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Better understanding of use of checklists in healthcare urged

Report urges ‘reality check’ over use of procedural checklists

Issued on 16 September 2009

A new report, involving the University of Leicester, has called for greater understanding of how checklists can be used to improve safety. The report has been described as “counter-revolutionary” and providing a “a long overdue and desperately needed reality check for checklists in medicine” by Faculty of 1000 Medicine.

Checklists - which prescribe the critical steps healthcare workers need to take to execute procedures correctly – have achieved some remarkable successes in improving patient safety.

Enthusiasm for checklists has rocketed since a study in Michigan hospitals showed that using a checklist could virtually eliminate common infections in intensive care units.

But, writing in The Lancet, two of the authors of that study, Peter Pronovost and Christine Goeschel of Johns Hopkins University in Baltimore, urge greater understanding of how checklists work. Widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patient safety and to high quality care, they warn.

“Checklists can be a really good way of making healthcare safer. There’s no doubt about that. They work by improving recall – prompting people to do all the necessary steps – and by making clear the minimum expectations. But they have to be used wisely,” says Professor Pronovost, a MacArthur Foundation “genius” award winner who was rated one of the 100 most influential people in the world by Time magazine in 2008.

Writing with social scientists Charles Bosk of University of Pennsylvania and Mary Dixon-Woods of the University of Leicester in the UK, Pronovost explains that developing good checklists is hard, but securing effective implementation in healthcare organizations is much harder.

“The real threat to safety arises when a hospital thinks it has solved a problem by handing the workers a checklist and telling them to use it. The reality is that getting the checklist right is just the beginning. You have to get people motivated to cooperate. That’s the really hard part, and it needs good understanding of how to implement checklists”.

Professor Bosk points out that simply having checklists in a hospital does not stop errors occurring. He gives the example of Jesica Santillan, a 17-year old girl who died in 2003 when she was given an organ transplant with a mismatched blood type. “That error happened even though there were checklists for checking blood type. The big challenge is how to get staff to use checklists consistently,” he says. “They’re not a magic pill – a checklist isn’t something a hospital can swallow and expect care to get better, safer, or cheaper”.

The mistake most commonly made when introducing checklists is to assume that a checklist – a technical solution – can solve a cultural problem. Many doctors resist using checklists because of how they are socialized, the authors say. “And it’s a mistake to think that you can get workers to use checklists just by insisting on it. Instead, the Michigan study shows that you need to create incentives for people to cooperate”. This includes using audit and feedback to create reputational and social incentives, and having advocates in organizations who act as champions. And organizations themselves need to provide the right kinds of support. But, says Professor Dixon-Woods, the science of checklist implementation is in its infancy, and needs much more attention. “We need a better grip on the social factors that affect uptake of patient safety measures”, she said.

The authors of the article also comment that checklists work well for some types of problems in healthcare, but not others. “People often say that checklists in aviation help pilots complete take-off and landing safely, and that’s true. It’s less often pointed out that checklists are also used for baggage handling too, and there they don’t work so well. It’s the same in healthcare – checklists are not the answer to everything. We need a reality check for checklists.”

Notes:

1. “Reality checklist for checklists” by Charles Bosk, Mary Dixon-Woods, Christine Goeschel, and Peter Pronovost, is published in The Lancet, 8 August 2009.
2. The Michigan study (also known as the Keystone study) involved a using a 5-step checklist to minimize the risk of patients getting catheter-related bloodstream infections. Each year, around 80,000 patients in the US get these infections, and between 30,000 and 60,000 of these patients die. When the program was implemented in 103 intensive care units in Michigan for 18 months, infection rates dropped by 66%, resulting in estimated savings of $200 million and 2,000 lives saved. The results were published in the New England Journal of Medicine on December 28, 2006. Programs based on the Michigan study are now being implemented in many countries, including the UK and Spain.
3. Peter Pronovost is a critical/intensive care physician who has been called “Dr Checklist” and “the father of checklists”. He is a professor and director of the Quality and Safety Research Group at the Johns Hopkins School of Medicine in Baltimore, USA. He leads the World Health Organization’s evaluation work to improve patient safety measurement and leadership globally, and serves in an advisory capacity to the World Alliance for Patient Safety. He was chosen by the editors of Time Magazine as one of their 100 most influential people in 2008. He was also, in 2008, named a MacArthur Foundation fellow, an award given to “talented individuals who have shown extraordinary originality and dedication in their creative pursuits and a marked capacity for self-direction”. These fellowships are also known as “genius awards”.
4. Charles Bosk’s work on patient safety is supported by a Health Investigator Award from the Robert Wood Johnson Foundation and Veterans Affairs Health Services Research and Development Service.
5. Peter Pronovost and Christine Goeschel have received grant and contractual funding from foundations and non-profit agencies to help lead quality and safety projects, including the Agency for Healthcare Research and Quality (US) and the National Patient Safety Agency (UK).

6. Mary Dixon-Woods has recently completed an Economic and Social Research Council Public Services Programme fellowship to study regulation of doctors in the UK. The study was reviewed by Faculty of 1000 Medicine: evaluations for Bosk CL et al Lancet 2009 Aug 8 374 (9688) :444-5 http://www.f1000medicine.com/article/id/1163508/evaluation