Business process management

Defining hospital processes with simple checklists saves lives and money

With major surgery now occurring at a rate of 234 million procedures per year — one for every 25 people — and studies indicating that a significant percentage result in preventable complications and deaths, the World Health Organisation recently launched a new safety checklist for surgical teams to use in operating theatres, as part of a major drive to make surgery safer around the world. [1,2]

According to a year-long, eight-nation project (instigated by the World Health Organisation and co-sponsored by the Harvard School of Public Health), surgical teams that followed a basic cockpit-style checklist in the operating room, from discussing expected blood loss to confirming the patient's name, reduced the rate of deaths and complications by more than a third. 

And the principle is simple — capture every activity, role and decision that can be made from the beginning to end of a surgical procedure and publish it as a checklist. We know that the human brain can't remember everything, so it's best to focus on the complicated challenges and leave the simple reminders to a standard form.

In the fast moving world of surgery we are seeing newer and better procedures being delivered all the time. This presents an issue for an already over-burdened system as surgeons vary in experience and skill sets — and many spend time working in more than one institution. This ultimately leads to a position where some skills are not being kept up to date as certain hospitals do not have the constant throughput of patients due to the financial pressures on each trust.

Cockpit style checklists

The first point listed in the World Health Organisation Declaration on Patient Safety, made in Jakarta in 2007, states that “no patients should suffer preventable harm”. To honour those that have died, those left disabled, our loved ones today and those yet to be born, we must strive to achieve this, and that is where surgery checklists can make a significant difference.

A checklist like those used in aeroplane cockpits relieves much of the organisational pressures on both surgeons and other staff as they are uniform across operation procedure and hospital structure.

As an indication, below is a list is common-sense questions that need to be asked in the surgery room before the surgery commences:

1. Has every person in the room introduced themselves by name and role?
2. Has the surgeon (or chief surgeon) verbally confirmed the patient name, site of operation, and title of procedure?
3. Has the anaesthetist verbally confirmed the patient name, site of operation, title of procedure and name of anaesthetic?
4. Has the nurse verbally confirmed the patient name, site of operation, and title of procedure?
5. Has the surgeon confirmed what are the critical steps of the procedure?
6. Has the surgeon confirmed the operation duration?
7. Has the surgeon confirmed his level of anticipated blood loss?
8. Has the anaesthetist declared if there are any patient specific concerns?
9. Has the nurse indicated that sterility has been achieved?
10. Has the nurse confirmed that there are no equipment issues or concerns?
11. Is all essential imaging on display?

This simple list is a set of questions that are applicable to every surgery, but there are so many questions that are critical, but only applicable to a few niche surgeries.

Take, for instance, the creation of a simple five-step checklist in Johns Hopkins Medical School in 2006 by the anaesthesiologist Peter Pronovost after he discovered that there were repeated flaws in his area of expertise. The pre-insertion checklist he had was:

1. wash hands;
2. don surgical hat, gloves and gown;
3. clean insertion site;
4. drape the patient; and
5. apply sterile dressing .

The results of this were measured and compared to pre checklist operations — and the results were staggering. The infection rate “pre checklist” was 4%; it was 0% where the checklist was used. The checklist saved 1500 lives and the resultant financial savings reached over US$200 million. [3]

World Health Organisation study

In the recent study by the World Health Organisation, it was revealed that the 234 million surgeries account for approximately 164 million additional years lived by humankind.

Meanwhile, the rate of deaths that occur in surgical patients account for between four and eight in every 1000 patients and the rate of complications experienced after surgery accounts for between three and 17 patients in every 100.

Only a small percentage of inpatient deaths are avoidable — but approximately 50% of all after-surgery complications are avoidable. With the annual cost of dealing with post surgery complications believed to be up to US$25 billion per annum, there is a significant opportunity to save much needed financial resources, while also saving lives.

The study was conducted between October 2007 and September 2008. Eight hospitals were used as a sample, based around the world and representing a disparate and diverse patient population.

The study was based on observational data to review the phenomena of a checklist in a surgery environment. Original records were reviewed and data was collected across a patient population of 3,733 people.

The criteria used was that all should be above 16 years of age, that they were non-cardiac patients, an untainted dataset, with the patients used in this measurement for a sequentially admitted patient set from each institution.

The actual study itself covered a set of 3,955 patients from across the same hospital group. Again they were over 16, non-cardiac and sequentially admitted. The patients were monitored to discharge or for 30 days — whichever happened first. The target was 500 patients per hospital site.

This World Health Organisation study was carried out in major hospitals with worldwide reputations. It is considered that the results would be more profound when applied to the third world. In central Africa alone it is estimated that 1 out of every 150 patients die just at the anaesthetic stage of a surgery, compared to 1 in about 200,000 in the USA.

Study results

In the one-year pilot study involving 7,600 patients, the hospitals saw the rate of serious complications fall from 11% to 7%. Inpatient deaths declined by more than 40% overall, with the most drastic reductions occurring in hospitals with fewer resources.

The following statistical results came from the study overall. Note that there is no evidence of any checklist being used in any institution for Group A — and Group B had the checklist used during their treatment programme.

• Group A represents the pre-study 3733 patients.
  11 out of 100 patient’s rate of post surgery complication;
  15 out of 1000 patient’s mortality rate.
• Group B represents the 2955 patients treated during the study.
  7 out of 100 patient’s rate of post surgery complications;
  8 out of 1000 patient’s mortality rate.
• Required 1 out of 1000 patient’s lower rate of surgery wound infection
  47 out of 1000 patient’s lower rate of secondary unplanned reoperation

An additional result of using the surgery checklist was a near 100% adherence to the hospital’s administrative excellence requirements — a result which would have a profound effect on each hospital’s financial position.

Putting into practice

What this low-cost, low-tech check list system has really shown is that an automated system could have enormously positive financial implications.  Just in the UK, if every operating room adopted a business process management system to create a surgical checklist, the NHS could save up to £2 billion a year on the costs of treating avoidable complications.

The Institute for Healthcare Improvement, a US-based process excellence organisation, has issued advice to its member hospitals (two thirds of all hospitals in the USA), to implement a patient checklist to effect its “saving 5 million lives” campaign.

Barak Obama has just told the Senate to come up with $100m in savings every 90 days — recognising that there is a need to cut costs. He also appointed Jeff Zeits as the Chief Performance Officer in the USA, as he recognises that the country needs a “Best Practice” leader.

Obama’s administration has even appointed a Chief Technology Officer in the USA in the form of Neesh Chopra, recognising that they need technology to help them get through the mess the world is in.

With this in mind, there is no doubt that, closer to home, the NHS needs a best-practice library too. However, just because you stand up and say that the country and all your institutions (including healthcare) need a best-practice library for process innovation and value delivery, does not mean that you can just create one overnight. Or does it?

There are several issues with creating best-practice libraries across multiple organisations: justifying cost and making the approach self-funding; quick assembly; and managing a multitude of versions without too much complexity.

A viable solution would have to automatically import and catalogue any process models that already exist across the estate (no matter what technology they are in), enable a full business architecture for all of these models so they can be easily managed by anyone with a decent school education, and facilitate automation in any technology that already exists in the base.

Technology provides a valuable advantage, but if you are going to use it, you have to do so in a way that hurts no one — displaces nothing, and improves everything.

It is possible to create a business process architecture that requires no rebuilding or coding. One point and click is all that’s required, so maybe it’s time we embraced this "change nothing, use everything I already have" technology for a safer, more efficient health service.

Alan Crean, CEO, ProcessMaster.

References

1. The WHO Safe Surgery Saves Lives website
www.who.int/patientsafety/safesurgery/en/

2. Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine, Volume 360:491-499 January 29, 2009 Number 5.
http://content.nejm.org/cgi/content/full/NEJMsa0810119

3. Harvard School of Public Health news: A simple checklist that saves lives. www.hsph.harvard.edu/news/hphr/fall-2008/fall08checklist.html

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