Lastly, the checklist involves a Time Out: this requires that everything stops and no one interrupts. In an emergency, or under extreme time pressure, it is difficult to get everyone on the team to stop what they are doing and attend completely. The loss of team discussion under time pressure has been described by some centres implementing the Safe Surgery checklist.6 ,13 These are the times when mistakes are most likely to occur, yet paradoxically also when the Time Out portion of the checklist (the briefing to support complex work) is least likely to be performed as intended.
Checklists put everything you need to do right in front of you. You can see the beginning, middle and end of what needs to be done. Though this helps some people tackle tasks in front of them, it can also be distracting. If you are the type who prefers to take things one step at a time, you might enjoy working through a checklist. Big picture people might struggle with a large collection of isolated items, however, and might need other tools such as mind maps, ideas lists and deadline reminders to help them focus on what needs to be done.
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.
That brings us to the last point about checklists - they DO NOT replace knowledge. An investor interviewed for the book said it best when describing that the checklist is “not a fail safe thing…you still need expertise and insight into the process to be able to ultimately perform each step correctly”. These checklists wouldn’t help me if I didn’t know what I was doing to begin with. Rather than being a “Step by Step to Collecting Data”, people can perform a task however they want and the checklist makes sure that in the end that task was performed correctly.
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