This isn’t an anti-checklists post.

It’s an illustration of why picking up an example of good practice in one location, and dropping down in another doesn’t always work. No matter how brilliantly conceived, beautifully constructed or obviously ‘good’ the original good practice might be.

So, next time a politician or clever speaker at a conference tells you “it’s just a simple matter of transferring good practice”, please ask them; “what about Atul Gawande and the Hospital Checklists?” (and then get sacked or thrown out of the conference).

Checklists are a good thing. The thinking behind checklists is difficult to argue against. Basically a checklist breaks down a complicated procedure into a series of logical, easily understood steps. This helps a person/operator successfully complete the procedure.

The origins of the modern checklist (which is a fascinating story) track back to 1935 and the adoption of the B17 Flying Fortress Bomber by the U.S. Airforce. The B17 checklist helped to reduce accidents caused by human error, and versions of it have been ubiquitous in the aircraft industry for the last 80 years.

Checklists are so effective that they aren’t just restricted to aviation. They have a role in everything from; ‘packing for your round the world trip’ through to auditing and ‘shutting down your nuclear reactor in an emergency’. Useful in any complicated situation where the human brain could become confused or muddled, particularly in a stressful situation. So, it’s no surprise that the medical world (eventually) picked them up.

Atul Gawande helped us love checklists. You’ve probably heard of Atul Gawande, author of the 2009 bestseller, The Checklist Manifesto? (Yes, I do own a copy, a birthday present from my Father in Law).

The book talks about how eight hospitals took part in a pilot of the  World Health Organisation (WHO), 19 Point, Surgical Safety Checklist during 2007/8. The results were impressive:

• Post operative complications reduced by almost a third.
• Death rates reduced by almost a half.

The WHO went on to recommend that the Surgical Safety Checklist (or something similar) was adopted by all hospitals. The UK National Health Service (NHS) required that all its facilities use the checklist, and by 2012 over 2000 facilities worldwide had tried checklists. An impressive example of ‘evidence based good practice’ being rolled out across organisations.

If you want to get a feel for just how enthusiastically this example of good practice has been ‘rolled out’, have a look at You Tube and search for ‘WHO Surgical Safety Checklist’. You might be surprised by just how many diverse organisations and groups have uploaded videos, I was. You can lose a few hours browsing the 3000+ search results. ‘How NOT to do the WHO Surgical Safety Checklist’ is a particularly uncomfortable yet compelling video to watch.

Checklists haven’t worked like they should. This feels like a bit of a spoiler, but do have a look at this article from Nature; Hospital checklists are meant to save lives – so why do they often fail?

The Nature article uses an example of 200,000 procedures carried out at 101 hospitals in Canada, where there was no evidence of any reduction in complications and deaths following use of checklists. It also details the failure to match results of the Michigan Checklist, which was used to prevent problems associated with the introduction of catheters into veins (eurrgh!).

For me, the article is making a very clear point that; checklist aren’t the problem, it’s how the people who receive the ‘new’ checklist choose to use it. There are a number of ‘issues’ used to illustrate this: (have a look at the helpful graphic)

• Staff resisted, or failed to complete the checklist. Sounds like a bit of the ‘not invented here syndrome’ to me.
• The checklist was illogical or inappropriate. Fair point, one size rarely fits all.
• The checklist was seen as a waste of time. A bit like the first point, people don’t see it as useful.
• ‘Parachuted in’ solutions. It was just another ‘initiative’ dropped on front line staff by Managers and Administrators.
• It felt ‘Imposed’. People do have a tendency to resist things that are imposed upon them, regardless of how much it is the ‘right thing to do’ (I know I do).
• It didn’t fit the local context. The requirements of a checklist developed in a well-resourced American hospital might not apply in an under-resourced hospital in a conflict zone. You may not have the same standard of equipment or even the same number of people available to perform the task.

It’s all about the implementation. The Nature article goes to talk about the need for careful thinking about how you transfer good practice and the growth of Implementation Science.

As an example of proven good practice (which saves lives) the WHO Surgical Safety Checklist stands out. It’s been enthusiastically adopted in many places, just have a look at You Tube. However there are places where it has failed to have the desired impact. Based on this experience I think there is a case for thinking more widely about the process of implementation in the transfer of good practice and the role of Implementation Science. Good practice transfer is not always a simple case of ‘just do it’.

So, what’s the PONT?

1. Checklists are a very effective way of reducing human error in complicated (and straightforward) procedures. An example of ‘transferable good practice’.
2. Issues around ‘implementation’ the WHO Surgical Safety Checklist have prevented them from being fully effective in some settings.
3. Universal acceptance and use of the Surgical Checklists might take time (Aviation checklists are after all 80 years old).

Related Post: Why is Good Practice such a bad traveller? http://whatsthepont.com/2012/08/19/why-is-good-practice-such-a-bad-traveller/