A Checklist-Based Intervention to Improve Surgical Outcomes in Michigan

Abstract

Importance Previous studies of checklist-based quality improvement interventions have reported mixed results. Objective To evaluate whether implementation of a checklist-based quality improvement intervention, Keystone Surgery, was associated with improved outcomes in patients undergoing general surgery in large statewide population. Design, Setting and Exposure Retrospective longitudinal study examining surgical outcomes in Michigan patients using Michigan Surgical Quality Collaborative clinical registry data from the years 2006–2010 (n=64,891 patients in 29 hospitals). Multivariable logistic regression and difference-in-differences analytic approaches were used to evaluate whether Keystone Surgery program implementation was associated with improved surgical outcomes following general surgery procedures, apart from existing temporal trends toward improved outcomes during the study period. Main Outcome Measures Risk-adjusted rates of superficial surgical site infection, wound complications, any complication, and 30-day mortality. Results Implementation of Keystone Surgery in participating centers (n=14 hospitals) was not associated with improvements in surgical outcomes during the study period. Adjusted rates of superficial surgical site infection (3.2 vs. 3.2%, p=0.91), wound complications (5.9 vs. 6.5%, p=0.30), any complication (12.4 vs. 13.2%, p=0.26), and 30-day mortality (2.1 vs. 1.9%, p=0.32) at participating hospitals were similar before and after implementation. Difference-in-differences analysis accounting for trends in non-participating centers (n=15 hospitals), and sensitivity analysis excluding patients receiving surgery in the first 6- or 12-months after program implementation yielded similar results. Conclusions and Relevance Implementation of a checklist-based quality improvement intervention did not impact rates of adverse surgical outcomes among patients undergoing general surgery in participating Michigan hospitals. Additional research is needed to understand why this program was not successful prior to further dissemination and implementation of this model to other populations.

Analysis of Development in Patient Safety Over the Last 15 Years

“…The power of peer communities comes from peer learning and tapping into intrinsic motivation among professionals (Dixon-Woods, Leslie, Tarrant, & Bion, 2013;Gould et al, 2015). This concept has not reaped rewards in others (Reames, Krell, Campbell Jr., & Dimick, 2015;Urbach, Govindarajan, Saskin, Wilton, & Baxter, 2014). To achieve success, some project-based initiatives, such as the CLABSI checklist, required major changes in teamwork and culture (Pronovost et al, 2006).…”

Perioperative interventions and post‐operative outcomes

“…In contrast, researchers could not affect surgical outcome after introducing a checklist based quality program in a study including >64.000 patients from 14 participating centres in Michigan, USA [143]. The authors suspected a failure since their program was implemented in the operation room; in a heterogeneous group involving complex procedures and frequently changing personnel.…”

“…They suspect that such a complex environment is less susceptible for change. This may have complicated their successful implementation across the whole organisation [143].…”

The Checklist: Recognize Limits, but Harness Its Power

“…37 In 2015, a dual disappointment was reported when a different research group in Michigan, using a surgical checklist modeled after that of Pronovost, found no improvements in infections, complications, or mortality among nearly 65 000 general surgery patients in 29 hospitals. 38 …”