A recent report from the Institute of Medicine noted that each year, 1 in 20 adults who seek outpatient care experience a diagnostic error, which can lead to serious complications or even death. The report called for delivery system, medical liability, and payment reforms to improve the problem. One such opportunity to improve health care value through cost reductions and quality improvement, as well as reduce the burden of chronic disease, is through the use of something most of us use in our daily lives: checklists.
Take, for example, a case of lower back pain. Checklists can provide physicians with ready access to clinical guidelines when incorporated directly into the physician order entry process of the electronic medical record, reinforcing long term-oriented patient care:
Mr. X, after wrestling with the question of whether the pain warranted the time and money to see a doctor, decides make an appointment because he would like to have his symptoms relieved as soon as possible. When the doctor takes a history and performs a physical, he recommends an appropriate, evidence-driven treatment plan of rest, aspirin, and physical therapy, which is reaffirmed by a checklist-driven notification in the medical record. If this regimen fails, the doctor could then consider a diagnostic imaging test or more invasive treatment. Yet, many imaging tests still take place well before the guidelines, and have been associated with 2- and 3-fold increases in surgical intervention rates. Mr. X was a little disappointed that the doctor did not order imaging initially but he understood after he and his doctor discussed why imaging was not necessary at this point.
As seen in the case of Mr. X, checklists can serve as a tool to help reinforce evidence-based decision making regarding potential diagnostic criteria. They have also been used in surgical settings for the management of avoidable complications, like those associated with central line catheters, which are tubes used to quickly administer medicines or perform tests on the heart that enter through a large vein in the neck, arm, leg, or groin. An article looking at the nearly 10,000 central line infections that took place in 2013 drew comparisons between these infections and car and airplane crashes. The author highlighted the evolution of thinking in the medical community around central line infections: while these infections were presumed unavoidable decades ago–similar to car crashes—clinicians have found that patient safety checklists can nearly eliminate these errors—as checklists have done for crashes in aviation.
Today, it’s standard procedure for pilots to routinely use checklists. Yet, this wasn’t always the case. In 1935, two pilots were testing out a new plane and crashed. Initially, it was concluded that the plane was simply too complex to fly. However, a group of pilots got together and posited that checklists could help them better navigate various complex points in the flight and avoid crashes in the future. Checklists have since been widely adopted across the aviation industry, and crashes are no longer deemed unavoidably complex, but instead are thoroughly investigated to pinpoint and learn from what went wrong.
In medicine, the same evolution is taking place. Dr. Peter Pronovost of Johns Hopkins University began investigating the inevitability of central line infections after an 18-month-old girl contracted one and died at the University. He found that the introduction of a patient safety checklist—along with efforts to educate providers about infection control practices and to foster an environment of collaborative adherence to the checklist—reduced the number of central line infections to zero in many cases. Since then, the recognition of “the checklist effect” within the medical community has spread.
Yet, the appeal of checklists has failed to gain traction in chronic disease management. This may largely be due to the fact that because many chronic diseases are significantly influenced by patients’ lifestyles and behaviors, they have been largely regarded as out of physicians’ control.
However, a new opportunity is emerging in the use of checklists in the management of longer-term chronic disease such as diabetes. Physicians at the Rio Grande Valley Accountable Care Organization (Rio Grande Valley ACO), however, are testing the limits of unavoidable outcomes in chronic disease management with a diabetes mellitus (DM) checklist. Once scrutinized for being one of the highest health care cost areas in the nation, a group of providers has begun to turn things around by changing the way they hold themselves accountable. Rio Grande Valley ACO is one of only five ACOs in the country that has agreed to take on financial risk for overspending or not achieving minimum health outcomes as a part of a national alternative payment model program. Physicians at this ACO have employed a number of delivery system reforms, including the creation and implementation of a DM checklist. The checklist prompts providers to check a series of measures, including blood sugar, pressure, and cholesterol levels, as well as to ask about aspirin use and smoking status, helping to ensure that patients with diabetes are comprehensively assessed, that any progress or issues are documented, and that patients are connected with any relevant additional resources.
After the first three years of using the DM checklist and implementing other delivery reforms, the Rio Grande Valley ACO saw significant cost savings and health improvements for its patients. The ACO generated over $20 million in savings in the first 18 months, and by the end of the second year, they had more than doubled the percentage of their patients with well-managed diabetes.
Even in the case of chronic disease management and other areas of medicine facing significant outside influence, the checklist ought not to be forgotten as an effective means of taking on complex tasks with seemingly unavoidable or uncontrollable outcomes. Checklists may not eliminate uncontrolled chronic disease, but the case of Rio Grande Valley ACO suggests that we may find that there is more within the physician’s influence than we once thought.