Health care leaders increasingly focus on improving the quality of surgical care through implementation of bundles, or checklists that encourage compliance with evidence-based processes of care. In a timely and important study, Anthony and colleagues provide high level evidence of the potential dangers of this type of approach. The authors conduct a single-center randomized clinical trial to reduce SSI after colorectal surgery by mandating adherence to 5 practices that have previously been shown individually to be effective in this regard. Contrary to expectations, patients in the intervention arm developed significantly more wound infections.

These findings have important implications for surgical quality improvement. Although it is clinically counterintuitive that enhancing adherence to known best practices would increase infections, there is well-developed economic theory to explain these findings. The bundled intervention may create what economists call a multitasking problem, which arises in complex situations when many elements of the job are important for outcomes but only few can be measured. When efforts are solely focused on increasing the use of these measurable processes of care, less attention is paid to the other, potentially immeasurable processes that are necessary to optimize outcomes. In this study, providers in the intervention arm may inadvertently worsen outcomes by reducing effort on important but unmeasured aspects of infection prevention.