From Boeing to Brookdale: How Checklists Are Remaking Senior Living

The nation’s largest senior living provider has been able to cut costs and improve resident wellness by implementing a seemingly simple innovation that the aviation industry pioneered … 80 years ago.

That year was 1935. The place was Wright Field in Dayton, Ohio, where a new type of aircraft, the Boeing Model 299, was taking the air.

Boeing was about to lock up a critical deal with the U.S. Army Air Corps for the planes, and this flight was part of final evaluations. But after a smooth takeoff, disaster struck quickly. The aircraft stalled and crashed.

Pilot error was identified as the cause, spurring talk that the 299 was “too much plane for one man to fly.” The future of Boeing was uncertain if the 299 was not viable. How did the company overcome the plane’s dangerous reputation?

Boeing B-17, U.S. Air Force photo

Boeing B-17, U.S. Air Force photo


By implementing checklists for takeoff, flight, pre-landing and landing, crews were able to safely fly the 299, which went on to be a huge success under a more familiar name: the B-17.

Prior to the B-17, airplanes were simple enough to fly without rigorous checklists to ensure safety. The plane’s history demonstrates the enormous power that checklists can have when it comes to executing complex tasks successfully, and yet other industries, including health care, took a long time to take a page out of aviation’s book. It wasn’t until Atul Gawande’s bestselling 2009 book The Checklist Manifesto that the idea of checklists in operating rooms became commonplace.

And now, checklists are becoming more common in another realm that is becoming more complex: senior housing and care.

Brookdale Senior Living (NYSE: BKD), by far the nation’s largest owner and operator, has managed to significantly cut costs and reduce hospitalizations from assisted living centers by utilizing a checklist tool known as INTERACT. While the results of the pilot project will not officially be published until 2016, some of the primary findings recently were announced at The Gerontological Society of America’s annual conference in Orlando.

Brookdale’s chief medical officer, Kevin O’Neil, M.D., spoke with Senior Housing News, providing more detail on what made the pilot project successful and why he believes that the checklist approach could catch on industry-wide.

An Innovation Challenge

Shortly after the Affordable Care Act was passed in 2010, the Centers for Medicare & Medicaid Services (CMS) launched the Innovation Center. Its goal was to test various new payment and delivery models, and as part of that, the Center made Health Innovations Challenge Grants available. Brookdale wasted no time in applying, with the goal of building up a care transitions program that it already had started to test on a small scale, at facilities in Cleveland, Kansas City and Lexington, Kentucky.

The core of that program was the INTERACT (Interventions to Reduce Acute Care Transfers) tool. Relying largely on checklists, INTERACT was developed by Joseph Ouslander, M.D., and his colleagues as a way for skilled nursing facilities to keep closer tabs on residents’ conditions and have fewer and more effective transfers into and out of facilities. Initial research showed how well it worked, helping nursing homes achieve a 24% reduction in 30-day readmissions.

O’Neil, who describes Ouslander as a colleague and friend, saw that INTERACT could be the backbone for a similar tool in assisted living, but it needed modification. The $7.3 million Innovations Challenge grant that Brookdale received would support the process of bringing the INTERACT checklists into assisted living.

“It was a competitive process,” O’Neil says of getting the grant. “CMS received thousands of letters of intent, critically reviewed about 3,000 and made 107 awards.”

With the money in hand, Brookdale enacted plans to pilot a modified version of INTERACT in close to 45 assisted living buildings. The provider, which operates about 1,100 facilities nationwide, conducted the pilot with researchers from the University of North Texas Health Science Center, the University of South Florida and Florida Atlantic (where Ouslander now is a faculty member).

Sealing the Cracks

The goals of the project were ambitious and multi-faceted, and the stakes were high.

Just as in the aviation industry, assisted living providers are dealing with life-or-death situations. O’Neil relates the story of his own mother. When she was transferred to an assisted living center from a hospital stay, there was a miscommunication about her medications. The assisted living staff did not know that she was on the blood thinner Warfarin, and it was only thanks to the vigilance of O’Neil’s sister that the error was caught before a health crisis, such as a stroke, occurred.

“I’m a big believer in checklists,” O’Neil says, of how programs like INTERACT could help prevent situations like this in the future. “Preflight checklists have helped dramatically reduce the instances of plane accidents and errors in that industry. What we wanted to do was improve and provide tools and resources to mitigate the risk of communication gaps, because important information can fall through the cracks.”

With the increasing complexity of the senior care ecosystem, there’s more potential for communication mis-cues.

As a practicing geriatrician, O’Neil used to do hospital rounds and also keep track of his patients as they moved into home or hospice care. Now, it’s rare for a physician to be so involved in every level of care, he says. Hospitalists will take the lead when a person is in the acute-care setting, while so-called “SNFists” fill that role more frequently in the skilled nursing facility. Add in pharmacy, primary care and other providers, and it’s easy to see how communication could become complicated.

And while saving a person’s life is the ultimate benefit, the potential upside of a system like INTERACT includes stronger referral and revenue streams. Now that hospitals are seeing Medicare dollars tied to their readmission rates, they are being more selective about post-acute referrals.

Not to mention the steep costs related to events like falls, which may become more common as acuity rises in assisted living.

A program at one Brookdale community tracked 12 resident falls in a month. While none was a crisis situation, the estimated cost for each instance ran to $3,000. Being able to reduce these sorts of adverse events through a checklist protocol that flags at-risk residents could be enormously impactful.

“That’s $36,000 a month, and then look company-wide,” O’Neil says. “You can extrapolate the cost savings.”


Adapting INTERACT for assisted living involved selecting the pieces of the existing SNF program that O’Neil, Ouslander and the other project leaders believed were most relevant.

One was the STOP AND WATCH Early Learning Tool. “STOP AND WATCH” is an acronym-based checklist to help assisted living staff keep tabs on resident condition. The “S” stands for “seems different than usual,” for example, while the “T” for “talks or communicates less, and the “C” for “change in skin color or condition.”

Source: https://interact2.net/tools.html

Source: https://interact2.net/tools.html

The SBAR was another checklist tool that was brought into assisted living. Going through this checklist—which covers situation, background, appearance, and review/notify protocols—helps ensure that when an assisted living staff member contacts a physician, nurse practitioner or other professional, all the essential resident information is at hand.

“I can tell you from prior experience, if I got call from AL, they often didn’t have specific info,” O’Neil says. “The reflex then is to the send [the resident] to the ER. There are not many office based physicians who are going to have someone urgently transported to their office. Unfortunately, the ER now is being used as a triage point.”

But just bringing these and other tools into the assisted living setting was not enough. A key element of the pilot was to train every staff member on how to use the resources.

“We trained everyone,” O’Neil emphasizes. “Not just the CNAs, but the housekeepers, the bus drivers, the dining services, the admin folks, because they’re living and working with these residents day-in and day-out.”

He relates the story of a housekeeper who noticed a resident seemed not quite herself, and reported it. The resident turned out to have an infection that could have put her quickly into septic shock; the housekeeper’s vigilance and communication likely saved the woman’s life.

Brookdale also looked beyond its own walls for this project. Through the National Center for Assisted Living, it enlisted about 40 other providers to give feedback on the usability of the assisted living tools. They reported that communication tools, decision-support tools and advance care planning tools were particularly effective.

“The advance care planning piece is really important because what we found, and we weren’t the only one of the awardees to find this, is that many of the folks who are bouncing back to the hospital are at the end of the disease trajectory,” O’Neil says. “If someone had a better discussion around advance care planning, what their wishes were, we’d see a lot fewer being subjected to burdensome and intrusive interventions.”

The tool selection, staff training, and industry input seem to have paid off, as reflected in the results shared in Orlando by lead researcher Thomas J. Fairchild, Ph.D., a professor at the University of North Texas Health Science Center.

Participating assisted living centers achieved reductions in the mean number of hospitalizations, 30-day readmissions and emergency department trips, and also saw the average total cost for each resident reduced by nearly $30 per day while the experiment was occurring.

A New Standard

While the Innovation Grant program has demonstrated the benefits of a checklist approach in assisted living, making the practice standard across the industry certainly is not a given. But already, Brookdale is planning for a wider implementation.

Part of the challenge will be in training. Up until now, specialists with the INTERACT initiative have been able to go on-site and do hands-on training personally. But this will not be possible given the scale of Brookdale. The company is developing a “train the trainer” approach, to increase the number of people with the expertise to teach the INTERACT protocols in communities, O’Neil says. This might involve a remote training program.

Another effort underway is to continue to refine the pieces of INTERACT that have been trickier to bring into assisted living, but are needed.

“One tool that people thought was not as helpful was the medication reconciliation tool. That kind of floored me,” O’Neil says. “I think part of it is the work [the tool] required. But nothing is more important.”

The challenges may be real, but for those who believe in the checklist approach, there’s reason to be optimistic that it could gain traction quickly. Not only because of the positive initial results, but because the costs to implement do not appear to be prohibitive.

Paper-based INTERACT tools are freely available through the Florida Atlantic University (FAU) website. Digital versions require a licensing fee, which providers can obtain through FAU or vendors that integrate INTERACT in their electronic platforms.

And even if it’s not INTERACT, more formalized systems to prevent hospital readmissions may be on the way to assisted living. One such tool, STRAIGHT LINE, was developed by an Idaho physician and entrepreneur and recently hit the market.

Last but certainly not least, there’s the influence that Brookdale wields in the industry due to its scale. Likely, if the company were implementing assisted living checklist tools on its own, this would cause other providers to pay attention and perhaps follow suit. But Brookdale is not  keeping its methods and results closely guarded. The priority, according to O’Neil, is to encourage large-scale change.

“We wanted to lead the charge, but it’s about improving the health, safety wellness of older adults in assisted living for the entire country,” O’Neil says. “We’re happy to share what we’re learning.”

Written by Tim Mullaney