Checklists: not just ticking off boxes

Checklists: not just ticking off boxes

January 2011
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Published in the January 2011 Today’s Hospitalist

WHEN “THE CHECKLIST MANIFESTO came out last year, I heard that it was required reading among federal officials involved in the bruising debate over health care reform. I thought, “I guess I should read it,” but I didn’t until now. And I’m glad I did.

In the book, Atul Gawande, MD “a surgeon at Boston’s Brigham and Women’s Hospital and staff writer at The New Yorker “explores the key tool used by the aviation industry to decrease errors and increase cockpit communication: a checklist. Mixing catchy stories with medical insight, Dr. Gawande discusses what he and his team of researchers undertook as part of a World Health Organization program to “reduce avoidable deaths and harm from surgery worldwide.”

He’s at first skeptical about such a grandiose goal. But when the group starts talking about a checklist for perioperative care, he becomes enthusiastic.

As Dr. Gawande explains, the role of the checklist is not to replace the creative and technical impulses of those who use it. Instead, it’s designed to round out those efforts with a systematic approach that increases communication among members of very complex organizations sharing high-risk endeavors. As he puts it, the goal is not “just ticking [off ] boxes “¦ Embracing a culture of teamwork and discipline is.” Sound familiar?

While the book doesn’t provide a sample checklist, Dr. Gawande makes several recommendations about how to produce one.

One, define a specific point at which the checklist will be used. Two, decide whether you want a DO-CONFIRM list, in which team members perform tasks and then stop to confirm they have done them, or a READ-DO list, in which team members carry out tasks while checking them off. Three, keep the list short, between five and nine items. Four, keep the wording simple and the list length to one page. And five, test and pilot the checklist before adopting it.

Procedural specialties already follow checklists when they identify patients and surgery sites. But what about cognitive specialties like hospital medicine? One idea throughout the book is the concept of “huddling,” in which team members gather for a short briefing on the plan of care.

Admission huddles at the bedside with the attending, nurse, residents and anyone else caring for a patient can serve as the pause point to initiate a checklist. That could include a review of medications and possible side effects; concerns a nurse may have about the patient; and a discussion on what to expect during the hospitalization. This enhanced communication can identify potential pitfalls, clarify discharge goals, and bring patients and nurses in as true partners.

We’ve now started holding admission huddles at my hospital. The magic of the checklist is not the actual “checking off” of items, but the dynamic that entails, flattening out the totem pole of health care teams to make every one equally accountable for patient care.

So, are you ready for a checklist?

Ruben Nazario, MD, is a pediatric hospitalist practicing at Inova Fairfax Hospital for Children in Falls Church, Va.

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