Checklists help us organize our lives and processes and represent an effective way to ensure that important things get done. Over a decade ago, one of us (P.J.P.) created a simple paper checklist that defined actionable tasks for central intravenous placement, resulting in a 70% decrease in the rate of deadly central line–associated bloodstream infections (CLABSIs) in the United States and several other countries. Since then, checklists have permeated medical practice and have been credited with making care safer by supporting clinician decision-making, clarifying therapies to avoid preventable harm, and augmenting communication among care teams. When coupled with efforts to support culture change and peer learning, checklists can help improve the quality of care. Oddly, the one stakeholder who does not yet routinely use checklists in medicine is the patient. We believe that the next phase in health care improvement will occur through patient engagement, and we propose that interactive checklists, or “Smartlists,” may be the key to achieving this objective.
Facilitating Patient Engagement Through Checklists
Patients often face substantial uncertainty about their disease, risks, care options, follow-up, and, most important, behaviors that will help them to get well and stay well. However, much of the information that is provided to patients is ambiguous and generic. For example, discharge instructions for a patient who has had a hip replacement are similar to those for a patient with heart failure in that both sets of instructions simply encourage the patients to follow up with their physicians. We believe that customized, patient-centered checklists can help to mitigate such ambiguity and facilitate patient engagement by improving communication between patients and their clinicians, helping patients to make decisions, and ensuring that patients perform important tasks, thereby reducing the risk of preventable harm.
Checklists work by providing specific information regarding who needs to act, what actions need to be taken, and how, where, and when each action should occur. As such, customized patient-centered checklists have a wide range of applications, with the potential to improve patient education, pre-procedure planning, discharge instructions, care coordination, chronic care management, and plans for staying well. However, the utility of current paper-based checklists is poor. Consequently, we believe that it is time to replace the antiquated paper-based checklist with a digital tool that can facilitate patient-clinician communication and improve outcomes.
Bridging the Technological Gap: The Development of an Effective Mobile Platform
Given that cell phones and other electronic devices are an integral part of modern-day life and are increasingly being used for the delivery and consumption of health care information, several companies have created mobile platforms featuring customized patient-centered checklists. In addition to making personalized checklists both feasible and scalable, electronic platforms create a means of connecting producers and consumers of information.
An effective platform should include at least two levels of patient-oriented checklists: (1) general or disease- and procedure-specific checklists including information regarding patient actions and how, when, and why they should occur, and (2) checklists customized by the physician for individual patients for the purpose of encouraging clinician-patient dialogue and individualized care. Such a platform should also support easy customization of content without requiring clinicians to start from scratch, foster communication between patients and clinicians by creating alerts and providing feedback on adherence, and facilitate learning and improvement by encouraging patients and clinicians to see what others have included on their checklists.
Given our experience with the development and use of checklists, we worked with engineers, implementation specialists, doctors, and, most important, patients to create a customizable, electronic, interactive, multimedia platform to make it easy for doctors and patients to develop customized checklists, or “Smartlists,” for optimal care. This platform, which is free to patients and sold to providers, has been designed with easy-to-use search technology so that patients can receive step-by-step checklists pertaining to nearly 1,000 surgical conditions along with specific questions that they can ask their providers. Some adopters have customized their checklists and made them interactive, thereby allowing the clinician to ensure that the patient is on track during his or her health care journey. While it is too early to comment on the impact of this platform, one practice has reported that the use of Smartlists has been associated with decreases in the number of emergency room visits after surgery, the number of cancelled operations, and the amount of time that office staff spend with patients on the phone. More formal testing of Smartlists is underway.
Bridging the Cultural Gap: Facilitating the Adoption of Checklists as a New Standard of Care
In addition to the technical changes described above, a cultural change is needed to convince patients and clinicians to work together as partners. Doctors need to encourage dialogue with patients, and patients need to feel engaged in their own care. There is also an information gap: information is frequently siloed, and peer-learning communities, which have a vital role in reducing health care–acquired infections, are largely absent. Our experiences with implementing checklists have led to several insights that may help to facilitate the adoption of patient checklists as a new standard of care.
- Encourage customization from a template. When developing the CLABSI checklist, we found that the Centers for Disease Control and Prevention (CDC) guidelines recommended 90 interventions without prioritizing which were most important, causing wide variation in practices. Our checklist summarized the recommendations regarding the five most effective practices with the lowest barriers to implementation, and we encouraged hospitals to use our checklist as a template and to customize it as appropriate for their own situation. If we had encouraged all users to follow our version of the CLABSI checklist, it is likely that buy-in would have been poor and the endeavor would have failed miserably. While each customized checklist varied minimally and contained the five most important practices, some users reformatted the items and inserted their logo and others added new items as appropriate for their own context and culture. The ability to create a customized checklist on the basis of an existing template reduced the time and effort that otherwise would have been required to create a checklist from scratch. We encourage clinicians to follow this practice when creating customized checklists for their own patients.
- Create a learning community. An essential factor that contributed to the reduction in bloodstream infections was the creation of a culture in which doctors and nurses collaborated to ask questions, learn, and improve together. These communities took many forms, including in-person meetings and webinars among multiple ICUs within a hospital, health system, or state. By sharing their own experiences through these learning communities, clinicians stopped viewing CLABSIs as inevitable and started viewing them as preventable. It is also important for patients to be part of this learning community. Patients are often hesitant to speak up and physicians oppose being questioned. If a checklist is to be effective, patients should be encouraged to question clinicians, and clinicians must embrace being questioned by patients.
- Make implementation easy. When we started the CLABSI-reduction program, the CDC guidelines and our checklist recommended using chlorhexidine to disinfect the skin, but most central line insertion kits were prepackaged with povidone-iodine. Thus, clinicians were required to seek out chlorhexidine, and compliance was understandably low. To address this issue, we worked directly with hospital leaders and device manufacturers to assemble kits that were prepackaged with chlorhexidine. By making chlorhexidine the default option, this one change increased compliance with the checklist from about 20% to nearly 100%.
- Provide transparent measurement and accountability. At the end of the day, results matter. In the CLABSI effort, the CDC provided definitions and mechanisms to collect and report valid, although not perfect, measures of infection. Hospital and ICU leaders reported and reviewed these infections and created shared accountability for improvement. Staff in the ICU posted the number of patients with an infection and highlighted the weeks without an infection. When an infection occurred, staff investigated and sought to identify gaps in care. The ritual of adding another week without an infection helped to engage all staff in the effort.
Linking Patient Engagement to Improved Outcomes
Valid and transparent measures are needed to evaluate patient engagement, and these measures must be linked to improved outcomes. The Patient Activation Measure (PAM) offers hope, although it is not used routinely in clinical practices. The various Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores provide valid measures of a patient’s experience and can be enhanced if linked across episodes of care.
The Next Frontier in Patient Engagement
The effective use of patient-centered checklists can align required actions and incentives across the vast and complex health care system by (1) ensuring that the same critical information is accessible to both clinicians and patients, (2) supporting shared decision-making, (3) encouraging active participation of patients in their own care, and (4) facilitating the navigation of complex post-discharge instructions. Ultimately, smartphone-based checklists should help care teams and patients work together to improve patient outcomes.
Disclosure: All of the authors are co-founders and hold equity in Patient Doctor Technologies, a start-up company that seeks to enhance the partnership between patients and clinicians with an application called Doctella.
This article originally appeared in NEJM Catalyst on December 10, 2016.