Checklists in healthcare is not the same as in other industries
and is not easy
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.
My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU
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
http://www.sustrans.org.uk/assets/files/guidelines/appendix.pdf
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.
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.
©M HEMADRI
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