In Atul Gawande’s The Checklist Manifesto (2010), he relates several stories of how seemingly benign errors can lead to medical emergencies and even death. Failure to pay attention to small details often have serious implications in almost every arena of life: “Whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all” (Gawande, 2010). Pilots, surgeons, investors and many other professions have implemented the use of checklists to prevent failures and improve quality.
Deploying new healthcare technology involves many complex components: connectivity, inputs, outputs, and parameters, just to name a few. Installation or use of these products can reveal flaws in development that can ultimately lead to harm. Every step of the process requires attention to detail by the developer, the installation team and those creating workflow guidelines. Because there may be many people working on the project together, it becomes imperative that the methods and approach be consistent and repeatable to prevent errors and missed steps.
Gawande (2010) shares that people “require a seemingly contradictory mix of freedom and expectation.” With an implementation often having many resources and various milestones, project management tools, such as a checklist, become imperative. The argument then becomes is the checklist the “holy grail” of a project implementation or rather should it be used as a guide for the team to perform within a culture of safety? Can a checklist be the catalyst to move a team from an aggregation of individual experts into an expert team, where each member knows their role and feels empowered to speak up when a misstep is noticed?
What Makes a Quality Checklist?
While a checklist may come in many different formats, such as a project plan, testing plan, or an installation guide, there are several common features that make a checklist successful. A quality checklist is easy to utilize, is meaningful, and has clear instructions that follow common terminology utilized across an organization. The checklist must clearly identify tasks and project objectives and provide a verification process for necessary tasks. In addition, it must be customizable and practical to fit specific requirements and workflows. According to Peter Provonost, a Johns Hopkins Safety expert, a successful checklist should be modified by the user to instill a sense of ownership and investment in the process. A checklist should be iterative; updated to reflect new information or steps. Ultimately a checklist should allow the user to be more efficient and streamline a process.
An effective checklist is not defined by the act of ticking a box on a paper. Many pre-flight checklists utilized by commercial pilots do not come with check boxes, but instead are a two-sided card that helps them focus on required tasks during flight preparation. By being clear and succinct, the pre-flight checklist serves as a memory aid to ensure nothing is missed, allows for the mastery of repetitive tasks and encourages the use of critical thinking for problem solving of more complex tasks. The checklist should not be a how-to guide, but rather a simplified, practical reminder of the most important steps.
Provonost and Vohr, in their 2010 work, Safe Patients, Smart Hospital, relay a useful checklist requires strong leadership and end-user buy-in. The user must feel empowered to say that an error has been recognized and the team should pause and correct the misstep before continuing the process. With leadership, an effective checklist becomes not only a process tool, but also an adjunct to promote teamwork, encourage communication, invite collaboration, and define delegation.
A well-designed checklist should pinpoint process or procedure failures and allow for a non-threatening platform that leads to accountability and action.
Checklist Failure
While well designed checklists can lead to successful projects, poorly executed checklists can lead to task failures. If a user is simply checking boxes or does not understand what is being asked, complacency or missed steps lead to errors or breaches in the process. As an example, the Centers for Disease Control (CDC) comprehensive process for inserting a central line and preventing infection is over 120 pages long. Provonost (2010) related that at Johns Hopkins Medical, only 30 percent of patients were treated within those guidelines.
With poor adherence and inconsistent practice among physicians, infection rates skyrocketed. This inconsistent use of the devised checklist lead Provonost to devise a 5-step checklist for the insertion of central lines. Within 1 year of its implementation, the infection rate from central lines dropped to zero. There was a process and procedure before this checklist was implemented. What was the difference between the CDC guidelines and the Provonost checklist?
Provonost relates that the CDC guidelines were contained within a long document and had “convoluted and unclear” instructions. When a checklist is lengthy or unclear, people tend to “check the boxes” without comprehending the purpose of the checklist and simply view the completion of the document as just another task.
Checklists also fail within toxic team cultures, where the team does not feel safe to identify missteps or failures. Provonost (2010) relates that in 90% of the medical errors at Johns Hopkins, at least one individual was aware that something was wrong but failed to speak up, or even worse, were ignored when they did. This same toxic culture feeds the idea that checklists are for the novice team member and not for the expert.
The more complex the project or task, the more challenging it becomes to create an effective checklist. If the language of a checklist is not clear to all of those who use the document, then there is a strong risk that it will not be applied consistently and correctly by all team members. The checklist should identify not only the “what” of the task, but also the “who.” Each team member must be trained to understand the purpose and language of the checklist, their role in its completion and should feel empowered to speak up, if they find anything confusing or notice a failure in the intended process.
Using Checklists to Direct the Implementation Process
The goal of the checklist should be to ensure that the task or project is executed seamlessly and efficiently, minimizing errors and risk. The use of checklists in technical implementations or deployment of technology is a common practice, but without robust checks and balances, they can become cumbersome or meaningless. While human error is inevitable, there needs to be measures to prevent the continuation of an erroneous process. Risk mitigation to avoid human error requires a process where mistakes are documented and shared with others for awareness. A team that communicates well, while feeling safe and empowered to express concerns is essential to the process and the success of a checklist initiative.
It is essential, then, to establish a clear leader who is responsible to assign and manage task completion. That leader must feel empowered to question the process and ask for validation that a step has been completed satisfactorily. The more complex a project or task, the higher the risk for missed steps or even repetition of the same failures each time the task is performed. In addition, the more team members involved in a project also increases risk. There are many stories where everyone believed someone else was completing a task which prevented the task from being completed at all.
When a checklist is used for a complex project, such as implementation of a new technology in a healthcare setting, using a process such as PDCA (Plan, Do, Check, Act) systematically during and after each project creates a safety net for the team. Having a formal process to evaluate the effectiveness of the checklists used, evaluate lessons learned and make necessary corrections to the project plan/checklist serves provides an organized way to ensure that mistakes and misses can be project without impacting the project timeline. Using a formal process also provides a platform and safe space for team communication.
Checklist implementation allows a team to become more organized and allows the project implementation to become more predictable. The checklist should then become an organic document that is improved as the team continues to act, debrief, identify strengths and challenges in the process. Using this strategy allows a team to become more efficient and accurate with each implementation. Team members become more proficient in their role of project design, technical builds, and testing resulting in a smooth transition to the new process for the end user.
Keys to a successful checklist
- Clear and Concise with roles and responsibilities defined
- Customizable and flexible
- Considers the completion of the task, not checking the box
- Collaborative and considers the end user
- Creates a culture of safety
Conclusion
Implementing the checklist is not a simple matter of handing it out and asking staff to follow it, however. “It is not Harry Potter’s wand”, Pronovost says. Checklists might seem deceptively simple, but the effective use of them is a complex issue that encompasses different groups within the health-care system and organizational change—culture and custom must change, too.
References
Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Picador, 2010.de Veer, A.J., Fleuren, M.A., Bekkema, N. et al. Successful implementation of new technologies in nursing care: a questionnaire survey of nurse-users. BMC Med Inform Decis Mak 11, 67 (2011). https://doi.org/10.1186/1472-6947-11-67
Implementing Health IT: The successful implementation of a health IT system is essential to delivering safe care for patients and a more satisfying work experience for clinicians and staff. Retrieved from https://www.healthit.gov/topic/safety/implementing-health-it
Why checklists fail—and the three keys to making them succeed. Advisory Board. Advisory.com https://www.advisory.com/daily-briefing/2015/08/04/checklists
Laurance, Jeremy (2009). Peter Provonost: champion of checklists in critical care. The Lancet.com, vol 374, August 8, 2009. Retrieved from: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673609614392.pdf
Pronovost, P. J., & Vohr, E. (2010). Safe patients, smart hospitals: How one doctor's checklist can help us change health care from the inside out. New York: Hudson Street Press.
John Hopkins Medicine (2010). Three years out, safety checklist continues to keep hospital infections in check. Retrieved from: https://www.hopkinsmedicine.org/news/media/releases/three_years_out_safety_checklist_continues_to_keep_hospital_infections_in_check#:~:text=The%20checklist%20contains%20five%20basic,rates%20are%20higher%20and%20remove
