PATIENT SAFETY FIRST

Putting the Patient IntoPatient Safety Checklists

The AORN Journal

Sharon A. McNamar

http://dx.doi.org/10.1016/j.a

� AORN, Inc, 2013

FRED E. SHAPIRO, DO; NATHAN PUNWANI, MD, MPH;

RICHARD D. URMAN, MD, MBA

Editor’s note: This is Part II of two articles on on quality measures, including patient experi-

patient safety considerations in office-based sur-

gery settings. This article discusses methods for

providing patient-centered care and implementing

a patient’s safety checklist in office-based settings.

Part I was published in the September 2013 issue of

AORN Journal and addressed the benefits and risks

of office-based surgery, as well as how to improve

practices and the quality of care through the use

of the Safety Checklist for Office-Based Surgery.

Over the past two decades, there has been

a proliferation in the volume of office-

based medical and surgical procedures.

From 1995 to 2005, the number of office-based

procedures increased from 5 to 10 million.1 Dur-

ing the same period, the Institute of Medicine

published Crossing the Quality Chasm: A New

Health System for the 21st Century.2 The report

initiated a cavalcade of calls for the health care

system to be “respectful of and responsive to in-

dividual patient preferences, needs, and values.”2

Patients and payers alike are heeding these calls

for greater patient-centered care and are putting

the onus of responsibility for providing this on

medical providers.3 The Patient Protection and

Affordable Care Act4 authorizes the Centers for

Medicare & Medicaid Services (CMS) to develop

a hospital value-based purchasing program be-

ginning in 2013; this mandatory payment model

will link hospital reimbursement to performance

is seeking contributors for the Patient S

a, column coordinator, by sending topi

orn.2013.08.003

ence.5 In addition, the CMS accountable care

organization initiatives require participating

medical provider groups to demonstrate adequate

levels of patient satisfaction to be eligible for

shared savings.6

PATIENT-CENTERED CARE IN VALUE-BASED ENVIRONMENTS

The sustained increase in office-based procedures

and the growing chorus of demands for patient

empowerment are two trends that are redefining

health care. The convergence of these two bur-

geoning movements implies that office-based pro-

cedures will play a more pronounced role in a

value-based health care environment and will in-

evitably be the focus of patient-centeredness and

quality improvement activities.

Physicians and nurses who perform office-based

surgerymust actively partner with patients in quality

improvement efforts to deliver high-quality care.

Physicians and nurses should take advantage of the

idea of patient activationda patient’s knowledge,

skills, ability, and willingness to manage his or

her own health and caredand help patients eval-

uate and participate in the care they will receive.7

Research has demonstrated that highly moti-

vated patients are more likely to rate their health

care experiences as positive,8 and higher patient

satisfaction is positively linked to better compli-

ance with health regimens.9 Activated patients

afety First column. Interested authors can contact

c ideas to journalcolumns@aorn.org.

October 2013 Vol 98 No 4 � AORN Journal j 413

October 2013 Vol 98 No 4 PATIENT SAFETY FIRST

are half as likely to delay care and are one-third as

likely to have unmet medical needs.10 There is

some evidence that activated patients are not only

more likely to have better health outcomes, but

they may also have lower health care costs, be-

cause they tend to use hospitals and emergency

departments less frequently.11

Progress in patient-centeredness and satisfaction

generates benefits for clinicians, nurses, and other

office personnel as well. One major study showed

that patient-centeredness efforts promote better

provider and staff morale and minimize personnel

By embracing patient engagement, officepractices can design and use interventionsthat draw on patient activation, which in turnimproves the quality of care that they deliver.

turnover.3 Enhanced

patient experiences

are also positively

associated with de-

creased medical li-

ability claims.9 By

embracing patient

engagement, office

practices can design and use interventions that draw

on patient activation, which in turn improves the

quality of care that they deliver.

Patient-Centered Safety Checklists

Patient-centered checklists offer an important way

for patients to be activated and exercise self-

determination in choosing their health care. Check-

lists can assist patients in systematically organizing

their understanding, needs, and preferences for care.

The Institute for Safety in Office-Based Surgery

(ISOBS) has pioneered the Patient’s Checklist for

Office-Based Procedures (Figure 1).12 This memory

aid reminds patients to ask certain questions

before undergoing a procedure in an office-based

setting.

The patient’s checklist is divided into sections

and includes instructions to patients to inquire about

n their physician’s credentials (eg, board certi-

fication);

n how to communicate with the office staff; and

n whether

n their medical conditions are stable,

414 j AORN Journal

n the office is accredited and properly licensed

to perform the procedure,

n the office in which the procedure will be

performed is the most appropriate place for

the intervention,

n the office personnel can handle emergencies

and have transfer protocols in place, and

n there is a plan for recovery after the pro-

cedure.

By broaching these issues, patients can give

medical providers the opportunity to tailor care

according to their in-

dividual needs and

preferences. Addi-

tionally, when pa-

tients raise questions

and volunteer infor-

mation about their

needs and circum-

stances, providers can better plan for their care.

Such patient-centered decision making has been

shown to improve health care outcomes.13 For

example, when a patient inquires about the most

appropriate site for undergoing a procedure, a

potential “red flag” is raised that reminds the

clinician to assess all locations in which the pro-

cedure can be performed and the suitability of

each for the patient. The office practitioner is thus

prompted to customize the treatment plan in ac-

cordance with the best interests of the patient.

The lessons and experiences of the aviation in-

dustry and the World Health Organization (WHO)

in designing an effective safety checklist under-

score the importance of providing patients with

appropriate content and illustrations, if needed.14

The text and formatting of the ISOBS patient’s

checklist is conducive to attaining patient safety

goals. The checklist is only one page long. The

phrasing is straightforward and the checklist is

written in colloquial language that most patients

can comprehend. The checklist uses a simple font

and uppercase and lowercase text to make it easily

readable. The checklist also uses unobtrusive colors

Figure 1. A patient’s checklist can be used as a memory aid to remind patients to ask certain questions beforeundergoing an office-based procedure. Reprinted with permission from the Institute for Safety in Office-BasedSurgery.

AORN Journal j 415

PATIENT SAFETY FIRST www.aornjournal.org

October 2013 Vol 98 No 4 PATIENT SAFETY FIRST

to clearly delineate sections and their respective

questions. As with other checklists in health care,

the patient’s checklist is only a template and can

be adapted to specific practice settings and patient

needs.

LITERATURE REVIEW

We know of no studies to date that have evaluated

the effectiveness of safety checklists when used

by patients themselves. Instead, studies have in-

vestigated medical providers’ use of checklists,

especially in inpatient settings, and the effect on

patient-oriented outcomes and health care costs.15-17

For example, Haynes et al16 suggested the utility

of checklists in decreasing patient mortality and

One of the most significant barriers toimplementation of a patient’s checklist is lackof training on meaningful use.

morbidity. The global,

multicenter study was

sponsored by WHO

and showed that inpa-

tient surgical check-

lists reduced patient

death rates from 1.5%

to 0.8% and reduced complications from 11% to

7%.16 During surgical crisis simulations, teams

that used a checklist were four times less likely to

miss critical steps and processes than when they

relied exclusively on their memories.18 When the

ISOBS procedure checklist for office providersd

which is modeled after the WHO Surgical Safety

Checklistdwas adopted by a single plastic surgery

office, the complication rate dropped from 15.1%

to 2.7%.19

There is no reason to believe that patients using

their own checklists cannot register similar im-

provements in process and outcome measures of

health care quality. In fact, a patient’s checklist is

a valuable complement to a provider’s checklist.

Just like a provider’s checklist helps to ensure that

physicians and nurses do not overlook key steps

when performing a medical or surgical proce-

dure, a patient’s checklist helps patients remember

to ask the physician specific questions before un-

dergoing a procedure. By being prompted by such

patient queries, office personnel are reminded to

416 j AORN Journal

consistently implement critical steps in performing

a given procedure. This provides useful checks and

balances to help ensure that the provider’s check-

list is appropriately implemented and completed.

A patient’s checklist could theoretically reinforce

the effectiveness of the provider’s checklist in

improving patient-centered outcomes such as

morbidity, mortality, and patient satisfaction.

IMPLEMENTING CHECKLIST USE

Providers who perform office-based procedures

must weigh certain considerations before encour-

aging patients to use safety checklists. One of the

most significant barriers to implementation of a

patient’s checklist is lack of training on meaningful

use. Patients may not

know how to properly

use the checklist or

may haphazardly

complete the check-

list without asking the

necessary questions.

Similar problems have been observed among

health care providers after the adoption of patient

safety checklists.20,21 Provider groups often have

to establish training programs to educate clini-

cians and other personnel on how to competently

execute checklist protocols. This is a key role for

the nurse to instruct patients on the importance

of completing each component of the checklist.

Another major hurdle to the adoption of the

patient’s checklist is that some patients may not

be interested in shared decision making.22 Vulner-

able populations such as the elderly, immigrants,

and individuals with lower levels of education or

with lower numeracy (ie, people who are unable

to reason or to apply simple numerical concepts)

are typically less receptive to patient engagement.23

However, even these constituencies are as likely to

benefit from patient-mediated interventions as other

demographic groups with appropriate encourage-

ment and assistance.23 Furthermore, patients’ at-

titudes about their role in decision making are

malleable. Patients’ communication skills and

PATIENT SAFETY FIRST www.aornjournal.org

understanding of their medical conditions could

gradually improve through increased interaction

with medical providers. With greater competency,

patients’ confidence and receptiveness to shared

decision making also could increase. For these

reasons, medical providers should encourage all

patients to complete checklists. This guarantees

that gains in health care quality are broadly dis-

tributed and are not disproportionately concentrated

among select groups.

CONCLUSION

The health care system must be reorganized to

continuously improve and surpass patients’ needs

and expectations. Patients and payers are demand-

ing continual enhancements in care delivery, and

such efforts will inevitably involve office-based

procedures. A patient’s checklist is part of a broader

trend to make office-based medical and surgical

practices more patient centered. We believe that

the use of patient’s checklists can empower patients

to be prudent guardians of their health and health

care. Extending the concept of team-based health

care to patients themselves lays the foundation for

self-sustaining advancement in both patient-oriented

health outcomes and satisfaction. Physicians and

nurseswho provide office-based interventions should

incorporate patient’s and provider’s checklists into

their workflow to be in the vanguard of patient-

centered health care and quality improvement.

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4

Fred E. Shapiro, DO, is assistant professor of

anesthesia at Harvard Medical School and staff

anesthesiologist at Beth Israel Deaconess Med-

ical Center, Boston, MA. Dr Shapiro has no

declared affiliation that could be perceived as

posing a potential conflict of interest in the

publication of this article.

18 j AORN Journal

Nathan Punwani, MD, MPH, is a resident

physician at George Washington University

Medical Center, Washington, DC. Dr Punwani

has no declared affiliation that could be per-

ceived as posing a potential conflict of interest

in the publication of this article.

Richard D. Urman, MD, MBA, is assistant

professor of anesthesia at Harvard Medical

School and staff anesthesiologist at Brigham and

Women’s Hospital, Boston, MA. Dr Urman has

no declared affiliation that could be perceived as

posing a potential conflict of interest in the

publication of this article.