title: A 10-Item Checklist Improves Reporting of Critical Procedural Elements during Transurethral Resection of Bladder Tumor.
abstract: OBJECTIVE
  Previous studies have demonstrated significant variation in recurrence rates after transurethral resection of bladder tumor, likely due to differences in surgical quality. We sought to create a framework to define, measure and improve the quality of transurethral resection of bladder tumor using a surgical checklist.
  
  
  METHODS
  We formed a multi-institutional group of urologists with expertise with bladder cancer and identified 10 critical items that should be performed during every high quality transurethral bladder tumor resection. We prospectively implemented a 10-item checklist into practice and reviewed the operative reports of such resections performed before and after implementation. Results at all institutions were combined in a meta-analysis to estimate the overall change in the mean number of items documented.
  
  
  RESULTS
  The operative notes for 325 transurethral bladder tumor resections during checklist use were compared to those for 428 performed before checklist implementation. Checklist use increased the mean number of items reported from 4.8 to 8.0 per resection, resulting in a mean increase of 3.3 items (95% CI 1.9-4.7) on meta-analysis. With the checklist the percentage of reports that included all 10 items increased from 0.5% to 27% (p <0.0001). Surgeons who reported more checklist items tended to have a slightly higher proportion of biopsies containing muscle, although not at conventional significance (p = 0.062).
  
  
  CONCLUSIONS
  The use of a 10-item checklist during transurethral resection of bladder tumor improved the reporting of critical procedural elements. Although there was no clear impact on the inclusion of muscle in the specimen, checklist use may enhance surgeon attention to important aspects of the procedure and be a lever for quality improvement.
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York. Electronic address: cba2125@cumc.columbia.edu.
authors.forename: Christopher
authors.initials: C
authors.lastname: Anderson
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Ryan
authors.initials: R
authors.lastname: Weber
authors.affiliation: Department of Urology, University of Utah, Salt Lake City, Utah.
authors.forename: Darshan
authors.initials: D
authors.lastname: Patel
authors.affiliation: Department of Urology, University of Utah, Salt Lake City, Utah.
authors.forename: William
authors.initials: W
authors.lastname: Lowrance
authors.affiliation: Department of Urology, University of Oklahoma, Oklahoma City, Oklahoma.
authors.forename: Adam
authors.initials: A
authors.lastname: Mellis
authors.affiliation: Department of Urology, University of Oklahoma, Oklahoma City, Oklahoma.
authors.forename: Michael
authors.initials: M
authors.lastname: Cookson
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Lang
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: Daniel
authors.initials: D
authors.lastname: Barocas
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: Sam
authors.initials: S
authors.lastname: Chang
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Newberger
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Montgomery
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Alon Z
authors.initials: AZ
authors.lastname: Weizer
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Cheryl T
authors.initials: CT
authors.lastname: Lee
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Kava
authors.affiliation: Department of Urology, Hartford Hospital, Hartford, Connecticut.
authors.forename: Max
authors.initials: M
authors.lastname: Jackson
authors.affiliation: Department of Urology, Hartford Hospital, Hartford, Connecticut.
authors.forename: Anoop
authors.initials: A
authors.lastname: Meraney
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Daniel
authors.initials: D
authors.lastname: Sjoberg
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Bernard
authors.initials: B
authors.lastname: Bochner
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Machele
authors.initials: M
authors.lastname: Donat
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Harry
authors.initials: H
authors.lastname: Herr
mesh_terms: D057189:Checklist / Q000706:statistics & numerical data*; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D058996:Quality Improvement; D058028:Research Report; D012189:Retrospective Studies; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data
keywords: checklist; quality improvement; surgeons; urinary bladder neoplasms; urologic surgical procedures