As Atul Gawande would attest, checklists can prevent harm and save lives. In his popular book, “The Checklist Manifesto”, he shared stories of memory lapses, misses, and errors of ineptitude, committed by clinicians of various specializations and varying expertise. These factors characterize a good bulk of the mistakes we make in today’s stressful, fast-paced, complex world of healthcare. We could do with more help, and checklists are one means of outsourcing the storage of critical information. Checklists also increase the consistency of behavior and thus reduce variability in care delivery.
Unfortunately, the checklist has become somewhat of a dirty word in healthcare. While we value its power, checklists can be misperceived as a means to easily fix human error, alongside double-checks and additional safety steps. Checklists today require staff to indicate task completion through ticks, sign-offs, and witness acknowledgement. Despite the good intention, checklists are now auditing tools, a weapon to hold colleagues accountable. Checklist fatigue quite possibly exist in the healthcare industry and nowhere else.
In this BMJ article, Assoc. Prof. Robyn Clay-Williams, once a military test pilot and one of the first two women to serve as pilots in the Royal Australian Air Force, compared the use of checklists between aviation and healthcare. She and her colleague highlighted how healthcare checklists have deviated from that of aviation’s, thus limiting the checklist’s potential.
To illustrate this further, here's a comparison between protocols, checklists, and forms.
Protocol | Checklist | Form |
Detailed set of instructions and guidelines for specific task | Cognitive aid that enhances task performance | Documentation that captures specific information or data. |
Goal to standardize task performance for compliance | Goal to make task easier to perform | Goal to collect and capture information for future use |
Formal (authorized by organization; official document) | Can be formal or informal (may not be official nor need to be documented) | Formal (official document to be filed into records) |
Good design involves comprehensive instructions that communicate in detail what needs to be done | Good design complements and integrates checklist use seamlessly into workflow | Good design is intuitive for users to know what information is being asked and where to document it on the form |
Examples include hand hygiene, error reporting, BCLS, informed consent, blood transfusion, hotel cancellation | Examples include shopping list, audit checklist, emergency evacuation to-do list, holiday packing list | Examples include birth registration, blood product request, lucky draw, medication ordering |
Success is defined by user comprehension and compliance | Success is defined by improved task performance | Success is defined by accurate data capture |
Many healthcare checklists resemble wordy protocols, or feature unnecessary "data collection" functions (e.g. sign-offs by first and second checkers). Ironically, these checklists make the work even harder, interrupting the workflow and causing extra stress. As we try to improve efficiency and reduce burnout in the workplace, it's important to think about whether our checklists are genuinely helpful or just a hassle.
A good checklist should thus, first and foremost, provide meaningful assistance. To quote Prof. Ken Catchpole from this report, "Compare it with driving a car. If you had to go through a checklist every time you left your driveway—do I have enough gas, is my seat belt on, are the lights working—it would be frustrating and wouldn't improve your driving. But what if you had to change a tire on your car? That's something you probably don't do very often, but it has a number of key steps to remember that will definitely improve safety and performance, such as making sure the parking brake is on before you jack up the car.".
In reality, we create good checklists all the time! We create a checklist when we go shopping so that we don’t forget what we need to buy. We create a checklist of tasks we need to accomplish so as to meet a certain deadline, or at least allow us to identify and focus on high-priority deliverables.
In aviation, checklists feature just essential keywords, in procedural sequences that are logical to perform. Aviation checklists are concise, quick to read, easy to understand, and have no check boxes or sign-offs. Checklists are used all the time because pilots realize that human memory can be unreliable. Especially during emergencies such as engine fire, pilots don’t have the time or mental focus to accurately recall the entire safety procedure. In aviation, checklists are integral to all normal and abnormal operations, and are seen as a tool to make tasks easier to perform.
Here’s a simple list of strategies you can incorporate towards your next checklist design:
· Understand the task. Is a checklist the ideal solution?
· Keep instructions short, clear, and explicit.
· Do away with complete sentences. If necessary, use active voice.
· Use simple vocabulary. Avoid jargon that may be tedious to interpret.
· Include graphics and icons! This reduces a wordy appearance.
· Ensure each step flows well with the actual work process.
Lastly, always design for actual use! Design the checklist such that it integrates coherently into the existing work processes. Can it be built into an existing form? Will it be a reference card that’s easily accessible? Test the checklist with actual users and refine it based on their feedback to improve its usability and effectiveness.
The full potential of the checklist can only be realized when we accept that our memory is fallible. Checklists shouldn’t be painful. A well-designed checklist integrates well with existing work processes, and actually ensures optimum performance. A checklist is a list that which you check (i.e.: verify), not a paperwork for you to check (i.e.: tick). Consult your nearest friendly neighborhood human factors specialist for help with your checklist design.
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