Surgical Checklist Improves Quality of Care and Reduces Costs

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Previous research has indicated that the implementation of a surgical safety checklist before non-cardiac operations reduces major complications by up to 30 percent. New research from Brigham and Women’s Hospital (BWH) finds that not only does use of the checklist improve the quality of care by reducing surgical complications, but also may provide cost savings at the hospital level. This research is published in the September issue of Health Affairs.

“Our previous work showed a safety checklist for surgery saves lives. But what we have now found is that–even accounting for the costs of implementation–it saves dollars as well. We in medicine are running out of excuses for not taking a basic step like this seriously in every hospital,” said Atul Gawande, MD, MPH, senior author of the paper, surgeon in the Center for Surgery and Public Health at BWH, and associate professor in the Department of Health Policy and Management at Harvard School of Public Health.   

Researchers examined the costs of the World Health Organization (WHO) Surgical Safety Checklist over a one year period in the United States to determine whether use of the checklist could reduce costs at the hospital level. To determine cost, researchers estimated the cost of implementation and cost per use, weighed this against costs and rates of surgical complications determined by available evidence, and compared it to the cost of current practice.   

“When compared to the cost of current practice, the implementation and use of the checklist could save $103,829 annually for a hospital that performed 4,000 non-cardiac operations per year or about $25.96 saved per operation. If at least five major complications are prevented within the first year of using the checklist, then a hospital will recoup its investment within that same year,” said Marcus Semel, MD, a surgeon at BWH and lead author of the paper.  

The estimated cost was developed based both on the experiences of hospitals that have adopted the checklist and conversations with staff at those hospitals. The cost of implementation was determined by calculating the total time spent on implementation multiplied by the wages of those responsible for implementing, which typically included three champions or leaders of clinical departments, in collaboration with an implementation coordinator. Using these estimates, researchers determined an implementation cost of $12,635.   

The time taken to perform the actual checklist is approximately two minutes, and based on the experience of early adopters there has not been decreased productivity or disrupted work flow as a result of performing the checklist. Since the majority of the items on the checklist are verbal confirmations, there is no direct cost associated with performing each of the items on the list. One exception to this is the use of antibiotics to prevent infection. At hospitals that implemented the checklist, the rate of use of this medication increased by 26.5 percent. The resulting estimated cost per use of the checklist was between $5.50 and $22.  

Using available research, researchers determined the cost of any major surgical complication, and the rate of complications for all surgical procedures which they determined at $13,372 and 3 percent respectively. Researchers also used available evidence to determine the average number of inpatient surgical procedures and determined the cost of current practice by multiplying the number of non-cardiac inpatient operations performed per year by the complication rate and the cost per major complication. Researchers factored the effect the checklist had on reducing surgical complications based on previous research as well.  

Researchers then analyzed the overall cost of implementation and per use and determined that when compared to the current cost of practice, the WHO Surgical Safety Checklist could provide cost savings for hospitals throughout the United State that perform 4,000 non-cardiac surgeries annually.   

“Reducing complications and medical errors are an enormous benefit to everyone even when preventative efforts do not reduce costs,” said Semel. “Based on the findings from this and previous research, the WHO Surgical Safety Checklist can both improve the quality of patient care and reduce costs, and we would recommend the adoption of the checklist at institutions around the United States.”   

Researchers add that although additional benefits such as increased efficiency and staff retention were not included in this study, they may have the potential to add to the cost savings.  

This research was funded through the Harvard School of Public Health by a National Institutes of Health National Research Service Award.

Learn more about the Center for Surgery and Public Health or the Department of Surgery at BWH.

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