Understanding the Surgical Checklist with Dana-Farber Cancer Institute Physician Scientist Dr. George Molina

https://doi.org/10.56927/108341

Interview by Natalie Wing

HHPR Associate Editor Natalie Wing interviewed Dr. George Molina, MD, MPH, who is a surgical oncologist at the Dana Farber Cancer Institute and at the Brigham and Women’s Center for Surgery and Public Health. He also conducts research in public health regarding access to care and the impact of the surgical safety checklist. He completed a residency program in General Surgery at Massachusetts General Hospital and a two-year post-graduate fellowship at Ariadne Labs. He holds an MPH in Quantitative Methods from the Harvard T.H. Chan School of Public Health, an MD from Harvard Medical School and a BS in Cellular and Molecular Biology from Johns Hopkins University.

Natalie Wing (NW): Thank you again, Dr. Molina, for meeting with me. Let’s begin with your work. Could you describe your career to our readers, overall?

Dr. George Molina (GM): I'm a surgical oncologist, and I treat patients that have abdominal cancers—mostly pancreatic cancer, stomach cancer, liver cancer. I work closely with medical oncologists or doctors that give chemotherapy and with radiation oncologists. This is very much a team approach. So that's my clinical career as a surgical oncologist. And then, I also have a research career, which is aligned with my clinical work. And that is, how do we improve access to the care my colleagues and I provide for these cancers? We're making very significant advances in the kinds of treatments that we have that can prolong life, and in some patients, cure them. But there's a gap—a gap in who actually has access to them. So my research really deals in that space: how do we improve access to complex GI cancer care?

NW: I remember you mentioned in an earlier conversation that another field of research that you were working on is a surgical checklist. Can you describe this checklist in more detail? What inspired you to create it and what does it entail?

GM: That's my other line of work, which I've been doing for several years. That work is really centered around how do we make surgery safer in the operating room. Now more than 10 years ago, Atul Gawande, an academic surgeon, with many other colleagues and the World Health Organization, set out to focus on how to make surgery safer. What they decided to focus on was on a checklist, which included things that should be done for every operation, regardless of why or where it's being done. And the checklist is made up of three “pauses”. It's meant to be items that the team in the operating room (a nurse, a surgeon, a scrub tech, the anesthesiology team, and anybody else that forms that team) discuss and make sure that are being done. The team makes sure that everybody's on the same page.

So there's the first pause; this varies depending on your hospital. But the first pause is before the anesthesia is started–before the patient is put to sleep, and they confirm the patient's name, scheduled procedure, the site of the procedure (is it the right side or left side of the extremity, etc.). Again, they make sure that everybody's on the same page, including the patient. Oftentimes, many hospitals will include the patient in this discussion—the patient will say their name and date of birth–to confirm it's the right patient–and say, in their own words, what surgery they're having (to prevent operating on the wrong side, or the wrong operation being done on the the wrong patient). Then, other items include a discussion between the various team members about estimated blood loss and if all the instruments that the surgeon is going to need are available. In many parts of the world—not only in the US—an operation is started and stopped because they don't have the necessary equipment.

And sometimes, an incision can be made for no reason. That doesn't really happen to us, because we have so many resources, but you can imagine, in a place with limited resources, that can be a problem. So before anything has happened, you confirm all these things.

Other items are antibiotics. There's been data, with strong evidence, showing that antibiotics should be given before an operation starts, and actually up to 30 minutes to an hour before the incision is made to have the best protective effects. So, the team has to discuss which antibiotic to give–it depends on what part of the body you're operating on–and then whether it's been given at the appropriate time. Those are some of the elements of the first pause and then the second pause happens.

The patient is asleep—this is before the surgeon makes the incision—and once again, you confirm important aspects of the operation to make sure that nothing has changed from the previous pause. And depending on where the first pause is done, maybe not all members are there,? The primary surgeon, the attending, may not be there at the first pause—one of his assistants might be there instead. So usually in this pause, there's the introduction of all team members, where everybody can speak up and say their name. And then the way that I like to conduct the checklist—and many hospitals have added this extra line—is where the surgeon will make a comment inviting anyone to speak up if they see something that concerns them throughout the operation. This is because of the historical and cultural nature of surgery: it's been a very top-down hierarchical model, where usually the surgeon is considered the captain of the operating room, and there have been these strict unspoken rules of who can speak up and when they can speak up. But the checklist really tries to do away with that vertical nature, vertical hierarchy–make it more horizontal–and empower professionals in the operating room that historically have not been empowered to speak up.

Then the third pause is usually when the operation is finished or is about to finish–before the patient leaves the operating room–to confirm the name of the operation–because sometimes you might be planning one thing, and it might change a little bit, depending on what you see. And usually, as a surgeon, you have to talk to patients about that. This is to really document the appropriate name of the operation that was done and any specimens that have been removed. If you're a cancer surgeon, you’re removing an organ with a cancer, and sending it to pathology. There have been, however, lots of specimens that don't make it to pathology, and when you lose a specimen, it can be problematic. If the person ever had cancer, for instance, you need more information to dictate treatment and for prognostic purposes–how aggressive the cancer is, whether lymph nodes are involved, whether the margins are positive or negative, will really dictate whether this person, has a lower survival or higher survival.

And then there are various other components to account for, like what is the management plan for pain? Where is the patient going? Are they going to the ICU? Or are they going to the regular floor?

And, kind of taking a step back–for all of these three pause points, hospitals throughout the world have modified the checklist to include whatever other item may be pertinent to their local customs and processes of work. So one thing that's been added in many hospitals is fire risk, because there have been fires in the operating room.

That's the gist of the checklist in my work. We have shown that using the checklist leads to fewer complications and lower mortality, and it actually improves teamwork, communication, the perception of the culture of safety in the operating room, respect for one another in the operating room.

NW: What's the process of implementing those changes—like accounting for fire risks—into action? Is the checklist widespread at this point, or is there still variation?

GM: So it's a more nuanced answer, I would say. The checklist is used everywhere, now. The checklist is widely used throughout the world—there's probably not an operating room that doesn't use a form of the checklist. In the US, it's actually part of our Center for Medicaid and Medicare Services requirements, so you have to have a checklist of some kind in your hospital.

The issue that we're finding is how well it's used. That's what varies: how well teams are actually using the checklist. Are they just checking things off? Are they discussing them? We think that the power of the checklist comes from when the entire team is engaged, and performing the checklist, and discussing the various items. The power of the checklist is to give everybody a voice and to allow everybody to speak up, so mistakes can be found. We're all humans; things can happen, but the sooner somebody identifies a possible mistake, the sooner you stop it or correct it, so that the effect on the patient can be minimal to none.

So yes, a checklist is used everywhere for the most part, but how well it's used is varied. Right now, our work is dealing with how to help teams improve their checklist performance, in real time to change their behaviors.

NW: Given the hierarchy that you mentioned before, how difficult do you think it is to properly implement the checklist to elicit communication and teamwork in operating rooms?

GM: I think it can be hard. For our work, we had a statewide initiative in South Carolina, a few years back. There are about 50 hospitals in the entire state that started the program. This was an initiative—a state level initiative—with all the hospital leadership involved and interested in implementing the checklist. We had various components of what entailed this checklist implementation, so at the end of the day, only 13 hospitals actually completed the program.

It's hard, because it takes local champions; it actually takes a surgeon, for instance, to be respected and somebody that people listen to to change behaviors. It's sometimes much easier to want to move things along in the interest of time, than taking these pauses to discuss these things. People feel like, “Oh, it won't happen to me or to my patient.” So at the patient level, it's hard sometimes to quantify the severity of these errors, but they do happen, and it can be hard. The implementation piece we have seen is much harder than what initially was thought.

NW: So, hypothetically, after proper surgery checklist implementation, what do you see as the next steps?

GM: So the first step would be forming a team that's going to take it upon themselves to modify the checklist to local customs, and then implement it and then do a widespread implementation. But then the hard part is sustaining this effort, making sure that teams continue to use the checklist, and then modifying the checklist as things come up. Sometimes checklists, after being initially modified, become too long; everybody wants to add this or that based on anecdotal experiences.

So the next stage is not just using the checklist and making sure it is sustained and used effectively, but also maybe finding some items are not needed; maybe some items that we initially thought would be needed are replaced or removed or new items come up, because things happen; the process of care changes.

Part of the work that the lab is doing is emphasizing this idea that we should revisit our checklist. It shouldn't be that you modified it, formed a team, implemented it, and then just let it be; every five years, you should revisit your checklist, bring back this group of people to revisit the checklist, see how things are going, see what the uptake has been, see how sustainable it's been, and then, reignite those efforts, so there is quality improvement work. It's an ongoing effort; it's not just “Okay, it's done; we're done with it.” It really takes a sustained effort.

NW: Thank you for your answer. As my final question, I’m wondering: what changes have you seen as a result of the checklist?

GM: So it's a hard question to answer, honestly, because I trained, and have been working, in the checklist era. So the checklist first came out in 2009. I started my training as a surgeon in 2011. The hospital that I was at was already using the checklist. But what I've been told by other surgeons is that, before, the patient would be in the operating room, they would be intubating the patient, and the surgeon would just come in, scrub, put on the gown and start operating. There wouldn't be any discussion of what procedure we're doing; the surgeon would assume that everybody knew what was happening, that everybody had reviewed the paperwork, the charts, and that everybody knew why this patient was here and what surgery they were having. Maybe there had been some discussion between the surgeon and the scrub tech about the instruments, but there wasn't a culture of discussing all of these items, as a team, and now there is, and nurses have been empowered to make sure that these things are happening. Nurses have really taken on the baton, I would say, quite a bit, and they track the implementation of the checklist—at least the hospitals that I've worked at. And there's a real sense of discussion, a real sense that everybody understands what's happening.

NW: Thank you so much. That was the last of my questions. Thank you again for your time, for your expertise, and again for everything.

GM: Of course, it was my pleasure.