Development and Implementation of a Coronary Care Unit Quality Improvement Checklist

Abstract

Introduction: Real time checklists, adopted from high reliability industries, have been used in many healthcare settings to assure that key care deliverables and processes are applied consistently. The purpose of this quality improvement initiative is to describe the development and implementation of a daily rounding critical cardiac care checklist and assess its impact on increasing compliance with guideline-recommended cardiac performance measures. Methods & Design: This is a prospective, observational cohort study in the coronary care unit (CCU) of a university-affiliated major teaching hospital in southeastern Michigan, from Jan 2014-Jan 2015. Each CCU cardiac patient served as their own control, utilizing each patient day for monitoring of adherence to 20 key care deliverables (based on eligibility) as audited by a quality technician using an aligned checklist. The rate of adherence to the items on the checklist, and the rate of corrections which occurred within 24 hours of being identified as an omission were measured monthly. The results were then summed up into four quarters and compared between teaching and non-teaching services. Results: During the study period, the total number of patients enrolled was 550 patients. These patients were followed for a total number of 1457 days. The overall rate of initial adherence to the items on the checklist was 88.4%, and it improved to 95.5% with the use of the checklist in the final adherence rates. Both initial and final rates of adherence were found to be higher on the teaching service compared to the non-teaching service. Conclusion: The use and application of a daily CCU checklist by an assigned quality technician can identify and correct deficiencies in desired care. Despite the intensity of the interventions, the enhanced engagement and alignment of the nursing and physician staff and the reliable processes put into place, the goal of achieving 100% adherence rates to eligible and appropriate clinical measures was not achieved. This project provided a great deal of insight into the barriers, challenges and limitations that need to be overcome for successful implementation, utilization, value and sustainability of an applied healthcare checklist, to improve intended and desired performance measures and drive favorable outcomes in a real world setting.