Monday, 25 March 2013

Checklists in Healthcare - not easy

Checklists in healthcare is not the same as in other industries and is not easy

Checklists are the hot and happening thing in healthcare today, it is to improve the safety and quality of care delivery.

The WHO safe surgery checklist was evolved after good research showed its benefits across the world in reducing deaths and complications. It is a simple one page document. Prof Atul Gawande who pioneered this effort has described the background using construction, airline and other industries as examples.

The checklists as used in industry and by some eminent healthcare providers places seem to be different from the kind of checklists that we do, including the WHO surgical checklist.

In industry checklists are used to define what precisely the work is, in what order the work has to be done – the people who do the work look at it, do the work as it says (execute the work) and tick the box (checklist) to indicate that the work has been done according to the work specification. Often that is the main documentation to record the completion of the work. Here is an example of a construction checklist I have no special knowledge or affinity to this particular checklist, it simply comes high up on a google search. I encourage you to look at the detail with which the work is specified. I am reliably informed that many construction checklists are even more detailed and project specific. Prof Gawande's book points that in construction work, checklists are done for every component with about 16 different specialities being involved.

In aviation the checklist is aircraft specific. Here is a checklist for a Piper PA28 which is a very small basic plane which is often used to train pilots and it runs to 11 sheets. It is both precise and detailed – it tells you what degree and what RPM to set and so on. The checklist is read out loud and followed every time. It is never 'tick'/'check' marked, never signed and never filed anywhere.

The ‘check’ in industry e.g. construction – is to indicate the tick, cross, ‘check mark’ other marking in the document – a one step process that documents that the defined work is done. In aviation it is a document that is followed but not filed.

The ‘check’ as used by us in healthcare in general and UK in particular – seems to indicate that we need to check (as in inspect/confirm/verify the correctness/hold back/restrain/stop); by the way this is the dictionary definition. This is a two step process – do the work document it and then confirm in a different document that the work is done. The WHO checklist is an additional document – i.e. the antibiotic is ordered and given elsewhere in the process, documented elsewhere and these are confirmed in the checklist; the checklist becomes a supplementary document. This also gains medicolegal importance and adds the bulk of the medical notes. The WHO checklist is allowed to be changed but is often not and where they change it, is still organisation specific and not specialty specific (and never ever patient specific).

When the industry and aviation use detailed and project/plane specific checklists why did healthcare choose to use a single page, generic, general checklist? Clinical medicine and healthcare delivery is obviously more complex than industry or aviation, yet the checklist is a simple single page. The beauty of the WHO checklist lies in its simplicity. It has proven itself under research conditions across the world. However, it is valid to ask whether it is proving itself in real time practice in the NHS. The evidence is not clear yet if there has been a year on year decrease in the incidence of various problems the WHO checklist is supposed to address. The consensus is that the checklist helps.

My personal view is that a one size fits all checklist that the WHO Surgical Checklist is will see its own limitation in time; after all there was a checklist even prior to the WHO one. Procedure specific checklists are the needed urgently - a good example is the matching Michigan checklist for the insertion of central lines. For surgical patients, each patient/procedure should have a customised detailed and specific checklist with an obligation for the surgeon, anaesthetist and their teams to modify the checklist prior to surgery to a patient specific checklist. This empowers the local team members and the process becomes directly relevant to the specific procedure that a specific patient is having on a given day. That is when the power of the checklist seen by Atul Gawande in aviation, construction and finance can truly be realised in healthcare.

Follow me on twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click 


Philhigton said...

As a professional aviator I think that there is a lack of clarity about checklist use in healthcare. In aviation we have three types of checklists. Each have their specific function and mode of use. The Normal Checklist is a 'check' list. Its purpose is to make sure that safety critical items have been completed before the next safety-critical step begins. It does not drive activity because all items would ordinarily have been performed prior to the reading of the checklist. The mode of use is Challenge and Response.

The Non-normal checklist is structured to drive activity at any time that events cease to be normal and the underlying assumption is that memory is unreliable and it is better to perform the correct actions slowly than incorrect ones in haste . The mode of use is Read and Do.

The Emergency checklist is used when a delay of even a few seconds would immediately compromise safe flight. There may be about a dozen of these emergency checklists for a large commercial aircraft. The initial actions are performed by rote, having been practiced and rehearsed many times. There are usually fewer than seven items (maximum capacity for short - term memory) in the initial actions. Once safe flight has been assured (not the problem solved, just some sort of control regained) the initial items are checked in Challenge and Response fashion. The second stage of the checklist is a 'how to' guide similar to the abnormal checklist used as Read and Do.

The WHO checklist is a normal checklist. Challenge and Response. It simply seeks a deliberate check that safety critical items have been completed before the next step. It requires Adult behaviour, professional modes of speech and no concurrent activity. Its proper use is a professional duty because it drives the safe execution of the task (the surgery).

The NPSA rather muddied the waters in the UK by adding the Brief and Debrief which serve a different purpose and function and consequently have a different mode of use around the Sign In, Time Out and Sign Out of the WHO original.

The two most important things about checklists wherever they are used are that they should be fit for purpose (the WHO Checklist is) and there should be the professional discipline to use them correctly.

Phil Higton Terema

M HEMADRI said...

Thanks Phil for your most valuable comments explaining checklists - clearly and briefly.

I am beginning to hear that WHO checklists since they are mandatory are part of medico-legal documentation which now requires a signature so that specific persons can be identified with possibly consequences to follow when things go wrong. Of course this is couched in the language of enhancing patient safety, assigning responsibility and holding people to account.

What started as an effort to change culture seems to be taking on a very conventional managerial avatar now.

Anonymous said...

LifeWings works with medical teams to select , develop, and implement the best tools and checklists for improvement at individual hospitals. Implementing standardized healthcare checklists may provide some improvement but we have found that each facility has unique challenges and processes. By performing thorough risk assessments and collaborating with medical teams, we can help uncover where the greatest needs for checklists exist and gain buy-in from all levels to develop a realistic tool. Our program ensures that hospital hardwires these checklists and tools into your system for optimal and sustainable results. By adapting crew resource management (CRM) techniques used successfully for years by organizations with outstanding safety records, LifeWings trains healthcare personnel how to communicate and utilize these tools consistently.