Jan 7, 2010

Implementing the Safe Surgery Checklist in New Delhi, India

This year we started a Global Health Initiative within the Harvard IHI Open School Chapter. We aim to make quality improvement and patient safety truly global. Last year one of the members of the Harvard Open School Chapter, Shabnam Hafiz, introduced the Safe Surgery Checklist at three hospitals in Pakistan. Building upon this momentum and furthering the cause of global patient safety I decided to implement the checklist at hospitals in New Delhi, India during the winter break. As I work on spreading the checklist, I will be sharing my experiences with the readers of this blog. I hope you will find the posts interesting and insightful.

In implementing the checklist, I wanted to do it in a manner that could be replicated by other people wishing to create change, sometimes without significant access to the top leadership at a hospital. I wanted to conduct an experiment in bottom-up change.

One of my physician friends was working as a Resident at a government hospital in Delhi. I got in touch with him when I reached Delhi, and over a cup of coffee I explained the surgical safety checklist to him. He offered to set up an appointment for me to meet with the head of surgery at his hospital to discuss the checklist. Two days after that, I went to the hospital and in a five minute meeting explained the checklist to the Chief of Surgery. She was ready to implement it and remembered having read the journal article. I then met with other surgeons at the hospital, and also the Chief of Anesthesiology. Everyone was ok with the idea and it was decided that I would hold a trial run of the checklist in the OT the next day.

The next day I reached the OR early and explained the checklist to the OR nurses and clarified their doubts. Then I ran the checklist in two OR’s. As this was the first time even for me, I felt a little rushed in the first case and did not feel that the process was as effective as it should have been. In the second case I tried to get some nurses to take over from me, but they were a bit hesitant. In the third case another nurse did volunteer to run the checklist.

What was amazing was that on the very first day we managed to identify gaps in care. One of the questions on the checklist asks ‘Has the site been marked’, it turned out that it was not a routine procedure to mark the incision site preoperatively at this facility; the senior surgeon noted this deficiency and told the surgeons to carry it out for future surgeries. A discussion with the anaesthsiologist revealed that mostly preoperative antibiotics were given in the ward, and the gap between the administration of the antibiotic and the skin incision possibly exceeded 60 minutes in most cases.

After the OR trail run I approached the Administrative Head for his permission to hold a formal presentation to explain the significance of the checklist and to show the videos. He was very supportive and the presentation will be held next week during which I hope to train other people in implementing the checklist.

Suggestions, comments and feedback welcome. Watch this space for updates.


Wales Chapter for Healthcare Improvement said...

Sonali, this is incredible work and I eagerly await the next instalment of your successes. This is a great example of the "Check a Box. Save a Life." Sprint in action, and so many will be inspired and encouraged to act by learning of your efforts.

You said, "She [the Chief of Surgery] was ready to implement it and remembered having read the journal article ." This is a perfect example to call to action the thousands of healthcare students and junior professionals who can really help raise awareness about, and implement, this life saving intervention in operating rooms across the globe. The Chief had read the article (possibly even knew the statistics) and with a nudge in the right direction from you it has been piloted and continues to obtain momentum in a hospital in New Dehli, India. Countless patients will avoid harm and even death as a result of your leadership.

What a fantastic start to 2010! Good luck and enjoy this adventure...

Warmly, Andy

Shabnam said...

Great work, Sonali! It's so wonderful to see how you are able to have the checklist implemented in such a short time and have such wonderful outcomes. I remember having the same exact struggles as you, but time will improve many of the obstacles you feel you are facing. Just continue to help train the faculty and staff and they will incorporate it as they go. I'm so impressed with your work!!!

Shaun Noronha said...

Great work, Sonali!

A suggestion, though...
Given how clique-ish surgeons are, they might be reluctant to listen to a public health person about their "business". If you want to see changes in practice, I'd suggest you discuss it with senior surgeoans, and try to get them to present. That would be more convincing to the baccha surgeons.
Just a thought.

Anonymous said...

Sometimes I just think culture plays a trumping role. How many checklists do we already have that haven't really brought about any significant change in countries like India, let alone the United States? Eg: From personal experience, in spite of detailed ACLS checklists and protocols from institutions such as the AHA, it really is a minority that actually bothers to put them into practice and fact-checks everything. This is all the more so in public hospitals as compared to private ones. But then one can't really ignore the fact that there is a lot of cross-pollination between public and private doctors in India.

IMHO there is a general placidity when it comes to evidence-based medical practice in countries like India, something that I think is largely due to a combination of cultural inertia in the medical profession, internal power plays of dubious value, inadequate technological infrastructure that aids doctors in decision making, denial of the fact that medical knowledge has far surpassed the limits of human memory, financial conflicts of interest and a lot of bureaucracy to stifle professional responsibility. All of this serves to maintain the status quo.

In the end my thoughts always end with just one question: why is it that it's so incredibly difficult for independent audit studies to take place in India? Consultants and hospital superintendents cringe at the very thought of such a scientific study. We subconsciously KNOW that we are now beyond incompetent and yet we choose to remain in denial and block it out from our thinking - Thought Suppression, a classic psychological coping strategy http://en.wikipedia.org/wiki/Thought_suppression . Not very helpful...