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Advancing the Use of Checklists for Evaluating


Performance in Health Care

Article in Academic medicine: journal of the Association of American Medical Colleges May 2014
Impact Factor: 2.93 DOI: 10.1097/ACM.0000000000000285 Source: PubMed

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Michael A Rosen Peter J Pronovost


Johns Hopkins Medicine Johns Hopkins Medicine
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Commentary

Advancing the Use of Checklists for


Evaluating Performance in Health Care
Michael A. Rosen, PhD, and Peter J. Pronovost, MD, PhD

Abstract
Patients frequently do not receive performance, which is described in this that evaluate technically specified and
recommended therapies because issue of Academic Medicine. adaptive performance are needed
performance expectations are often because some aspects of clinical
In this commentary, the authors
unclear. Clinical guidelines provide offer several points to consider as performance cannot be captured on a
exhaustive details and recommendations, checklists become more prevalent in checklist. Fourth, checklists provide an
but this information is not formatted in medical education and clinical practice. opportunity to evaluate and improve an
a way that supports decision making or First, culture is a much larger part individuals performance concurrently
bedside translation of therapies. When of the equation than the checklist; with the context in which it is delivered.
performance expectations are unclear, it is understanding what all stakeholders A tighter connection between education
difficult for clinicians to assess their own expect to gain will help engage checklist and training activities and process
or others competence. Checklists offer use. Second, the construction, validation, improvement strategies will accelerate
hope because they codify interventions, and maintenance of checklist evaluation improvements in safety and quality.
remove ambiguity, and increase reliability tools is labor intensive, requiring Schmutz and colleagues have provided
of care processes. Schmutz and colleagues innovative dissemination approaches advancements in performance evaluation
developed a robust methodology to to ensure maximum access and use of that will help health care achieve higher-
create a checklist for evaluating clinical checklists. Third, integrated systems quality and safer care.

Editors Note: This is a commentary on Schmutz yet too often lack actionable guidance to bloodstream infection,3 to surgical care,4
J, Eppich WJ, Hoffmann F, Heimberg E, Manser translate care at the bedside. Guidelines and ventilator-associated pneumonia.5
T. Five steps to develop checklists for evaluating do not prioritize the often-exhaustive Additionally, evidence shows they have
clinical performance: An integrative approach.
number of decisions and actions, and led to reduced mortality.6 However, the
Acad Med. 2014;89: XXXXXX.
they are usually ambiguous. Further, these process for developing each of these
guidelines do not recommend therapies checklists has varied significantly. Schmutz
when the evidence is incomplete, even and colleagues7 have developed a robust
P atients frequently do not receive
though a clinician must prescribe some
therapy. How guidelines are laid out
methodology for creating a checklist that
evaluates clinical performance. Their
recommended therapies because (i.e., formatted) violates the principles contribution is important and greatly
performance expectations are often of usability by offering long lists of steps needed. Below, we offer some points
unclear. Current practices for summarizing with conditional probabilities that do not to consider as checklists become more
evidence into clinical guidelines support decision making, particularly prevalent in medical education and clinical
undoubtedly contribute to this problem. when clinicians are under time pressures practice.
Clinical guidelines are usually scholarly and other stressors.1 Further, unclear
performance expectations, along with Our experience when implementing
Dr. Rosen is assistant professor, Armstrong general self-assessment biases, likely checklists in clinical practice indicates
Institute for Patient Safety and Quality, Johns
Hopkins Medicine, and assistant professor, underlie the discrepancies found between that culture matters. The degree to
Department of Anesthesiology and Critical Care external observations of physician which a checklist influences processes
Medicine, Johns Hopkins University, Baltimore, competence and physicians self-assessment of care and outcomes depends on the
Maryland.
of their competence.2 attitudes and behaviors of those using
Dr. Pronovost is senior vice president of the checklist.4,8 Checklists are usedand
patient safety and quality and director, Armstrong
Checklists offer hope. Well-constructed usefulonly if staff believe they will truly
Institute for Patient Safety and Quality, Johns
Hopkins Medicine, and professor, Department checklists codify interventions, remove change care and improve the outcome. To
of Anesthesiology and Critical Care Medicine, ambiguity, and increase the reliability of illustrate, simply mandating the use of a
Department of Surgery, and Department of Health care processes. In educational settings, surgical checklist in 133 surgical hospitals
Policy and Management, Johns Hopkins University,
Baltimore, Maryland. checklists can serve not only as evaluation in Ontario did not improve outcomes.9
tools but also as a common and easy means The transformation of culture from I
Correspondence should be addressed to Dr.
Pronovost, 750 E. Pratt St., 15th Floor, Baltimore,
of communicating a set of expectations cant to I can is the larger part of the
MD 21202; telephone: (410) 502-6127; e-mail: regarding effective performance. Checklists equation, and checklists are but a small
ppronovo@jhmi.edu. have translated evidence-based and fraction of this equation.
other best practices to the bedside for a
Acad Med. 2014;89:0000.
First published online wide range of complications and care Checklists used in educational assess
doi: 10.1097/ACM.0000000000000285 processes, from central-line-associated ments should expect similar effects. A

Academic Medicine, Vol. 89, No. 7 / July 2014 1

Copyright by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Commentary

persons motivation to learn and the defined, expertise involves fitting or health care are to partner with patients
expected utility of the learning experience adapting the performance capacities and their loved ones to eliminate harm, to
will influence the learning outcomes. of an individual to the nature of the optimize outcomes and experience, and
Understanding what educators and tasks within a work domain.11 Medical to reduce wasted resources and costs. To
learners expect to gain from evaluation education adapts an individuals abilities achieve these goals, clinicians must excel in
checklists will be key when designing and performance processes by developing technical work and teamwork. They must
strategies that engage stakeholders in in him or her a large, interconnected be supported by leaders and a positive
checklist use. Ultimately, these tools knowledge base and refining his or her culture, and they must have reliable access
should be introduced with appropriate psychomotor and procedural skills. to well-designed technologies, to helpful
engagement and cultural change However, the other side of the expertise tools and clear work processes, to effective
interventions to ensure buy-in. equationthe nature of the task and learning and development opportunities,
the often-uncertain demands it places and to meaningful and timely feedback on
The process to develop checklists that on professionalsis equally important. their performance.
Schmutz and colleagues articulated is clear, Redesigning tasks to eliminate needless
Acknowledgments: The authors thank Christine G.
reproducible, and robust. It is also labor complexity and ambiguity can decrease Holzmueller for editing the manuscript.
intensive, particularly when you consider the learning curve for clinicians. For
the potential number of components example, most improvement efforts focus Funding/Support: None reported.
required to evaluate clinical performance on one type of harm, but patients are at
Other disclosures: Dr. Pronovost reports receiving
for a condition. Take, for example, the risk for multiple harms. Each harm type grant or contract support from the Agency for
septic shock checklist they developed; there needs a checklist; each checklist needs Healthcare Research and Quality (AHRQ), the
are 33 evaluation items for this one clinical multiple items; and some of these items Gordon and Betty Moore Foundation (research
scenario. To yield maximum benefit, the may need to be performed multiple times related to patient safety and quality of care),
health care community must decide who a day. For example, a patient in intensive the National Institutes of Health (acute lung
injury research), and the American Medical
will develop these checklists and how care is at risk for over a dozen different
Association (research related to improving blood
they will be shared. Perhaps professional harms and would need approximately pressure control); honoraria from various health
societies, accrediting organizations, or 200 interventions every day to prevent care organizations for speaking on quality and
large health systems could build, maintain, all of these harms. This would require patient safety (the Leigh Bureau manages these
and share checklists. Ideally, there should an unwieldy checklist, relying on the engagements); book royalties from the Penguin
be one open-source repository, like the heroism of clinicians to manage it, when Group; stock and fees to serve as a director for
Cantel Medical; and fees to be a strategic advisor
EQUATOR Network,10 which maintains it would be more reliable to design safer
to the Gordon and Betty Moore Foundation.
an electronic library of guidelines and systems.12 Many of the items on the septic Dr. Pronovost is a founder of Patient Doctor
checklists for reporting different types of shock checklist could be automated if Technologies, a startup company that seeks to
research. The decisions about development, the electronic medical record was linked enhance the partnership between patients and
maintenance, and dissemination of to other devices and if clinicians were clinicians with an application called Doctella. Dr.
checklists will greatly affect the value these supported with analytics. In this way, the Rosen reports receiving funding from AHRQ,
the Gordon and Betty Moore Foundation, VHA
tools have for medical education. effectiveness and efficiency of educational
Inc.s Center for Applied Healthcare Studies, and
processes would be tied to the quality Gradian Health Systems, LLC (all research related
Recognizing that much of health care is and of the work system that is in place to to patient safety and quality of care).
will likely remain unspecified, or at least manage, in this case, sepsis.
underspecified, is also of great importance. Ethical approval: Reported as not applicable.
This is true even with diseases like sepsis Checklist developers should examine
for which the protocols have higher-than- the work they want to evaluate within References
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2 Academic Medicine, Vol. 89, No. 7 / July 2014

Copyright by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Commentary

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Academic Medicine, Vol. 89, No. 7 / July 2014 3

Copyright by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.

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