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
It’s likely that the bulk of the audience doesn’t need any explanation of what a checklist is. In a nutshell, it is a list of questions or bullet points that characterize the status/progress of a certain activity or process. The list may contain any essential data regarding your accomplishments or plans. Due to their versatility, checklists can be leveraged in any industry regardless of the business focus. But what is the purpose and benefit of using this process organization tool?
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.
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.
‘Normal’ checklists are effective whenever there are advantages to standardising performance, time is not critical, the series of tasks is too long to be committed to memory (or there are likely to be interruptions to execution of the task that might interfere with memory retrieval), and the environment enables a physical list to be accessed and used.
Most companies strive to arrange their best practices in the most convenient way. Checklists work well here. Providing essential information for repetitive tasks in the form of a list proves a company’s consistent approach to any level of activity. As an example, introducing specific rules and policies to new team members is quite practical when done through checklists.
Law school exams. I stumbled upon the power of checklists for managing complex problems while in law school. In a law class, a single three-hour long essay exam determines your final grade. You’re presented with one or two complex hypothetical situations and are required to identify and analyze all the legal issues in them. To excel on law school exams, knowing the law isn’t enough. You have to be adept at applying it to different legal scenarios.
2. Focus only on the “stupid” essential stuff that’s frequently overlooked or skipped. You don’t need a checklist that lists every single step on how to complete a task. That renders a checklist useless. Instead, just focus on putting down the “stupid” but essential stuff that you frequently miss. Your checklist should have no more than 9 items on it. The shorter the better.
And the tragic thing is it’s often the “stupid” simple stuff that gets people killed or keeps them in the hospital for longer than they needed to be. I have an acquaintance who ended up in the hospital for two weeks because he got the wrong heart medicine. The problem was ultimately one of miscommunication — a basic thing you think would be a given, seeing as how hospitals can transplant human faces and whatnot.
Thanks for this great post. I was very skeptical about the idea for being an automaton by following a checklist or a schedule of all day, day or mounth. And then my life was a real impasse. I ignore what great things I did it and so for. Afte that I decided to get a plan of my live. I decided to savor my live by listing waht I did and what I want to do.
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.
Checklists seem simple, Gawande says, and are sometimes hard for us to accept as a necessity when we're in high-powered jobs that rely on our skills and knowledge. But humbling ourselves by using a checklist can improve our performance and help us achieve more consistent results. "They remind us of the minimum necessary steps and make them explicit," writes Gawande. "They not only offer the possibility of verification but also instill a kind of discipline of higher performance."
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
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