Checklist Introduction Research Articles

Validated checklist for assessing communication skills in undergraduate medical students: bridging the gap for effective doctor-patient interactions.

Communication skills are fundamental in healthcare, but assessing them among medical students presents challenges. In the Indian context, the lack of a specific assessment tool further compounds the issue. Thus this study aimed to develop and validate an observation-based communication skills checklist tailored to Phase I Bachelor of Medicine and Bachelor of Surgery (MBBS) students. The checklist was developed using both inductive and deductive approaches and underwent rigorous testing to ensure its reliability and validity. After piloting, the finalized version was administered to 84 Phase I MBBS students. Results indicated a critical content validity ratio of 0.78, face validity of 0.80, and an impressive Cronbach's alpha of 0.91, indicating good internal consistency and reliability of the checklist. The students scored over 80% in all checklist domains, except for empathy (73%) and support (74%), highlighting areas for potential improvement. Nonetheless, about 75% of students expressed satisfaction with the checklist's communication skills assessment. The feedback from faculty members was positive, as they found the checklist was easy to use, quick, and effective for evaluating communication skills. Consequently, the checklist's introduction has been well received by both students and faculty. In conclusion, the developed checklist proves to be an effective and valid instrument for assessing communication skills in Phase I MBBS students. By integrating this tool into observed station clinical examinations, medical educators can comprehensively evaluate students' communication behaviors. Moreover, the checklist serves as a valuable resource for bridging the gap between theoretical knowledge and practical application, enabling future physicians to excel in doctor-patient interactions, a crucial aspect of patient-centered care.NEW & NOTEWORTHY This article presents a highly unique and novel approach by introducing a structured checklist for communication skill assessment in medical students. Its rigorous validation process ensures reliability and effectiveness, while its adaptation to sociocultural norms highlights its relevance and applicability. The user-friendly design with a single-page layout and dichotomous scale further enhances its practicality in objective structured clinical examinations. The developed checklist equips educators with a valuable resource to assess and improve students' communication abilities.

1016 A Quality Improvement Project Addressing the Healthcare Dimension of Effectiveness in a Large Cardiothoracic Surgery Department by Ensuring the Contents of the Current Emergency Surgical Chest Drain Boxes Are Correctly Stocked Through Additional Rigorous Checks by June 2022, by Using the Model for Improvement Approach

Abstract Background Emergency chest drain insertion on cardiothoracic wards is frequent occurrence due to complications such as pneumothorax. The emergency insertion requires the immediate availability of a significant amount of sterile equipment. A box containing all the equipment on the ward was checked and restocked by the ward nursing staff, however, data suggested missing equipment was prevalent. This has implications for clinical effectiveness, timely intervention, and ultimately patient safety. Aim This project establishes the frequency of missing items and aims to reduce this frequency through more rigorous checks of the emergency chest drain box contents. Method Retrospective analysis of the box contents was performed over 3 months to establish baseline data. Thoracic surgery doctors completed a questionnaire, before and after the changes, about their experiences with the emergency chest drain boxes and missing items. A revised stock checklist was produced in collaboration with the project champion, the audit lead for thoracic surgery, and the procedural document team. The checklist introduction used transformational leadership. Subsequent completeness data was collected, in addition to a follow-up questionnaire. Results There was an 81% reduction in the 3-month average number of reported missing items following implementation; and a 92% increase in perceived confidence that the box will be correctly stocked. Conclusions An 81% reduction using two Plan Do Study Act (PDSA) cycles represents an improvement in effectiveness. There are plans to implement a single-use, pre-packed emergency chest drains insertion pack. The ongoing third PDSA cycle introduces the single-use pack, ongoing improvement will be demonstrated with repeat audits.

Is pregnancy status being assessed within women's secure services?

AimsTo establish rates of pregnancy testing on admission of women within a blended secure service.BackgroundWomen with psychiatric illness are known to be at increased risk of pregnancy, often due to engagement in risky sexual behaviours such as having a higher numbers of sexual partners and engaging in sexual activity whilst under the influence of drugs or alcohol. Awareness of pregnancy at the point of admission to psychiatric hospital would inform ongoing care plans to manage the pregnancy in the safest, least restrictive environment and inform future prescribing decisions, to minimise the risk of teratogenicity associated with some psychotropic medications. Ardenleigh in Birmingham is a blended female secure unit. No pregnancy screening guidelines for this population currently exist. This audit sought to establish current rates of pregnancy testing at the point of admission with a view to developing future guidelines.MethodA retrospective case note audit of electronic records of all patients admitted to Ardenleigh blended women's service as of 1st September 2019 (n = 26). The expected standard for pregnancy testing within one month of admission was set as 100%.ResultKey results include: The majority of patients (67%) were aged under 35 years (range 20–56). The most common ethnicities were Caucasian (42%) and African-Caribbean (38%). Almost half (46%) had a primary diagnosis of paranoid schizophrenia.Two women were known to be pregnant at the point of admission. Only 54% of women with an unknown pregnancy status were screened for pregnancy within one month of admission.Rates of screening were particularly poor in women aged under 25 years (43%) and between 36 and 45 (0%).Women not screened for pregnancy were typically admitted from other hospital settings, including AWA services (27%) or other medium secure units (55%). 2 women admitted from prison were not tested (29%)Of those tested, the majority were checked using urine hCG (92%).None of the women tested were found to be pregnant.ConclusionOverall pregnancy testing on admission to the unit was poor, with only 54% of service users screened. Less than 100% compliance could result in serious consequences for both the woman and unborn baby if a pregnancy is not discovered. Updating the admission checklist for Ardenleigh to include pregnancy testing may prove beneficial. It is recommended that a re-audit is completed 6 months following checklist introduction.

Improving fetal congenital heart disease screening using a checklist-based approach.

To determine if using a checklist of specific ultrasound image criteria to screen the fetal heart improves the cardiac exam completion rate, defined as the ability to classify the heart as normal or abnormal. This is a retrospective cohort study of patients with singleton pregnancies who underwent a fetal anatomy survey between 18 and 28 weeks' gestation. A checklist was used from 1 September 2015 to 31 March 2016 to categorize exams as complete-normal, complete-abnormal, or incomplete. Performance was compared with a 7-month period prior to checklist introduction (1 December 2014 to 30 June 2015). Checklist utilization improved the cardiac exam completion rate by 8.9%. With the checklist, 1083 of 1202 exams (90.1%) were completed compared to 987 of 1193 (82.7%) pre-checklist, P < .001. We did not detect a change in cases classified as abnormal and referred for echocardiography: 25 (2.1%) with the checklist and 16 (1.3%) pre-checklist, P = .16. We did not detect more congenital heart disease (CHD), 12 (1.0%) with checklist screening, 5 (0.4%) pre-checklist, P = .14. Critical CHD was not missed in either group. Using the checklist improved the cardiac exam completion rate. There was no change in congenital heart disease detection.

Spinal surgery complications: an unsolved problem\u2014Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them?

PurposeTo investigate whether the World Health Organization Safety Surgical Checklist (SSC) is an effective tool to reduce complications in spinal surgery.MethodsWe retrospectively evaluated the clinical and radiological charts prospectively collected from patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist’s effectiveness.ResultsThe sample size was 917 patients with an average of 30-month follow-up. The mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). In total, 159 complications were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction in the overall incidence of complications following the introduction of the SSC: In 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%).ConclusionsThe SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the preoperative and postoperative phases in order to further reduce the incidence of complications.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

A Hemodynamic Safety Checklist Can Improve Blood Pressure Monitoring in Patients with Acute Spinal Cord Injury

The American Association and Congress of Neurological Surgeons recommended mean arterial blood pressure (MAP) in patients with acute spinal cord injury (SCI) should be 85-90 mm Hg for the first 7 days. We evaluated whether hemodynamic management differed between a primary-receiving and tertiary hospital in the first 24 hours for patients with acute SCI and assessed whether use of a checklist could improve hemodynamic management. Observational review was performed of 79 patients with acute SCI before and after introduction of a blood pressure monitoring checklist and staff educational program designed to improve tertiary center management. Hemodynamic management in the primary-receiving hospital was compared with the tertiary center before and after checklist introduction. At the primary-receiving center, mean number of documented MAP readings/hour was 2.2 and 3 before and after checklist introduction. The proportion having >50% of MAP recordings <80 mm Hg was 26% and 22%. The proportion having >50% of MAP recordings <70 mm Hg was 8.5% and 7%. At the tertiary center, mean number of MAP readings/hour was 1.3 and 2.7 before and after checklist introduction (P= 0.02). The proportion having >50% of MAP recordings <80 mm Hg decreased from 36.5% to 16% after checklist introduction (P= 0.05). The proportion having >50% of MAP recordings <70 mm Hg decreased from 9% to 5.5% (P= 0.6). Polytrauma, inotrope use, and head injury significantly correlated with low MAP recordings (P < 0.05). Polytrauma was an independent risk predictor for low MAP recordings (P < 0.05). Achieving MAP targets for patients with acute SCI is challenging. Checklist use and staff education were associated with improved hemodynamic management. Presence of polytrauma identified patients at particular risk.

Comparing the Effects of Paper and Digital Checklists on Team Performance in Time-Critical Work.

This mixed-methods study examines the effects of a tablet-based checklist system on team performance during a dynamic and safety-critical process of trauma resuscitation. We compared team performance from 47 resuscitations that used a paper checklist to that from 47 cases with a digital checklist to determine if digitizing a checklist led to improvements in task completion rates and in how fast the tasks were initiated for 18 most critical assessment and treatment tasks. We also compared if the checklist compliance increased with the digital design. We found that using the digital checklist led to more frequent completions of the initial airway assessment task but fewer completions of ear and lower extremities exams. We did not observe any significant differences in time to task performance, but found increased compliance with the checklist. Although improvements in team performance with the digital checklist were minor, our findings are important because they showed no adverse effects as a result of the digital checklist introduction. We conclude by discussing the takeaways and implications of these results for effective digitization of medical work.

Improving quality of care for maternal and newborn health: a pre-post evaluation of the Safe Childbirth Checklist at a hospital in Bangladesh

BackgroundBangladesh has achieved major gains in maternal and newborn survival, facility childbirth and skilled birth attendance between 1991 and 2010, but excess maternal mortality persists. High-quality maternal health care is necessary to address this burden. Implementation of WHO Safe Childbirth Checklist (SCC), whose items address the major causes of maternal deaths, is hypothesized to improve adherence of providers to essential childbirth practices.MethodThe SCC was adapted for the local context through expert consultation meetings, creating a total of 27 checklist items. This study was a pre-post evaluation of SCC implementation. Data were collected over 8 months at Magura District Hospital. We analysed 468 direct observations of birth (main analysis using 310 complete observations and sensitivity analysis with the additional 158 incomplete observations) from admission to discharge. The primary outcome of interest was the number of essential childbirth practices performed before compared to after SCC implementation. The change was assessed using adjusted Poisson regression models accounting for clustering by nurse-midwives.ResultAfter checklist introduction, significant improvements were observed: on average, around 70% more of these safe childbirth practices were performed in the follow-up period compared to baseline (from 11 to 19 out of 27 practices). Substantial increases were seen in communication between nurse-midwives and mothers (counselling), and in management of complications (including rational use of medicines). In multivariable models that included characteristics of the mothers and of the nurse-midwives, the rate of delivering the essential childbirth practices was 1.71 times greater in the follow-up compared to baseline (95% CI 1.61–1.81).ConclusionImplementation of SCC has the potential to improve essential childbirth practice in resource-poor settings like Bangladesh. This study emphasizes the need for health system strengthening in order to achieve the full advantages of SCC implementation.

The economic evaluation of an antibiotic checklist as antimicrobial stewardship intervention.

An antibiotic checklist was introduced in nine Dutch hospitals to improve appropriate antibiotic use. We estimated the cost-effectiveness of checklist use. We compared 853 patients treated with an antibiotic before checklist introduction (usual care group) with 1207 patients treated after introduction (checklist group). We calculated the change of costs between these groups per unit effect [incremental cost-effectiveness ratio (ICER)]: per extra patient receiving appropriate treatment; and per day reduction in length of hospital stay (LOS). We also calculated the benefit-to-cost ratio per day reduction in LOS. Finally, we estimated the number of checklists after which the expected benefits would compensate for costs in one hospital. The cost of checklist use per patient was €10.10. Of the usual care patients, 48.8% received appropriate antibiotic treatment compared with 67.5% of the checklist patients (+18.7%). The ICER was €54.01 (1010/18.7) per extra patient with appropriate treatment. In a model calculation the expected effect of appropriate antibiotic use was a reduction in LOS of 1.05 days, which was extrapolated to a reduction of 19.64 hospital days per 100 patients. The ICER was €51.43 (1010/19.64) per day reduction in LOS. The estimated benefit of a 1 day reduction was €611. The benefit-to-cost ratio was 11.9 (611/51.43) per day reduction in LOS, indicating a cost saving of €12 for every euro spent on checklist use. The benefits would compensate for costs after use of 11 checklists. Efforts for further implementation of the antibiotic checklist can be justified by potential economic benefits.

Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial

ObjectivesQuality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay. MethodsAn antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol. ResultsBetween 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6–11.5) versus intervention 10.1 days (95% CI 8.9–11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0–3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance. ConclusionsUse of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.

Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist?

Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgency of the case; and decrease documentation discrepancies among nursing, obstetric, anesthesia, and pediatric staff. Retrospective review of 600 CDs on our 2 labor and delivery suites before and after the introduction of 2 consecutive versions of our obstetric safe surgery checklist (100 cases in each cohort) was undertaken. The first version was released in 2010, and after modifications based on initial findings, our current version was released in 2014. One hundred consecutive CDs were identified from each of the 3 periods at each hospital, and charts for those patients and newborns were abstracted. Notes by obstetricians, nurses, anesthesiologists, and pediatricians were reviewed. We compared the rates of agreement in the documentation of the indication for the CD between the different members of the team. Chi-square analyses were performed. Complete agreement among the 4 specialties in the documented indication for CD before introduction of our initial safe surgery checklist was noted in 59% (n = 118) of cases. After initial checklist introduction, agreement decreased to 43% (n = 86; P = 0.002). We then modified our checklist to include indication for CD and level of urgency and changed our policy to include pediatric staff participation in the timeout. Agreement in a subsequent chart review increased to 80% (n = 160), significantly better than in our initial analysis (P < 0.001) and our interim review (P < 0.001). The greatest improvement in agreement was observed between obstetricians and pediatricians. Implementation of a safe surgery checklist can improve communication at CDs, but care should be taken when implementing checklists because they can have unanticipated consequences. Ongoing review and modification are critical to ensure safer medical care.

Abstract 247: The Use of a World Health Organisation Derived Safe Surgery Checklist to Improve Patient Experience in the Cardiac Catheterisation Laboratory

Background: The WHO safe surgery checklist has reduced morbidity and mortality during surgery. Whether or not a modified WHO checklist could improve patient and staff experience in the cardiac catheterisation laboratory (CCL), where the majority of procedures are carried out under local anaesthetic, has not previously been investigated. Methods: Starting in March 2013, a WHO-derived checklist, specifically modified for the CCL, was introduced at the Royal Brompton Hospital. For three months, weekly PDSA cycles and staff feedback were used to optimise checklist design, followed by a full rollout. Patient experience (n=76, taken throughout the six-month period) and staff safety climate (taken 2 and 7 months after checklist introduction) surveys were undertaken to measure subjective impact. Clinical outcomes and efficiency data were obtained from in-house databases. Results: • By six months, a full checklist (Figure 1) was completed in 367/417 (88%) of procedures (Figure 2). Patient surveys revealed that the majority of patients (57%) noticed the staff ‘Time Out’ and when questioned, strongly associated the checklist with safety (mean score 9.3/10 using Likert scale) and found it highly reassuring (mean 8.9/10). • The majority of procedures that used the checklist (56%) were shorter than average, whereas the majority of procedures that did not use a checklist took longer than average (P&lt;0.0001) • When the full checklist was used, screening time was correspondingly reduced in 25% more procedures Conclusions: The introduction of a WHO-derived checklist was associated with high levels of patient satisfaction, improved efficiency, and enhance team cohesion during procedures in the cardiac catheterisation laboratory.

The WHO surgical safety checklist in a dental‐teaching hospital department of oral surgery – a model for implementation

AbstractIntroductionThe World Health Organisation's (WHO) surgical safety checklist was introduced in 2008. We describe a model for implementation of the surgical safety checklist in an oral surgery‐teaching department and present the results of an audit of compliance as well as a review of relevant critical incidents.MethodAn adapted checklist for all surgical procedures was developed and introduced into our oral surgery‐teaching department as a pilot in 2009 and as a protocol in 2010. Feedback regarding the pilot phase of checklist implementation was obtained from clinical staff, and 2 years of audit data relating to compliance with the surgical checklist was collected. Submissions of critical incidents over a 4‐year period, prior to and after surgical checklist introduction, were also analysed.ResultsFeedback in the pilot phase of surgical checklist implementation from clinical staff was generally positive. Audit results display increasing levels of compliance with the checklist process in our unit. Two out of 102 critical incident reports reviewed were found to be relevant to the surgical checklist process and are presented.ConclusionThe WHO surgical safety checklist can be successfully implemented in an oral surgery‐teaching hospital setting. Levels of compliance with the checklist in our unit are high. Demonstrating an improvement in outcomes since the introduction of the checklist is a challenge, but there is limited evidence of improved patient care from reviewing critical incident data in our unit.

Does use of a World Health Organization obstetric safe surgery checklist improve communication between obstetricians and anaesthetists? A retrospective study of 389 caesarean sections

We evaluated the impact of the World Health Organization Obstetric Safe Surgery Checklist (WHO Checklist) on perioperative communication between anaesthetists and obstetricians by performing a retrospective audit in a Teaching hospital in London, UK. Caesarean section births from February to March 2009 and April to May 2011 were studied. Caesarean section notes from obstetricians and anaesthetists managing the same woman during the study period were reviewed. Grading differences between obstetricians and anaesthetists before and after checklist introduction were evaluated. Communication failure (where obstetricians and anaesthetists had documented different caesarean section grades [level of urgency]) and good communication (where obstetricians and anaesthetists had documented the same caesarean section grade) were observed. In total, 195 caesarean sections before introduction of the WHO safe surgery checklist and 194 caesarean sections after checklist introduction were studied. Grading differences occurred in 24.1% of caesarean sections without checklists compared with 10.3% with checklists (P < 0.001). During emergency caesarean section alone, grading differences between obstetricians and anaesthetists were smaller, although this was not significant (P = 0.222). We conclude that implementation of a WHO Obstetric Safe Surgery checklist improves the communication of caesarean section grade (urgency) between obstetricians and anaesthetists.

Effect of A 19-Item Surgical Safety Checklist During Urgent Operations in A Global Patient Population

To assess whether implementation of a 19-item World Health Organization (WHO) Surgical Safety Checklist in urgent surgical cases would improve compliance with basic standards of care and reduce rates of deaths and complications. Use of the WHO Surgical Safety Checklist has been shown to be associated with significant reductions in complications and deaths. Before evaluation of this safety tool, concern was raised about whether its use would be practical or beneficial during urgent surgical procedures. We prospectively collected clinical process and outcome data for 1750 consecutively enrolled patients 16 years of age or older undergoing urgent noncardiac surgery before and after introduction of the WHO Surgical Safety Checklist in 8 diverse hospitals around the world; 842 underwent urgent surgery-defined as an operation required within 24 hours of assessment to be beneficial-before introduction of the checklist and 908 after introduction of the checklist. The primary end point was the rate of complications, including death, during hospitalization up to 30 days following surgery. The complication rate was 18.4% (n=151) at baseline and 11.7% (n=102) after the checklist was introduced (P=0.0001). Death rates dropped from 3.7% to 1.4% following checklist introduction (P=0.0067). Adherence to 6 measured safety steps improved from 18.6% to 50.7% (P<0.0001). Implementation of the checklist was associated with a greater than one-third reduction in complications among adult patients undergoing urgent noncardiac surgery in a diverse group of hospitals. Use of the WHO Surgical Safety Checklist in urgent operations is feasible and should be considered.