was a way to do that?

A: Exactly. You can be aware of these practices from randomized clinical trials and from other studies, but is there a platform whereby we can ensure the right thing is being performed every single time? That is where a checklist can help. For example, we have known for decades in surgery that good nutrition is closely linked to surgical outcomes and yet improving nutritional status can be difficult without having a plan for making change. This is really the field of implementation science.

Q: Many people are familiar with the World Health Organization Safe Surgery Saves Lives Checklist and other tools used immediately prior to and during surgery. The Strong for Surgery checklists come into play long before the patient gets to the operating room. What are the advantages to this?

A: Every patient and surgical team wants the best possible outcome and we found that patients, by and large, are very eager to get engaged and be active participants in their care.

If you think of a person who is about to train for a marathon, their preparation happens well ahead of race time. They are looking at how they eat and their training schedules. They talk to other people about the marathon well ahead of race day and then race day just becomes a culmination of all those different efforts. Yet, historically in health care we say, “Don’t worry about anything. Just show up on the day of surgery,” and that doesn’t make sense.

Q: Do you find that engaging patients in their own care also helps improve their experience of care?

A: Absolutely. One example is the patient that was featured in a Wall Street Journal article that Laura Landro wrote about a year ago. He was one of my patients, Doug Rice. Doug was recovering from pneumonia and was diagnosed with lung cancer. The first time I met him in my office, he had a pack of cigarettes in his pocket and poorly-controlled blood pressure because he wasn’t always compliant with his medications. I know my surgical abilities, but I can only do so much to optimize outcomes without my patients’ help—we need an effective partnership.

So, we engaged him right then and there. Doug quit smoking, took better care of his health, and started an exercise program. He not only got through surgery successfully, but two years later, he is not just cancer free, he is living cancer free. He’s in the best shape of his life.

All surgeons know that surgeries can be opportunities to engage patients in not only getting the best surgical outcomes, but also an opportunity to improve their health and become active, functional members of society. The more actively you can get patients to participate in their own care, whether surgery or any other allied field, the better that they do. These are really transformative opportunities. 

Q: Do you ever worry about “checklist fatigue” in health care? What can be done to prevent or counteract that?

A: I do think there is checklist fatigue and I also think everyone is sick to death of the comparison between health care and the aviation industry!

The biggest myth about checklists is that they are passive instruments that will always work even if you only go through the motions. However, if a step in a checklist is not done, you should ask yourself about the barrier to delivery of that step. Is there some way to overcome that barrier? Is there an opportunity for improvement that means we should tweak that checklist? Strong for Surgery checklists are actively reviewed so that we can keep up to date with the latest literature and look for additional opportunities for improvement.

For example, it was just announced that the National Institutes of Health will be funding a huge clinical trial on whether vitamin D can prevent the onset of type 2 diabetes. We will not know the results of that for a few years. What happens if two years from now we find out that, yes, it does work? If that happens, you could make the argument that all our patients who are pre-diabetic should be on vitamin D. You need to have the change vehicle in place so you can make sure that all our patients receive that information. Making sure these checklists are active and dynamic instruments is the best mechanism to prevent checklist fatigue. Building the checklists into the culture of practice is key. 

You also need to make sure that the people using the checklist have an opportunity to voice their concerns. If you say, “You have to use this checklist and I don’t care what your opinion is,” of course that will build resentment. On the other hand, if we say, “This is a potential way to help you deliver the best outcomes for your patients and we want to listen to your opinions about whether the checklist is a good thing or not,” we change the dynamic of that conversation.

I think we should also minimize comparisons to the aviation industry. We have learned a lot from aviation, but aviation is not health care. We have started to hear that some hospital teams use the analogy of working with athletes. Could you think of your patient as a potential athlete? Athletes come in all sizes and shapes and we are trying to get them to reach their optimal performance on game day.  Can you do the same thing with your patients?

Q: The Improving Safety and Reliability for Surgical Procedures Expedition will cover best practices during all phases of the surgical process—preoperative, perioperative, and postoperative. Is there a common element to improving care for patients throughout their surgical experience?

A: The common element is teamwork. This means putting teams in place to help patients throughout their journey. You create an environment to engage patients preoperatively, take them through the surgical journey, intraoperatively, and postoperatively. It includes the entire continuum of care because it does not end in the postoperative period. The goal is to take patients through the surgical journey and get them back to being active, functional members of society again.

Q: What keeps you so passionate about your work?

A: I’m motivated by both personal experiences and having the good fortune to work with great collaborators and mentors. I grew up in the United States, but I had an opportunity to return to India and I lived there for several years before returning to the US. What I have seen throughout my life is that, no matter where they are in the world, patients seek health care in a time of need. Those who seek professions in health care do so with the goal of helping other human beings. What other field is there where you could honestly say you have helped so many people? I believe everybody in health care shares that passion.

The best outcomes in health care come from simple steps. Washing hands, keeping a clean environment, teamwork—we know these things work, yet we still struggle to implement these steps as part of our day-to-day work. If we can create these opportunities for change, I truly believe the best days are ahead of us. We are going to see better outcomes than we could ever have imagined.

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