Recently, I was working on a lecture about systems-based healthcare and wanted to discuss one aspect of this important concept: protocols and checklists.

In very rare circumstances, surgeons have to change what they’re doing on the fly. However, most of the time we know exactly what we’re going to do and how we’re going to do it. With this in mind, it’s important to stress that the systems we create – the habits we construct – are incredibly important, and when they fail can be catastrophic.

For those who are interested, a systems-based medical approach to patient care includes the following topics as determined by the ACGME (American College of Graduate Medical Education – the accrediting body for the MD medical education world):

1. Working effectively in various health care delivery settings relevant to the clinical specialty.
2. Coordinating patient care within the system.
3. Incorporating considerations of cost awareness and cost-benefit analysis.
4. Advocating for quality patient care and assisting patients in dealing with system complexities.
5. Working in interprofessional teams to enhance patient safety and improve patient outcomes.
6. Participating in identifying system errors and implementing potential systems solutions.

Ask yourself the following question: “Do I practice medicine with these concepts in mind?” I’ll tell you honestly that in some cases I do not. For example, I rarely spend much mental energy considering the cost of what I do in favor of working on the benefit side of the patient care equation. The idea of spending a significant amount of my time worrying about cost of treatment is anathema to me. Am I an accountant or a physician? This, of course, is the reason I detest medical insurance companies. They act as if they are more concerned about their bottom line profits than whether my patient should have this or that treatment.

And, of course, that is exactly what they’re doing – by law. As a corporation their legal purpose is to make money for their shareholders. That’s US law, not my opinion. My goals are divergent from the insurance companies, since I am paid to do two things: care for patients and teach our trainees.

But I digress.

An important part of the systems-based medical approach is number six above: preventing medical errors. One way to prevent errors is to be prepared. For example, I strongly advocate preparing well for any procedure beforehand and being as efficient as possible. If you are going to perform a wound debridement it would be optimal to spend a few minutes setting up all of the materials and instruments necessary to do the procedure. It makes no sense to undress the wound, then walk out of the room for a scalpel, then have to leave again for a different instrument and new dressing supplies or other instruments. Instead, take the time to prepare.

How might we prevent inadvertent mistakes? First, for those of us working with trainees, we have to realize that like all of us, no one is perfect, and our trainees are still learning. This is why I rarely fully trust any of my trainees with my patients. Sorry residents – that’s just how it is.

Now, preventing unfortunate circumstances from occurring takes two steps. The first is to create a checklist of the critical steps of the process. The second is to gather all of the necessary materials prior to the procedure.

The checklist is an incredibly powerful tool that many of us take advantage of without even realizing it. We usually run through procedures in our minds before actually doing it to make sure we haven’t forgotten anything. What if we were to do this on paper in a more formalized manner? Working with checklists essentially creates protocols for predictable circumstances.

As an example take a look at the image below. This is a nail procedure set up instruction image that I created for my medical assistants. For a while we were having efficiency problems when they wouldn’t set up for everything I’d need when doing a toenail procedure. I would have to go in and out of the room to acquire the correct instruments, which was highly annoying. This problem was easily rectified with a protocol change.

Now I simply see my patient, obtain consent, anesthetize the digit, and let my staff know to set up for a nail procedure. This improves efficiency and looks much more professional from a patient perspective. To take this one step further, I could have created a physical checklist with all of the pivotal steps in the process. The same type of resource can be successfully created for any procedure, including wound care and surgeries.

Industries, like airlines and military among others, have made using protocols and checklists regular behaviors to all of our benefit. Atul Gawande, MD, PhD discusses these concepts further in his excellent book The Checklist Manifest, which I highly suggest you read. Until then, consider how checklists and protocols fit into your medical practices.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]