As discussed previously, checklists are used in aviation, and at this point, there is no argument about this practice. It is the way it is. In healthcare, checklists implementation has been a slow process but is now an expectation in many settings. So how did we get here.
Despite initial reluctance from physicians and other medical providers, checklists have become an essential tool in modern healthcare systems. The transition to checklist use was driven by the recognition of their potential to improve patient safety and reduce medical errors along with some compelling studies and evidence.
Barriers to Implementation of Checklists
1. Cultural Resistance: The hierarchical nature of surgical (and other medical) teams can lead to reluctance among senior surgeons to embrace standardized protocols, perceiving them as challenges to their autonomy.
2. Perceived Redundancy: Some clinicians view checklists as redundant, especially if existing protocols are in place, or providers feel they are already doing all these steps. This can lead to skepticism about their added value.
3. Time Constraints: Concerns about checklists prolonging surgical procedures can result in resistance, with staff fearing decreased efficiency in the OR .
4. Lack of Awareness and Training: Insufficient understanding of the checklist’s purpose and inadequate training can lead to improper implementation and skepticism about its efficacy. Some physicians may not truly engage in use of the checklists, making them nothing more than a “pencil whipping exercise”.
Initial Work
The concept of using checklists in healthcare was ultimately inspired by their success in other high-risk industries. In the aviation setting it was in the 1930s, that checklists got their start as a way to reduce pilot errors and improve flight safety[1]. Though it may seem counterintuitive, even the most expert and experienced pilots can make critical errors. They know how to fly the plane, but because of interruption or inattention, critical errors can occur. Use of checklists help to minimize the likelihood of a time dependent and critical step being missed. Though these efforts may have started in the 1930’s, full cultural change and adoption took decades.
Given the difficulty in adoption of checklists in Aviation, it shouldn’t be a surprise that it wasn’t until the late 20th and early 21st centuries that healthcare settings began to seriously consider adopting this approach.
How Did Change Begin in Healthcare?
- Dr. Peter Pronovost’s ICU Checklist: In 2001, Dr. Peter Pronovost, an anesthesiologist at Johns Hopkins Hospital, developed a simple five-point checklist for reducing central line-associated bloodstream infections (CLABSIs) in intensive care units. This checklist dramatically reduced infection rates and saved lives, demonstrating the potential of checklists in healthcare settings. This was some of the initial evidence that checklists could work in healthcare.
- As in aviation, it isn’t that doctors and nurses don’t know the important steps in caring for patients who have central lines, it is just that there are a myriad of reasons that important and intended steps don’t get done. Healthcare providers are often multitasking and get interrupted. They might not have all the equipment they need; they could be distracted and mistakenly miss a step. Development of a checklist, helps make sure all the equipment is assembled, helps people pick up where they left off if they get interrupted, and ensures care when people are distracted.
- WHO Surgical Safety Checklist: Building on Pronovost’s success, the World Health Organization (WHO) launched the Surgical Safety Checklist in 2008. This landmark study published in the New English Journal of Medicine demonstrated that a 19-item checklist designed to improve team communication and consistency of care in operating rooms worldwide was remarkably effective. The World Health Organization (WHO) Surgical Safety Checklist was used across eight hospitals and led to a significant decrease in both complication rates (from 11.0% to 7.0%) and mortality rates (from 1.5% to 0.8%).
- This was yet another study showing that the use of checklists could improve outcomes in even the most complex areas of healthcare.
Overcoming Resistance in Healthcare
It should not be surprising that many physicians were skeptical of checklists, viewing them as an oversimplification of complex medical procedures or a threat to their professional autonomy. There is enormous pride in the skills and excellence that physicians believe they bring to their profession. Physicians believe that they bring a unique approach and perspective to each patient they see. This individualized approach can feel very special, but it can also mean that physicians choose complexity oversimplification, in those instances in which simplification is appropriate and valuable. In other words, if a squirrel could do it, let the squirrel do it, since there are so many instances that remain beyond the possibility of a checklist.
Using something like a checklist may have seemed like the antithesis of the individualized care that physicians believed they provided to their patients. However, over time several factors began to help open the door.
1. Evidence-based results: Studies showing significant improvements (such as those noted above) in patient outcomes helped convince skeptical healthcare professionals that there could be benefit in the use of checklists.
2. High-profile advocates: Respected medical professionals and institutions championing the use of checklists lent credibility to the approach.
3. Customization and flexibility: Checklists were adapted to specific healthcare contexts, making them more relevant and acceptable to medical staff. This helped show that checklists were not a “one size fits all,” but could be used to help in specific and unique areas.
4. Cultural shift: A growing emphasis on patient safety and quality improvement in healthcare as a whole created a more receptive environment for checklists. This included increased use of public reporting of healthcare outcomes (including error and mortality rates) as well as some insurers no longer paying for preventable healthcare errors that cause harm to patients.
Expansion and Integration of Checklists
As the benefits of checklists became more apparent, their use expanded beyond the surgical suite. Checklists are now used in various healthcare settings, including:
– Emergency departments
– Operating rooms
– Labor and delivery units
– Medication administration
– Intensive care units
– Patient handoffs and transfers
Current Status and Future Directions
At this point, checklists are widely accepted as a valuable tool in healthcare, though their implementation and adherence still face challenges. Ongoing research continues to work on ways to optimize checklist design, implementation strategies, and integration with electronic health records to make it easy to use in the moment[1].
Checklists can seem silly and juvenile when considering the enormity and seriousness of the surgical suite. Each surgery is indeed unique, but the initial preparation as well as those final moments are not. And in those moments, it is possible to use simple steps to overcome the fatigue, interruption, and limits of human performance that may occur during the surgical procedure.
The success of checklists in healthcare demonstrates the potential for cross-industry learning and the importance of simple, standardized processes in complex, high-stakes environments. As healthcare continues to evolve, checklists remain a crucial component in the ongoing effort to improve patient safety and quality of care. They are not static or cast in stone. They are fluid and should be modified to meet the needs of the team and the patient. But once those needs are determined and based on the best evidence, checklists will ensure that those critical steps are done for every patient, every day and every time. Wouldn’t you want this for yourself or those you love.