checklist vs. checklist

Bettygene.Egan at KP.ORG Bettygene.Egan at KP.ORG
Fri May 3 15:02:46 UTC 2013


I have been reading the numerous emails on this subject and find the 
dialog robust.  It is also clear that this is a very challenging area with 
many opinions.  Ross and Harold's comments relate to a project that I have 
been working on and some of you may recall seeing at last year's DEM 
Conference in Baltimore.  Dr. William Strull and I briefly talked about a 
tool for patients named SMART Partners.  S=symptoms, M=medication/medical 
history, A= assessment, R= review, T= to do.  The concept of the SMART 
Partners is to provide patients with a tool to help prepare them for their 
appointment and to be engaged in their care, a checklist of sorts for the 
patient.

I ran a very small pilot in one of our medicine clinics and the results 
show that the patients like the guide, 86% (n=590) said they will use it 
at a future visit.  A post-survey for the physicians shows an increase in 
obtaining information from the patient in the first couple of minutes than 
before using the guide. 

My point is ... I don't believe that we will ever be able to stop errors 
from occurring, similar to we will never stop car accidents from 
happening, however, as we remain open to opportunities for small changes, 
like seat belts, we can continue to minimize the risks. Small changes can 
have big impacts.





Bettygene Egan, MBA
Sr. Project Manager
National Risk Management
One Kaiser Plaza, 18 Bayside
Oakland, CA 94612
Office: (510) 271-5713  TL: 8-423-5713
Cell: (510) 912-5148
Fax: (510) 271-6988

Administrative Support:
Van B Nguyen - (510) 267-4892

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From:   Harold Lehmann <lehmann at JHMI.EDU>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   05/03/2013 06:33 AM
Subject:        Re: checklist vs. checklist



I have been thinking for a while of the concept of a "Task Guide"---where 
an authority (faculty member; a crowd) sets up the sequence of steps 
required to accomplish a task and, for each step, suggests a number of 
resources that could help the user. The classic use case is evidence-based 
medicine, where the steps are "Find appropriate guideline; find 
appropriate systematic review; search PubMed Clinical queries," etc. At 
each step, there are links, e.g., to databases of guidelines, to appraisal 
guides.

So when I look at this list that Ross has assembled, I am thinking, can we 
assemble resources that speak to each step? They may be System 1 or System 
2 oriented, I suppose.

E.g., I can imagine a user asking, "Can you help me think of other known 
causes of this problem?" [Yes, these are differential-diagnosis lists from 
textbooks, review articles, or diagnostic decision support systems.] "Can 
you help me maintain an open mind?" [Probably the same list.] "How do I 
know when the timing is complete?" [Resources on good interview 
technique]. Etc.

Such a resource list yoked to good practice might provide a way of us 
projecting to the larger community what we know about overcoming barriers 
to improving diagnosis in medicine and providing direct help.

Harold

-- 
***************************************************************************
Harold P. Lehmann, MD PhD
Interim Director, Division of Health Sciences Informatics
Johns Hopkins University School of Medicine



From: Ross Koppel <rkoppel at sas.upenn.edu>
Reply-To: Society to Improve Diagnosis in Medicine <
IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Ross Koppel <rkoppel at sas.upenn.edu>
Date: Thursday, May 2, 2013 9:54 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: checklist vs. checklist

Checklist for what? 

A checklist for a procedure is one thing.  A check list to improve Dx is 
another.   For the procedure, you want tools, steps, etc.  Checklists are 
great.  (OK, also see Peter P's very nuanced article in Millbank Memorial 
Quarterly...maybe not so cut and dry) 

For Dx, on the other hand, I can imagine a checklist that's a bolus of 
difficult questions that may not improve outcomes, but rather just anger 
the clinician.  Consider the following almost absurd but not irrelevant 
questions: 
     Do you remember other known causes of this problem? 
    Have you prematurely closed inquiry? 
    Did you take enough time?
    Have you examined the pt's history carefully enough? 
    Do you remember your pharmacology well enough? 
    Did you meet with the radiologist(s) for fully explore the 
ambiguities? 
    When you go into another room, do you increasingly wonder why you are 
there? 
    Are you willing to admit your ignorance? 
    Should you talk to someone else?
    Did you do the all of the appropriate tests but none extra?
 
 
I would suggest that some of the Dx-related questions are very different 
than asking about the availability of gloves.  More important, some are 
unlikely to get answers beyond annoyance.

Ross Koppel, Ph.D. FACMI
Sociology Dept and Sch. of Medicine
University of Pennsylvania, Phila, PA 19104-6299
215 576 8221 C: 215 518 0134
On 5/2/2013 8:37 PM, Robert L Wears, MD, MS, PhD wrote:
Certainly it can often be used as an excuse, but the effects of 
time/production pressure are 
often more subtle and distributed.  People habituate to various 
constraints -- if they are 
often time pressured, and must sacrifice thoroughness for efficiency, 
those behavioural 
patterns tend to carry over into other instances where time pressure may 
be absent.

I'd suggest reading Erik Hollnagel's book on the efficiency-thoroughness 
tradeoff.  One idea 
he brings up is that people tend to be biased to favour efficiency over 
thoroughness, and 
that this is so deeply ingrained one would suspect an evolutionary basis 
for it.  Saving a bit 
of time is not often important, but in an open system, a world with 
uncertainty, risk, and 
unexpected events in it, a bit of extra time sometimes turns out to be 
critical in dealing w/ 
the unexpected.

The full reference is:

Hollnagel, E. (2009). The ETTO Principle:  Efficiency-Thoroughness 
Tradeoff (Why Things That Go Right Sometimes Go Wrong). Farnham, UK: 
Ashgate.

bob

On 2 May 2013 at 3:19, Jason Maude wrote:

> I initially saw my GP (very experienced and senior partner in the
> practice) who was certainly not rushed as he even asked me about some
> other things I had seen him with before. The x-ray was carried out at
> the small local hospital that was attached to the practice. There was
> no queue to get the x-ray done so I don't believe that the radiologist
> was rushed. It was then looked at again by a couple of nurse
> practitioners, all in the calm of a sleepy English country town
> hospital!
> 
> This is why I started to conclude that lack of time could often be an
> excuse rather than a legitimate explanation. I also blamed myself for
> too easily accepting what seemed a plausible diagnosis. I should have
> asked "what else could it be" and acted as the trigger for more
> thinking. The whole episode showed me what an easy trap it is to fall
> into.
> 
> So do we either accept this as the norm and say that nothing can be
> done (not enough time etc)- in other words there will be an inbuilt
> industry dx error of 10-20% - or is there a way we can force change.
> My view, reinforced by this episode, remains that the differential (or
> say 3 diagnoses) must be recorded in the medical notes at the time of
> the consultation.
> 

Robert L Wears, MD, MS, PhD
University of Florida    Imperial College London
wears at ufl.edu            r.wears at imperial.ac.uk
1-904-244-4405 (ass't)            +44 (0)791 015 2219
What hits the fan will not be evenly distributed.
 



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