A COVID-19 parable
Sally started work as a client care representative at ABC Veterinary Hospital 6 weeks ago. She was just starting to understand the work flow when everything changed. There have been emails every 3 days with new processes, a lot of stress at work due to fear of potential shorter hours, and everything takes longer with curbside receiving.
On Saturday, she got a call from Mrs. Smith about her sick, coughing cat, Fluffy. She determined that the cat did need to be seen, that Mrs. Smith had not had a positive COVID-19 test, and she asked her to wait outside in her car and call when she arrived. Sally put the appointment on the book.
When Mrs. Smith arrived, Jennifer, a staff member went outside to get the cat. Jennifer couldn’t remember whether she was supposed to wear a lab coat or gloves and which type of mask. It was busier than expected and she thought it would be just quicker to grab the cat and come back inside than put on the wrong stuff. She knew they were supposed to be preserving surgical masks and all the cloth ones in the hospital were in the wash. When she got outside, Mrs. Smith obviously had a respiratory illness. As the car window was opened, Mrs. Smith had a coughing fit and handed over the sick cat not in a carrier.
Five days later, Jennifer had a fever, cough, and was diagnosed with COVID-19.
Could this happen in your hospital?
This situation is probably everyone’s nightmare and also sadly easy to image. In this case, the initial screening questions included asking about a diagnosis of COVID-19 but Sally forgot to ask if the owner was ill. Because Jennifer was not totally clear on what she was supposed to wear for each type of curbside admission, she just didn’t wear anything at all. Because no one thought about whether the cat could also have COVID, it is unclear whether Jennifer was infected by the owner, the cat**, or outside of work.
There had been multiple discussions about how to handle these situations both in emails and at staff meetings. However, the emails had been coming at a really fast rate and it was hard to keep track.
Change is hard
Making change to work flow is hard. It is even harder when changes happen multiple times in a short period. It is difficult to make sure work flow changes are rolled out consistently and followed by everyone, on every shift, no matter the day or time. As a business owner or manager, it is simply not possible to watch every process every time. You have to be able to set a system and trust that your staff will implement. However, if the system, is too hard, is not explained well, or is unclear, staff will default to their personal preference.
Checklists to the rescue!
As some of you know, one of my great geeky interests is the use and implementation of checklists. Humans have limitations in their memory and attention spans. We decline in accuracy and speed when we have to make decisions that involve multiple variables. Precise directed reminders can help avoid missing crucial steps in a process.
The airline industry proved that flight checklists make travel safer. Likewise, in 2009, a landmark study demonstrated that the use of a simple three part checklist made surgery safer. A meta-analysis of 50 studies confirmed that compliance with sepsis care bundles decreased mortality.
In veterinary medicine, checklists have been proven to:
Checklists are very useful with infectious disease. In fact, one of the first studies that showed the power of checklists was published in Lancet in 2005. In this study, households in Pakistan were randomized to either receive public health visits to provide soap, handwashing instructions, and a 6-point list of when to wash or to just receive visits to record disease incidence. At the end of the study period, the households who received the soap and checklist had 53% less diarrheal diseases and 50% less pneumonia. Interestingly, the researchers noted that most of the households in the control group actually had soap and thus the difference was attributed to the clear 6-point checklist of WHEN to wash.
Checklist design matters
The way checklists are designed and how they look impact whether they are effective. Studies have shown that checklists are more likely to be used if they use precise and simple language, if the most critical items are at the beginning, if they fit on one page with lots of white space, and if they use an easy to read, san serif font.
The checklist implementation process is crucial
The impact of surgical checklists on decreasing complications and mortality has been shown to be directly tied to the implementation process. Studies have shown that successful implementation involves both explaining WHY the checklist is needed and then showing HOW exactly to use it in a detailed way. In hospitals where leaders did not explain the rationale or directly show how to use the checklist, the surgery checklist was not fully used and the expected decreases in complication were not seen.
Implementation of COVID-19 checklists
In order to protect our veterinary staff, COVID-19 checklists are needed:
1) For those scheduling appointments to make sure the right screening questions are asked
2) For those receiving at the curbside
3) For animal handling inside the hospital
4) For those cleaning the hospital
The checklists will be strongest and most likely to be used if they are developed with full input of the staff doing the work. Once developed, they should be rolled out to all staff with an explanation for WHY and a clear explanation of HOW you expect the checklist to be used.
Fussy Checklist Details that Matter
One of the most common implementation mistakes I see is sending new protocols via email and then expecting they will be used. We have to remember that most people’s emails are overloaded and more importantly, are not being accessed in the moments we are providing patient care.
While confirming the introduction of a protocol in an email is appropriate, it alone is not enough. Additional steps to take include:
1) Have an easy to find electronic location where all protocols are stored.
This might be a short cut to a protocol book on every desk top. It might be a clear folder on a server tree or a clear location on your intranet. The keys are TRAIN people where to go for information, DATE your protocols, and DELETE old versions.
2) Discuss crucial protocols one on one.
In a small hospital, this may be the owner explaining to each person the new procedure. In a larger hospital, it may be the hospital administrator teaching the supervisors who then go over the new process with their team. Having each staff member initial a new protocol helps confirm they understand the process and its importance.
3) Put checklists where the work happens.
For COVID-19 checklists for scheduling, the proper location might be laminated and taped to each scheduling computer or phone. COVID-19 checklists for curbside receiving could be laminated and placed on patient clipboards. Cleaning checklists might be posted with the cleaning supplies.
4) DATE your protocols and checklists.
Especially if protocols are changing quickly, you want to make sure everyone knows that the checklist they have is the correct one. I like to make sure protocols and checklists have the date in the document title (so it is searchable by date on your computer) and also in the document footer so it is clear in any printed version.
5) LISTEN to feedback from your staff.
Most airline checklists go through several rapid cycles of implementation, testing, and revision to get to the most workable version. If you are open to feedback, your staff will be more engaged in the process AND more likely to use the final version.
Local is Best for COVID-19 Checklists
Checklist and protocols will work the best if they are developed by your team for your hospital. In addition, recommendations are changing rapidly. That being said, here are some resources that will help you develop checklists that will keep everyone safe in your hospital:
Coronavirus Disease: Owner Contact Guidelines
AVMA Minimizing COVID-19 Exposure
Curbside Check-in and Triage
Do you have awesome COVID-19 checklists you’d love to share? Please put them in the comments!
Stay Safe and Wash your hands.
**While there is evidence that cats can get sick from COVID-19 and pass the virus cat to cat, there is no current evidence that people can get the virus from pets.