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Original Investigation
March 2015

A Checklist-Based Intervention to Improve Surgical Outcomes in Michigan: Evaluation of the Keystone Surgery Program

Author Affiliations
  • 1Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
  • 2Surgical Innovation Editor, JAMA Surgery
JAMA Surg. 2015;150(3):208-215. doi:10.1001/jamasurg.2014.2873

Importance  Previous studies of checklist-based quality improvement interventions have reported mixed results.

Objective  To evaluate whether implementation of a checklist-based quality improvement intervention—Keystone Surgery—was associated with improved outcomes in patients in a large statewide population undergoing general surgery.

Design, Setting, and Exposures  A retrospective longitudinal study examined surgical outcomes in 64 891 Michigan patients in 29 hospitals using Michigan Surgical Quality Collaborative clinical registry data from 2006 through 2010. Multivariable logistic regression and difference-in-differences analytic approaches were used to evaluate whether Keystone Surgery program implementation was associated with improved surgical outcomes following general surgery procedures, apart from existing temporal trends toward improved outcomes during the study period.

Main Outcomes and Measures  Risk-adjusted rates of superficial surgical site infection, wound complication, any complication, and 30-day mortality.

Results  Implementation of Keystone Surgery in 14 participating centers was not associated with improvements in surgical outcomes during the study period. Adjusted rates of superficial surgical site infection (3.2% vs 3.2%, P = .91), wound complication (5.9% vs 6.5%, P = .30), any complication (12.4% vs 13.2%, P = .26), and 30-day mortality (2.1% vs 1.9%, P = .32) at participating hospitals were similar before and after implementation. Difference-in-differences analysis accounting for trends in 15 nonparticipating centers and sensitivity analysis excluding patients receiving surgery in the first 6 or 12 months after program implementation yielded similar results.

Conclusions and Relevance  Implementation of a checklist-based quality improvement intervention did not affect rates of adverse surgical outcomes among patients undergoing general surgery in participating Michigan hospitals. Additional research is needed to understand why this program was not successful prior to further dissemination and implementation of this model to other populations.