Monday, 25 March 2013

Checklists in Healthcare - not easy

Checklists in healthcare is not the same as in other industries and is not easy

Checklists are the hot and happening thing in healthcare today, it is to improve the safety and quality of care delivery.

The WHO safe surgery checklist was evolved after good research showed its benefits across the world in reducing deaths and complications. It is a simple one page document. Prof Atul Gawande who pioneered this effort has described the background using construction, airline and other industries as examples.

The checklists as used in industry and by some eminent healthcare providers places seem to be different from the kind of checklists that we do, including the WHO surgical checklist.

In industry checklists are used to define what precisely the work is, in what order the work has to be done – the people who do the work look at it, do the work as it says (execute the work) and tick the box (checklist) to indicate that the work has been done according to the work specification. Often that is the main documentation to record the completion of the work. Here is an example of a construction checklist I have no special knowledge or affinity to this particular checklist, it simply comes high up on a google search. I encourage you to look at the detail with which the work is specified. I am reliably informed that many construction checklists are even more detailed and project specific. Prof Gawande's book points that in construction work, checklists are done for every component with about 16 different specialities being involved.

In aviation the checklist is aircraft specific. Here is a checklist for a Piper PA28 which is a very small basic plane which is often used to train pilots and it runs to 11 sheets. It is both precise and detailed – it tells you what degree and what RPM to set and so on. The checklist is read out loud and followed every time. It is never 'tick'/'check' marked, never signed and never filed anywhere.

The ‘check’ in industry e.g. construction – is to indicate the tick, cross, ‘check mark’ other marking in the document – a one step process that documents that the defined work is done. In aviation it is a document that is followed but not filed.

The ‘check’ as used by us in healthcare in general and UK in particular – seems to indicate that we need to check (as in inspect/confirm/verify the correctness/hold back/restrain/stop); by the way this is the dictionary definition. This is a two step process – do the work document it and then confirm in a different document that the work is done. The WHO checklist is an additional document – i.e. the antibiotic is ordered and given elsewhere in the process, documented elsewhere and these are confirmed in the checklist; the checklist becomes a supplementary document. This also gains medicolegal importance and adds the bulk of the medical notes. The WHO checklist is allowed to be changed but is often not and where they change it, is still organisation specific and not specialty specific (and never ever patient specific).

When the industry and aviation use detailed and project/plane specific checklists why did healthcare choose to use a single page, generic, general checklist? Clinical medicine and healthcare delivery is obviously more complex than industry or aviation, yet the checklist is a simple single page. The beauty of the WHO checklist lies in its simplicity. It has proven itself under research conditions across the world. However, it is valid to ask whether it is proving itself in real time practice in the NHS. The evidence is not clear yet if there has been a year on year decrease in the incidence of various problems the WHO checklist is supposed to address. The consensus is that the checklist helps.

My personal view is that a one size fits all checklist that the WHO Surgical Checklist is will see its own limitation in time; after all there was a checklist even prior to the WHO one. Procedure specific checklists are the needed urgently - a good example is the matching Michigan checklist for the insertion of central lines. For surgical patients, each patient/procedure should have a customised detailed and specific checklist with an obligation for the surgeon, anaesthetist and their teams to modify the checklist prior to surgery to a patient specific checklist. This empowers the local team members and the process becomes directly relevant to the specific procedure that a specific patient is having on a given day. That is when the power of the checklist seen by Atul Gawande in aviation, construction and finance can truly be realised in healthcare.

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Sunday, 17 March 2013

A day in court

Attended Leeds Crown Court recently. First time in court as a professional taking the stand to provide witness evidence for defence (no not as expert witness).

Standing in the cold, very windy, wet pavement fully drenched in a queue to go through security to enter the court building was irritating and unpleasant start. Contrast that with the NHS, we do not keep our customers/patients/visitors on the pavement wet and soaking before they get into the hospital.

I believe there was a change of judges and our judge was given the case only at 4.30 pm on the previous day. Well, well, not so different from the NHS.

Then there was the matter of the court room itself. The judge informed us that the room was that of a criminal court whereas our case was a civil case. With some humour he added that we would find all the chairs were bolted to the floor as some people in criminal courts tended to use the chairs for purposes other than sitting. There was another attempt at humour about bowels which in my personal view did not really click as the case involved a patient who had severe complications on that subject. This would have been seen as poor taste in the NHS and it would be well possible that GMC or other authorities might take a dim view of this, if doctors were to joke about this.

Barristers, though masters in their work, seemed to show significant stress, one with furrowed brows and the other with clenched fingers to the point of blanching. It is not easy for the barristers as they stop between sentences to allow the judge to type his notes. I was particularly impressed with the claimant's barrister's knowledge of the relevant anatomy, pathology and their applications to the surgical technique. They still wear the funny wigs.

I noticed about 6 or 7 large lever arch files with identical individual copies for the judge, barristers, witness and solicitors. At least 4 large document transport boxes for the defence. Two large size luggage cases, many stroller type luggage cases, many 'pilot' boxes. If you hated the NHS paperwork you may want to change your mind and be thankful that you are not a lawyer.

It is very difficult especially for lay witnesses when the 'do you recall' question is put to them only then to be countered by 'it is not suggested in the notes' response. An expert witness was shaking his head in the yes/no directions as the witnesses were speaking – wonder if that would influence the witness responses.

If you thought NHS was hierarchy bound, think again. The court had highly defined places on who will sit where in strict order of rank with the bowing and formality. Apparently barristers who did not take toilet breaks at the right time have even gone into urinary retention. A colleague made an observation that the judges and barristers did not share the same cafeteria as the witnesses and visitors whereas in the NHS doctors shared the same cafeteria as visitors. I suppose the medical professional equivalent of the much valued water cooler conversations cannot happen due to concerns of potential confidentiality breaches; a lost opportunity.

The judge and lawyers were very polite, considerate and respectful to the doctors in room. The judge noticed that senior doctors were sitting on very uncomfortable observer benches and moved them to jury box chairs (there was obviously no jury in this case) which were far more comfortable.

In my personal view the overall customer experience is better in the NHS when compared to my one day at court but obviously you would expect me to say that. In terms of what goes on insider the court room, one clinical colleague called it daunting, another called it long drawn out and boring. Personally I found the triangulation between the witness's aim (to speak the truth, nothing but the truth and the whole truth), the lawyers aim (to get to that part of the truth which will support their client's case) and the judges aim (to constantly probe which way the balance tilted) confusing and demanding; this became particularly acute while in the witness stand.

What stuck to my mind was the judge saying in mild frustration something like 'in cases involving patient care the doctors can't agree on anything and then the lawyers can't agree on anything' and carrying on with a wry smile. Shows the importance of agreeing as the starting point of good clinical care, which incidentally is the best means of avoiding the courts in the first place.

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PS: The inability of doctors to agree is part of Clinical Wrongology. An attempt is made to resolve it by asking my 4 fundamental questions

Monday, 11 March 2013

'Nakamura invented the light bulb'

Would Nakamura invented the light bulb if he was working in the NHS?

Nakamura invented the light bulb, that is what we might probably say one day, that Nakamura invented the light bulb or to put it correctly that Nakamura re-invented the light bulb. Shuji Nakamura's inspiring story has been told before but here is an ultra-short version of it

Nakamura gets a masters from a relatively small university in a small city in Japan, goes off to work in a small company in a lab competes against the big companies, discovers many right things and makes products that would not sell.

Times get difficult, his department shrinks. He goes to his boss and wants to make a product that the big boys have tried to make and failed; with his record, he gets turned down. He goes to his boss's boss and gets some support to make it, despite his record of making nothing that sold, his company chairman gives him money, $2mil actually and he reinvents the light bulb. Well, he actually gets the blue component of the LED to work and the rest is history.

What is interesting is that Nakamura was a non-PhD working in the industry as a lab scientist who then gets a doctorate from his local university and within 5 years is head hunted by University of California and becomes a professor.

Nakamuras in NHS?

Let us imagine a scenario of a doctor who becomes a consultant in a DGH in the NHS and wants to do something that the big boys tried and failed.Then the DGH consultant fails as well, fails repeatedly - what are the chances that he will not be performance managed out of his/her activity and driven to the end of his wits.

What are the chances that the medical director or CD will be over-ruled by the CEO or Chairman and a doctor provided funding to carry on despite a record of 'failure'? What are the chances that even after this doctor discovered something interesting a big place will head hunt and make him/her an 'academic'? In fact he/she should be grateful if the GMC and the rest of the regulation did not land on him/her and crushed him/her out of existence.

Getting real

Now a lot of you are going to say that reinventing a light bulb while surely profound is unlikely to involve any damage to real human beings. You might say that any lurking Nakamuras in the NHS if supported could end up hurting patients. Good logical argument. Is that what is really hurting patients? Probably not. It is not any innovation by enthusiastic people that harms patients, it is the bureaucratic nay sayers who use the language of clinical governance and risk yet know very little about process capabilities, refuse to learn shared baselines, practice unimaginatively poor leadership who perpetuate harm in healthcare. They refuse to fix the system instead try to 'fix' the people in the system. Of course the medical profession does not do itself any favours by its ego, jealousy and macho attitude which will aim to shoot down anything that arises outside its hierarchical constraints by treating them as bad apples and recommending the use of evidence the origins of which  can probably attributed to the Abilene paradox.

In healthcare especially in the NHS it is pretty much impossible these days to take an extra breath without CD, CG, R&D, GCP, LREC, NREC, NICE, and every other alphabet in the soup wanting to spoil it for you, while claiming to support you. It is when people who are typically NHS managers and every other hierarchical bureaucrat stops behaving like researchers and most doctors who are not researchers begin to look at operational evidence as a valid method of creating a new practices, innovation and improvement that healthcare will be truly successful.

Allowing and managing 'Nakamuras' in healthcare is not easy but will be rewarding; eliminating the healthcare 'Nakamuras' will allow the managers to sleep peacefully but might push true healthcare innovation into a coma.

If you know of any 'Nakamuras' in the NHS please let me know by leaving a comment below.

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Links & reference
The dream of the blue laser diode
Time magazine short feature on Nakamura,9171,1604891,00.html

Monday, 4 March 2013

Preventative Health Checks: Just because you could, doesn’t mean you should

“Just because you could, doesn’t mean you should” was a “mantra” given to me by one of my family medicine teachers and I have come to appreciate its wisdom over years. Over the last decade as a practicing clinician, I have come to realize the limitations of modern medicine, started seeing patients as people with different goals and values and have been trying to equip myself with knowledge of patient centered healthcare.

Preventive Health checks in India have gained popularity in last decade or two. As a practicing physician in urban India, I come across patients who have been getting the “health checks” year after year. A huge number of patients are “self-referred” and get annual check-ups in hospitals and diagnostic centers. A good number of these check-ups are also offered through the employers and I have seen patients in their early 20s getting routine health checks as well.

I looked up the health checks offered and they come in various forms. I asked some of my patients to look at these packages and tell me which one they thought was the best package for them. Some picked the most expensive package; some went by the keywords like “full body check-up” or “advanced” check-up. Very rarely do I come across patients who understand exactly the tests they have been getting and the appropriateness of these tests. While there are some hospitals/centers that have put some thought in designing the “health package”, a majority of them take the “shot-gun” approach of offering multiple tests that all the patients undertaking these packages may not necessarily need. Some examples are routine ECGs/ECHO in young adults, pap smears in women older than 65 years, routine abdominal ultrasounds in young adults etc. Some even go to the extent of causing potential harm, for example, cancer biomarkers for several types of cancer- many of them have been studied to cause more harm than good. Also, In patients at little to low risk for heart disease, an electrocardiogram or stress testing can actually lead to harm. However, they seemed to be a common component of majority of health checks.

A recent analysis from Cochrane review concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased.” Due to missing or unreliable data, the authors could not estimate costs, harms, or the use of follow-up medications and testing as the result of screening. Although all the studies used for this review are from western context, I think this study brings out a whole new perspective on how we should look at the preventive health care sector in India.

I am a family physician who strongly believes that “prevention is better than cure”. I am a “prevention enthusiast” who believes preventive measures done right can not only add years to your life but also improve the quality of life. As Dr. John Mandrola says, “The four legs of the wellness table are good food, good movement, good sleep and good attitude. Doctors can’t do this for people, neither can screening tests nor pills.” Moreover, in most of the western countries, the preventive health care recommendations are offered and to an extent “tailored” to meet the patient’s risks as opposed to Indian setting where one can walk into any center offering health checks and get a whole host of tests done. So, if there is strong evidence showing general health checks do not decrease the risk of deaths from cardiovascular events or cancer, why are they so popular? Two of major reasons in my opinion are lack of patient engagement and education related to preventive care on part of family physicians and a “belief” held by majority patients that these health checks will make them healthy.

There has been extensive discussion following the Cochrane review and there are few things that one can argue upon as being beneficial. For example, Checkups can be beneficial in getting people to think about their health. Also, if the health check-up is being offered by your family physician, there is value in getting tailored approach to your preventive health check. There is also evidence for some meaningful screening approaches, such as screening obese patients for diabetes risk, patients with a family history of disease etc.

I guess, the bigger question, to ask is not whether preventive health checks are needed but how should they be designed so that they truly impact the lives of majority of people undertaking these health checks.

Dr. Danielle Ofri writes, “a detailed conversation is much more likely to uncover lurking medical issues than the physical exam or blood tests”. Even in the hospital setting, the advantage of detailed history and exam supersedes any combination of labs and imaging. You can see the results here and here. In my experience, however, these are two things most neglected and many a time skipped in most of the health checks being conducted.

Now, Let’s talk about the preventive measures that are backed by strong evidence but don’t make it to the preventive health checks: Counseling against tobacco and alcohol use, mental health screening for problems like depression and anxiety that are increasing in great numbers, obesity, infectious diseases (TB/HIV etc) and certain adult vaccinations etc.

So, Can we design a health check that can steer a patient towards wellness and just not give a “sickness free” check? Can we have a healthcare innovation from India that is disruptive enough to make a business case for “prevention” without relying on battery of diagnostic tests?

© Dr Jaya Bajaj
Guest Blogger

Dr. Jaya Bajaj is American Board of Family Medicine (ABFM) certified Family Physician with strong clinical and research background. She is a strong proponent and practitioner of patient-centric, evidence-based medical practice.

She graduated from ETSU Family Medicine Program, holds MPH in Biostatistics from University of South Carolina, Columbia, SC, and MBBS from Nagpur University. She also has completed Executive General Management Programme at Indian Institute of Management Bangalore.

She is passionate about improving patient care in India and believes technology can play a key role in bridging the knowledge gap. Dr Bajaj is the founder of HealthRadii, a healthcare networking site.

(Dr Bajaj's declaration: I am a family physician and this article only addresses preventive healthcare issues in adults.)