Background:
Although checklists have been used to improve quality of care in surgery and intensive care unit settings, it is unclear if they are helpful for hospitalized medical patients. We developed a checklist to address 4 conditions common in general medicine and linked to Medicare reimbursement: pneumococcal immunization and prevention of pressure ulcers (bedsores), catheter‐associated urinary tract infections (UTIs), and deep vein thrombosis (DVT).
Purpose:
To assess the feasibility and effectiveness of using a checklist to improve adherence to quality measures for hospitalized medical patients.
Description:
Two hospitalists and 1 generalist with institutional leadership roles in quality and safety met to review potential candidate conditions for an inpatient care checklist. Methods outlined in Gawande's The Checklist Manifesto and the published literature were followed to design the IBCD checklist. Ultimately, 4 evidence‐based processes of care were selected as most relevant for general ward patients: (1) pneumococcal immunization, (2) heel and sacrum skin exams to detect bedsores, (3) restriction of urinary catheters to reduce risk of catheter‐associated UTI, and (4) pharmacologic prophylaxis to reduce risk of DVT. The checklist was designed to be used by attending physicians after review of resident care on the postcall day, serving as a real‐time “quality audit” for newly admitted patients. After piloting the checklist with 2 hospitalists in spring 2010, a revised version was implemented for all general medicine teams in July 2010. To evaluate the impact of the checklist, chart audits were conducted for all patients admitted to general medicine in July 2010 for whom a checklist was completed. Baseline status on admission was compared with status after checklist use with a 2‐sample test of proportions. To assess how final adherence achieved during the intervention compared with a baseline, a historical control group of patients admitted to general medicine in July 2009 was used. In July 2010, 5 of 7 attendings (71%) used the IBCD checklist for 130 of 141 patients (92%). On admission, overall adherence to the 4 quality indicators was 63%. Use of the checklist prompted 87 actions and increased overall adherence to 86% (P < 0.001). Furthermore, rates of adherence were higher for all domains in 2010 than in 2009, and overall adherence was significantly greater in 2010 (86%) than in 2009 (57%); P < 0.001. Notably, immunizations and bedsores were the areas with the greatest improvement in adherence. Evaluation of this initiative is ongoing, and an electronic iPhone application version of the checklist is under development.
Conclusions:
A checklist in general medicine can result in improved adherence to process‐of‐care measures for conditions that are prevalent and tied to Medicare reimbursement. Future work will aim to assess the sustainability of checklist use and if this innovation can be disseminated to other centers.
Disclosures:
G. Kauffmann ‐ none; A. Davis ‐ none; E. Schulwolf ‐ none; V. Press ‐ none; K. Stupay ‐ none; V. Arora ‐ none