TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 7
November 2010

In this issue

-SAVVY: Checklists that improve care and reduce mistakes

-SKILLS: Convert checklists in your clinical head into a working checklist accessible to all

-SOUL: Seeing through their eyes
-STUMP THE SHRINK: What about program and behavior contracts?
-Until Next Time

Thanks for joining us for the November edition of TIPS and TOPICS (TNT).  Wishing you a great holiday season.

SAVVY

Checklists have been around a long time in healthcare in general, and behavioral health in particular. There have been checklists of diagnostic criteria; checklists of what accreditation standards to review in preparation for a quality survey; and checklists to make sure all the elements of the medical record are present and appropriately signed.  But checklists are taking on a new meaning in healthcare and behavioral health as the focus heightens on the quality and safety of care and on the prevention of mistakes. The goals of checklists are primarily to reduce error and adhere to the best practices in clinical care.

Tip 1

Consider checklists to promote best practices and reduce mistakes

”
A checklist is a list of action items arranged in a systematic manner that allows the user to record the completion of the individual items.” (Heitmiller,2009).  In aviation and industry, checklists have been used successfully in pre-flight checks as well as for emergency situations, trouble-shooting, and problem solving..

In “Is Your Doctor Using a Checklist?”, Lloyd I Sederer, MD, New York Office of Mental Health Medical Director and Jeffrey A. Lieberman, MD, Director, NYS Psychiatric Institute cover some points on checklists which are excerpted below:

• “Medical care has become a whole lot more complex…. Who can provide state of the art care and deliver complex treatments to numerous patients day after day without error? No one. It is simply not humanly possible to be error free.”
• Dr. Atul Gawande in his most recent book, The Checklist Manifesto: How to Get Things Right writes about the “19 Point Safe Surgery Checklist” that he pioneered through the World Health Organization (WHO). “When this checklist was tested in eight very diverse countries it reduced deaths by 47 percent and post-operative complications by 36 percent! To make his case personally, Gawande tells the story of how a patient he was operating on would have died of a complication during surgery had he not used his own checklist. But has this checklist been adopted universally, even if not welcomed? Not at all. Only 10 percent of U.S. hospitals employ or are planning to employ checklists.”

Why the reluctance to use checklists?  Drs Sederer and Lieberman explain.  But these reasons don’t just apply to doctors.  Think how much you can identify with these objections:

• “First, no one likes being told what to do, including doctors. A common reason for not doing what is proven to work is the rejection of “cookbook medicine.” That cry is amplified by statements that rigid rules constrain the art of medicine. But what will reduce what is called the “science to practice gap” in medicine (the gap between what doctors know and what they do)? In the delivery of mental health services, for example, as few as one in six people with depression receive minimally adequate care — even though detection, diagnosis and effective treatment can be routinized and vastly improved. This level of performance can be improved, and must be.”
• “Second, doctors are anxious about being sued. Anything that may be used as ‘evidence’ in malpractice law suits can evoke fear that it will be used by personal injury lawyers ready to pounce. While we will be silent about lawyers we will say that checklists and other means by which doctors demonstrate (in writing) they tried to do the right thing is the best protection should they be brought to court.”
• “Third, there is the time argument. Agreed, doctors do not have enough time to do all they need to do. Ironically, it is the lack of time, the rush to do all that needs to be done, that increases the risk of error, as doctors look for shortcuts and may make unfounded assumptions and decisions. A simple checklist has what engineers call a “forcing function,” an inescapable path that truly reduces errors. And reducing errors always saves time, if not now then surely later.”

The New York State Office of Mental Health is piloting a checklist for prescribing antipsychotic medications.  They developed this checklist with a group of experts after evidence became overwhelming that antipsychotic medications, while essential, carry many risks and are far from being prescribed according to the knowledge that exists about them. They are also very costly and a dollar spent unnecessarily on this treatment is a dollar less to spend on another treatment:

• “The checklist is a set of eight questions that begins by asking a prescribing doctor (or nurse with prescribing authority) whether the patient has a diagnosis that warrants the use of this class of medications. It goes on to ask about side-effects, patient preferences, using multiple medications at the same time (called polypharmacy), and the physical health of the patient.”
• “The checklist, which we call SHAPEMEDs (an acronym or abbreviation using the first letter or portion of a key word for the eight questions), does not tell the prescriber what to do. Instead it asks whether the doctor has considered a set of essential aspects of quality care. Key information that supports the principles that underlie these questions is supplied on the back of the form or by a roll-over hyperlink on its electronic version.”
• “I know that if SHAPEMEDs proves to be beneficial that I will encourage every patient and family I know to ask the doctor”…..are you using a checklist when you prescribe an antipsychotic medication?” Wouldn’t you want medicine to be as safe as science can make it be?”

References:

Genie Heitmiller, MD: “Checklists in Healthcare”. Society for Pediatric Anesthesia. October 16, 2009.
www.cisst.org/~cista/446/Papers/Checklists%20in%20Healthcare.pdf

Lloyd I Sederer, MD, Office of Mental Health Medical Director; with Jeffrey A. Lieberman, MD, Director, NYS Psychiatric Institute: “Is Your Doctor Using a Checklist?” March 2010.
http://www.omh.state.ny.us/omhweb/resources/newsltr/2010/mar

Tip 2

SAD PERSONS – A Checklist for Suicide Risk Assessment

This checklist has been around for decades; it’s just one example of how a checklist can be used in a variety of settings. The test can be administered by a social worker or other non-mental health care professional.  It is a screening tool only, and people with a high-risk score need further evaluation by a mental health professional. The risk-assessment tool assigns one point to each of 10 items on a risk-factor scale. The score is calculated from ten yes/no questions, with one point for each affirmative answer.

• Sex (male)
• Age less than 19 or greater than 45 years
• Depression (patient admits to depression or decreased concentration, sleep,  appetite and/or libido
• Previous suicide attempt or psychiatric care
• Excessive alcohol or drug use
• Rational thinking loss: psychosis, organic brain syndrome
• Separated, divorced, or widowed
• Organized plan or serious attempt
• No social support
• Sickness, chronic disease

This score is then mapped onto a risk assessment scale as follows:

0-4 Low
5-6 Medium
7-10 High

Modified SAD PERSONS Scale

The score is calculated from ten yes/no questions, with points given for each affirmative answer as follows:

• S: Male sex → 1
• A: Age <19 or >45 years → 1
• D: Depression or hopelessness → 2
• P: Previous suicidal attempts or psychiatric care → 1
• E: Excessive ethanol or drug use → 1
• R: Rational thinking loss (psychotic or organic illness) → 2
• S: Single, separated, widowed or divorced → 1
• O: Organized or serious attempt → 2
• N: No social support → 1
• S: Stated future intent (determined to repeat or ambivalent) → 2

This score is then mapped onto a risk assessment scale as follows:

• 0-5: May be safe to discharge (depending upon circumstances)
• 6-8: Probably requires psychiatric consultation
• >8: Probably requires hospital admission

Reference:

1. http://en.wikipedia.org/wiki/SAD_PERSONS_scale
2. Patterson; Dohn; Patterson (April 1983). Evaluation of suicidal patients: the SAD PERSONS scale. http://www.ncbi.nlm.nih.gov/pubmed/6867245
3. Oxford Handbook of Emergency Medicine. Third Edition. Page 609.

SKILLS

Checklists which enhance best practices and reduce errors are still very new in addiction and mental health treatment. The time is right to start innovating useful checklists. Robotic checklists should never replace clinical judgment.  But checklist-assisted clinical care can increase safety, quality and effective outcomes.

Tip 1
Make the checklist in your clinical head explicit and measureable

You probably already have a number of checklists you use now. When you move them out of your “clinical head” and formalize them on paper in a checklist, you can now study it and measure its effectiveness.  Try one checklist in a rapid cycle change process. Develop a checklist and try it out for a limited time. See if it helps clinicians be more consistent and safe. It doesn’t have to be perfect to start.

Staying with suicide risk assessment as a start, a checklist on handling suicidal ideation might look like this:

(i)  Talk with client live or by telephone as soon as possible to convey  concern and a sense of hope.
(ii)  Assess details of the suicidal ideation – precipitating events if any; frequency; content, how distressing?
(iii)  Assess details of a suicidal plan – general or specific; degree of lethality e.g., overdose of pills versus hanging or gun; how soon for an attempt e.g., can’t go on another day versus ruminating for months
(iv)  Assess access to suicidal methods e.g., storing six months of medication for a suicidal attempt; bought a gun yesterday or has easy access to family member’s gun collection
(v)  Assess mitigating and modifying factors e.g., strong religious beliefs that prohibit suicide; strong loyalty to children that would inhibit dying and leaving them as orphans
(vi)  Assess ability to have hope and to reach out for help if feeling very suicidal – “I really want to die, but I want to be there for my family so would reach out if I really had to and was scared of my impulsivity.”; degree of ability to ask for help even if feeling hopeless.
(vii)  Document this assessment in detail.

Try converting more of your “clinical gut” checklists into lists on paper, institutionalized in the assessment and treatment process.

Tip 2

Adapt successful checklists from other healthcare fields

There are several examples of the effective use of checklists have been published in recent years. Pronovost and his colleagues studied the checklist as a tool for the healthcare team to better understand the daily goals of patient care in the Johns Hopkins Hospital surgical intensive care unit (ICU).  The daily goals checklist was shown to increase the nurses’ and house staff’s understanding of the patient care plan from 10% to 95% over the span of 8 weeks and reduce length of stay (LOS) by 50%, from 2.2 days to 1.1 days.

Daily Goals Checklist

(i) What needs to be done for the patient to be discharged from the ICU?
(ii)  What is this patient’s greatest safety risk? How can we reduce that risk?
(iii)  Pain management and sedation
(iv)  Cardiac -volume status
(v)  Pulmonary -ventilator (plateau pressure, elevate head of bed)
(vi)  Mobilization
(vii)  Infectious disease -cultures, antibiotic levels
(viii)  Nutrition
(ix)  Medications -can any be discontinued?
(x)  Tests and procedures
(xi)  Review scheduled labs and x-rays
(xii)  Consultations
(xiii)  Communication with primary service
(xiv)  Family communication
(xv)  Can any catheters or tubes be removed?
(xvi)  Is this patient receiving DVT or peptic ulcer prophylaxis?
(xvii)  ICU, intensive care unit; DVT, deep venous thrombosis

Here’s what a Daily Goals Checklist might look like in a residential addiction treatment program:

Daily Goals Checklist

(i)  What needs to be done for the client to be discharged from residential treatment?
(ii)  What is this client’s greatest safety risk as regards relapse or continued substance use and recovery environment? How can we reduce that risk?
(iii)  Physical health needs – now and for ongoing care
(iv)  Emotional, behavioral, cognitive and mental health needs -now and ongoing care
(v)  Readiness to change and stage of change issues – motivational service needs now and for ongoing care
(vi)  Continuing care needs – treatment levels, referral and transition plan
(vii)  Recovery environment needs – living place, significant others, school or job, transportation, finances, legal liaison
(viii)  Medications -can any be discontinued?
(ix)  Psychometric testing
(x)  Consultations
(xi)  Review any results of test or consultations
(xii)  Communication with referral source
(xiii)  Family communication

Experiment with other checklists focused on what your data shows are your greatest challenges e.g., no show rates, premature discharge clients, repetitive brief acute care stays.

References:

Genie Heitmiller, MD: “Checklists in Healthcare”. Society for Pediatric Anesthesia. October 16, 2009.
www.cisst.org/~cista/446/Papers/Checklists%20in%20Healthcare.pdf

Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving
communication in the ICU using daily goals. J Crit Care 2003; 18:71-75.

SOUL

My sister in Australia sent me this poem.  While it was written about elderly people, the poem’s sentiments certainly can apply to our clients- those with addiction problems, psychotic illness or other stigmatizing disorders.

I wonder how many older adults this poem speaks for?  “It was reportedly written by a woman who died in the geriatric ward of Ashludie Hospital near Dundee, Scotland. It was found among her possessions and so impressed the staff that copies were made and distributed to every nurse in the hospital. Though it was addressed to the nurses who surrounded the woman in her last days, it cries for recognition of a common humanity…it could have been written to all of us.”

What Do You See, Nurse?

What do you see, nurse… what do you see?
Are you thinking – when you look at me:
“A crabbed old woman, not very wise;
Uncertain of habit with far-away eyes,
Who dribbles her food and makes no reply
When you say in a loud voice ‘I do wish you’d try.”
Who seems not to notice the things that you do
And forever is losing a stocking or shoe;
Who, resisting or not, lets you do as you will
With bathing and feeding, the long day to fill.
Is that what you’re thinking, is that what you see?
Then open your eyes, nurse. You’re not looking at me!

I’ll tell you who I am as I sit here so still.
As I move at your bidding, eat at your will:
– I’m a small child of ten with a father and mother,
Brothers and sisters who love one another;
– A young girl of sixteen with wings on her feet,
Dreaming that soon a love she’ll meet;
– A bride at twenty, my heart gives a leap,
Remembering the vows that I promised to keep;
– At twenty-five now I have young of my own
Who need me to build a secure, happy home.
– A woman of thirty, my young now grow fast.
Bound together with ties that should last.
– At forty, my young sons have grown up and gone,
But my man’s beside me to see I don’t mourn;
– At fifty once more babies play ’round my knee
Again we know children, my loved ones and me…

Dark days are upon me, my husband is dead.
I look at the future, I shudder with dread.
For my young are all rearing young of their own,
And I think of the years and the love that I’ve known.
I’m an old woman now, and nature is cruel.
‘Tis her jest to make old age look like a fool.
The body, it crumbles, grace and vigor depart.
There is a stone where I once had a heart.

But inside this old carcass a young girl still dwells,
And now again my bittered heart swells;
I remember the joys, I remember the pain
and I’m loving and living life over again;
I think of the years, all too few, gone too fast
And accept the stark fact that nothing can last;
So open your eyes, nurse, open and see…
not a crabbed old woman.
Look closer… see me!

NURSE’S RESPONSE – Author Unknown

What do we see, you ask, what do we see?
Yes, we are thinking when looking at thee!
We may seem to be hard when we hurry and fuss,
But there’s many of you, and too few of us.
We would like far more time to sit by you and talk,
To bath you and feed you and help you to walk.
To hear of your lives and the things you have done;
Your childhood, your husband, your daughter, and your son.

But time is against us, there’s too much to do –
Patients too many, and nurses too few.
We grieve when we see you so sad and alone,
With nobody near you, no friends of your own.
We feel all your pain, and know of your fear
That nobody cares now your end is so near.
But nurses are people with feelings as well,
And when we’re together you’ll often hear tell
Of the dearest old Gran in the very end bed,
And the lovely old Dad, and the things that he said.

We speak with compassion and love, and feel sad
When we think of your lives and the joy that you’ve had.
When the time has arrived for you to depart,
You leave us behind with an ache in our heart.
When you sleep the long sleep, no more worry or care,
There are other old people, and we must be there.
So please understand if we hurry and fuss –
There are many of you, and too few of us.

STUMP THE SHRINK

Here are some questions about Program Contracts in addiction treatment settings posed by an addiction counselor in Outpatient Services.  I have responded next to each of his questions.

Good afternoon doctor:
I have a question that I’ve been thinking about- and possibly been confusing myself with this issue. I have mixed feelings about it and I’m weighing the pros and cons. It’s about placing clients on contracts whether for inconsistent group and 1:1 therapy attendance issues or substance use after a baseline, etc.  I can see the positives but then there are a few negatives. They are in place to hold a client accountable. They are to be beneficial and help as a tool for counselors and team to be supportive towards the clients in their recovery.

Clients follow certain stipulations of the contract that meet their needs and the part I have a problem with is this: if they do not adhere to the contract rules they will be discharged for non-compliance, sent back to the assessor, etc.

My questions are:

1.  Is there a contract that can be made that is seeming to be less punitive?

Rather than a contract, which seems to be focused on behavior compliance, I’d suggest seeing poor attendance or substance use as indications of a less than adequate outcome of the therapeutic alliance and treatment plan.  If the outcomes of any illness or treatment plan are not good, the next step is to do an assessment with the client on what is not going well that they don’t turn up for appointments or can’t stay abstinent (if that is what they are working on).

There may be a variety of explanations that arise from that collaborative assessment: you are working on goals they are not interested in like abstinence when they just want to cut back.  Or they want to come to treatment, but are overwhelmed with transportation problems or a co-occurring disorder that compromises their managing their time well.  Or they have triggers and cravings to use for which they need more and better coping skills.

Depending on the cause(s) of the inadequate outcomes of poor attendance or substance use, the treatment plan would be discussed and changed.  Motivational “discovery” work may need to be the focus not “recovery” work yet for which they are not ready.  If they are wanting treatment, then they will collaborate on a treatment plan that has strategies in a positive direction e.g., I will stay away from that friend; or practice peer refusal skills in group; or get an alarm clock so I wake up in time to get to my appointments or whatever.

2.  Are contracts in your experience effective as a tool for behavior modification?

What I am saying is that the focus is not on a behavior contract, but on treatment plan changes based on an assessment of what and why things are not going well.  If the person is mandated and is just “doing time” not “doing treatment” in good faith, and is then not showing up or is repeatedly using substances and not open to changing the treatment plan in a positive direction, you can call the question and let the person know that they have a right to choose no further treatment. You will then need to let the referral source know that the client is not interested in treatment and therefore should do their time in the criminal justice system or take whatever consequences were originally presented.

3. Do you have information I can share with my colleagues regarding program contracts and the methodology of their effectiveness, if at all? Or do you have examples of contract(s) we can modify to be culturally sensitive?

Basically, I am saying that I don’t suggest contracts as a way of trying to get compliance.  That puts the emphasis on behavior change rather than treatment and attitude change and helping a person move through stages of change to self-responsible, accountable lasting change.  The goal of treatment is not to have someone comply with the program, but to be attracted into recovery for lasting change that is sustained beyond the confines and contracts of a program.  You may get someone to comply with a behavior contract if you have enough leverage to hold a negative consequence over his or her head.  But what happens when they are no longer under your program control?  Is their compliance translating into internal behavior and attitude change in the context of a therapeutic alliance? Or are they complying with a contract in order to just get through your treatment program and “graduate”.

Until Next Time

I look forward to seeing you in later December.

David