• A Checklist for Implementing an Effective Checklist

    Maggie Van Dyke Jun 18, 2014

    In his book, The Checklist Manifesto, Atul Gawande, MD, gives healthcare leaders tips on how to create checklists that can help reduce hospital-acquired complications and encourage teamwork.

    Access related tool: A Checklist for Creating Checklists

    The first checklist that the World Health Organization's (WHO's) Safe Surgery Saves Lives team created failed miserably. The goal was to develop a simple, inexpensive, and effective tool that operating room staff could use in a variety of surgical settings to reduce complications and deaths.

    But the team's first checklist failed the pilot test. "The checklist was too long. It was unclear. And past a certain point, it was starting to feel like a distraction from the person we had on the table," writes Atul Gawande, MD, in his book The Checklist Manifesto: How to Get Things Right.

    Fortunately, the WHO team, which was led by Gawande, did not quit. A second try resulted in a concise, 19-item checklist that could be completed in two minutes.

    Most important: the WHO checklist works. Postoperative complications and deaths fell by 36 percent on average in eight hospitals across the world that adopted the WHO checklist (Haynes, A.B., et al, "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population," NEJM, January 29, 2009, vol. 360, no. 5, pp. 491-499).

    In his book, Gawande describes the hands-on research he conducted to determine how to put together the WHO safe surgery checklist. In essence, he gives healthcare leaders a checklist for creating any type of effective checklist.

    Checklist Research

    Gawande spent a lot of time with aviation and skyscraper construction experts, learning how these specialized professions prevent safety disasters through the use of checklists. In addition, he provides fascinating glimpses into how checklists are used by many other industries, including gourmet restaurants, investment banking, and rock concert stage management.

    Gawande also describes the successful use of various checklists in health care, from the common recording of vital signs by nurses to the Keystone Initiative's checklist that decreased central line infections in Michigan intensive care units by 66 percent.

    By the end of his book, Gawande (and the reader) is seeing the potential for checklists everywhere.

    "We could adopt, for example, specialized checklists for hip replacement procedures, pancreatic operations, aortic aneurysm repairs, examining each of our major procedures for their most common avoidable glitches and incorporating checks to help us steer clear of them .. Beyond the operating room, moreover, there are hundreds, perhaps thousands, of things doctors do that are as dangerous and prone to error as surgery…"

    As healthcare leaders consider developing checklists, they can find two important lessons in Gawande's book:

    Zero in on killer items. Effective checklists do not try to spell out everything that team members--who are experts in their specific fields--already know. "Instead, they provide reminders of only the most critical and important steps--the ones that even the highly skilled professional using them could miss," writes Gawande.

    Boeing's Daniel Boorman, a veteran pilot and checklist designer, calls these steps the "killer items," or "the steps that are most dangerous to skip and sometimes overlooked nevertheless," according to Gawande.

    The WHO safe surgery checklist encompasses "the simple to the complex, with several narrowly specified checks to ensure stupid stuff isn't missed (antibiotics, allergies, the wrong patient)," according to Gawande.

    Include communication prompts. A short checklist cannot possibly highlight every potential safety issue. That is why checklists should include communication checks at important junctures, which prompt staff to work together as a team--so they can combine their expertise in identifying, preventing, or solving complex problems.

    For example, the WHO safe surgery checklist reminds all surgical team members to formally introduce themselves and briefly discuss critical concerns or aspects about a given case (e.g., a patient's respiratory issues, available blood supply) that could possibly impact the surgery or patient outcomes.

    "Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is," writes Gawande.

    A Checklist for Checklists

    Healthcare leaders are encouraged to reader Gawande's entire book to get a complete understanding of the nuances involved in developing an effective checklist. In the meantime, here is a summary of the key "checks" that Gawande identified during his research on checklists. Many of these recommendations come from Boeing's Daniel Boorman, whom Gawande quotes extensively.

    Access tool: A Checklist for Creating Checklists