Clinicians have long relied on an analogous form of decision support such as lists or algorithms for differential diagnosis. When a patient presentation is unusual (non-normal but not emergent), differential diagnosis lists (whether in old-fashioned textbooks or new-fashioned handhelds) support clinical performance by serving as a cognitive aid. The practice of reviewing a complete differential helps overcome anchoring and confirmation biases and can be a forcing function to ensure that every critical, and treatable aetiology is ‘ruled out’. Unlike non-normal checklists that are built into cockpit workflow, differential lists are often not well-integrated into clinical workflow and this may undermine their use.12
First, the structure varies from the design of aviation checklists, in that it combines procedures with formal team discussion; these processes are not mixed in the cockpit but remain distinct because they serve different purposes. The WHO checklist consists of a checklist (Sign In), a briefing (Time Out) and a checklist with a short briefing at the end (Sign Out). Checklists are suited to verification of procedures for linear processes; whereas briefings are suited to support execution of complex processes that may require appropriate adaptation and variation. Briefings are important because surgical outcomes are complex and emergent, and optimal performance of surgical procedures may require flexibility to accommodate the unexpected, however briefings should be instituted separately from the checklist. If briefings are too closely coupled to checklist completion, teams may miss the cognitive shift required to move from linear or procedural work to complex or adaptive work.
If your business needs checklists for various tasks or departments, Tallyfy might be the best solution. It lets you create master checklists that act as templates. You can then create a "run," or an instance of that master checklist, with its own name. Each run can be tracked, so you can see how your checklists are progressing, and you can have multiple runs of the same master checklist going at once. You can also invite your team to work on a checklist run, making it simple to manage team processes.
In addition to the above examples, I’m trying to develop more checklists for my work and personal life. I’ve looked at some re-occurring sticking points that happen throughout the day and have been experimenting with whether a checklist can help with it. My challenge to you this week is to take a look at your own life and see if there are areas where a checklist would help out. It’s not a sexy tool, but it’s a powerful one!
Pre-flight checklists are a good example. A regular pilot is aware of the importance of checking a list of tasks to prepare an airplane for takeoff. These include checking the operation of the altimeter, fuel gauges, flight controls, magnetos, engine idle, and other system parameters. Besides, preflight checklists are usually segmented in a way that the accomplishment of final items (status of doors/windows, mixture, lights, camera, and action) is completed after the set of initial tasks. The same thing is with the before-landing checklist. According to the FAA's practical test standards, these sets of tasks must be in a written form for pilots’ use.
In healthcare, this technique is used in resuscitation procedures. Healthcare workers are trained and recertified, in low and high fidelity simulators, to commence procedures such as Advanced Cardiac Life Support without referring to a checklist. When the patient is not readily revived or responding as expected, the team will refer to their checklists or algorithms to make sure the steps have been executed properly, and that they have not forgotten anything. For this reason, healthcare workers often keep a cognitive aid (a ‘checklist’ of sorts) posted on emergency carts, tucked into pockets or loaded onto mobile devices. ‘Boldface’ checklists can be effective whenever there is a critical sequence to be completed but time is short, or the situation does not enable a physical list to be immediately accessed and used.
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Checklist compliance is increasingly monitored in healthcare.5 Often, institutions conduct internal audits of checklist compliance in anticipation of regulatory inspections. Using ‘compliance with checklist’ audits as a measure of safety or quality, however, is problematic, as high checklist compliance is no guarantee that the task is well-executed,18 or that patient safety culture is high.20 In addition, some of the benefits that have been found to be associated with checklist usage, such as enhanced team building and nurses speaking up, are likely to be negated if compliance audits lead to sanctions.
This isn’t a problem unique to medicine, of course. It exists across almost every domain of life, be it business or science or even just getting things done around the house or on your car. More and more of our work requires coordinating different teams to get a task done. If you work for a big corporation, you’re likely collaborating with a whole host of people to complete a project. And just as in medicine, you’ve likely seen projects delayed or even fail not because of lack of know-how, but due to head-scratching ineptitude.
Second, the roles of the team members in completing the checklist are not clear. Who will read the checklist? Who will verify that the actions have been completed? Each clinician's role in the checklist should be formalised for the surgical setting, so that when tempo is high, steps are not missed. Third, compliance requires that boxes be ticked. This means that at least one team member will be occupied with completing the checklist and thereby not be available for other tasks. Boxes are more suited to a shopping list format, where items must be completed but order is unimportant, rather than an aviation-style checklist. Problems arising from combining a memory support tool with an audit device are discussed below.
To-do lists are definitely awesome for getting things done, but there’s another kind of checklist as well – what I call the “routine checklist.” With a routine checklist, you write down all the steps/tasks needed to complete a certain project or process. The list of tasks never changes. You use the same checklist over and over again, every time you do that particular process/project.
Concerns have recently been fuelled by the disappointing results after implementation of the checklist in Michigan17 and large-scale mandated implementation in Ontario Canada.5 Interpretations of results are also complicated by reported differences between perceived and actual application of the checklist. In a recent US study, hospital documentation indicated 100% compliance with checklists, but observers found that on average only 4 of 13 checklist items were actually completed.18 Even strong advocates for checklists admit that full implementation of the WHO checklist is difficult and that improvements require more than the checklist, including strong institutional leadership, data collection, and monitoring, and training in teamwork.4 ,14
Checklists don't have to be boring. Pocket Lists is a fun, personal checklist iOS that lets you organize your checklists with icons. Organize the things you need to do, then add an icon to each checklist to make it easy to identify. It can manage your daily tasks, with due dates and notifications, and can also keep track of your more detailed checklists to help with your work routines.
When it comes to checklist implementation, it is important to recognise that aviation checklists are integral to the normal workflow. The aircraft does not stop while the checklist is completed, and the timing of checklist completion is arranged so that it does not conflict with other essential flight activities. To that end, the checklist does not impose an additional burden or workload, but is actually perceived by aircrew as something that makes the flight easier. In contrast, the Time Out is performed before the case can begin, so essentially stands independently of the workflow. To that end, the Time Out is likely to be seen as something additional, and, unless it results in obvious time-saving downstream, will be perceived as an increase in workload. This mixture of purpose between checklist and briefing, in combination with implementation issues, may explain the range of outcomes as well as the range of enthusiastic to skeptical opinions about the mandated use of checklists in surgery.14–16
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