Questioning Why “Checklists” Work to Optimize Their Use in Patient Safety Interventions

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Dr.s Peter Pronovost and Atul Gawande are well known in healthcare circles for their pioneering work using “checklists” for patient safety.  One of the wonderful things about a using a checklist for a procedure involving a team of people is that it helps to take any toxic relationship dynamics or power struggles out of the picture.   We do things ‘right’ because of the checklist and doesn’t matter if you are the doctor or the nurse or if you have a history of aggressive or passive-aggressive behavior.  The checklist is the checklist is the checklist.

Seems like a good thing, right?

Sure it is.  But as a specialist in group dynamics and nurse I want to make sure that they are used most appropriately and see a potential danger that we would be wise to keep in mind as we utilize ‘checklists’ in healthcare.  After all, nurses and doctors have hundreds of procedures and protocols to follow that are based on safe standards of care and it doesn’t seem realistic to have checklists for all of them.

What is the Potential Danger of Using Checklists for Patient Safety?

A “checklist” that works could become an excuse not to do the work required to build healthy interpersonal relationships and workplace cultures. And doing that work is critical for the big picture of safe care for patients and healthy workplaces and careers for professionals. (Can you imagine a boat of birdwatchers?  Now think of someone pointing to a rare bird. Everyone rushes to the side of the boat from which the bird can be seen and the boat tips over and the bird flies away!)

Sometimes I think we react to trials of new models and/or research outcomes without full appreciation of the process involved. For instance, a surgical team has a facilitated meeting where they create a plan for members to speak-up when they see a problem.  They call it: “Houston” and members make a commitment to say “Houston” any time they see a problem.  It works well and so they tell others about their success, but when another team tries it is isn’t as successful.  That’s because, at least in part, that members of the team creating the model had voices in its creation and an inherent commitment in its success.  The PROCESS was key for the model’s success! As Dr. Pronovost describes in this Johns Hopkins video, as part of their checklist protocol, everyone on the team introduces themselves by their first name and this helps to level the heirarchy.

For some teams this may be enough healing of  relationships to ripple out in positive impacts everywhere, but when a team has more pervasive or complicated  toxic relationships that aren’t healed, they will manifest somewhere.  In fact, I think human beings are pretty creative in this way and the worry is that a checklist may give a false sense of security.  In other words, we’ll solve one problem, but if we don’t address the underlying dynamics another problem will likely crop up.  Maybe highly trained people will leave the team, some may develop stress-related illnesses or maybe there will be an increase aggressive and/or passive-aggressive behaviors and higher rates of error in a different procedure.  These will be hard to trace back to anything related to the checklists themselves, because the checklists may continue to work.  I think this phenomenon helps explain why some of the Joint Commission’s statistics on sentinel events show that some things get better and some get worse so the overall improvement is confusing. (Look at the events for 2010 compared to 2011 in the box on the lower left and be careful to recognize that the 4th column is only for half of 2012!)

How Can Leaders Make the Best Use of Checklists?

Leaders who understand and address underlying problems such as disruptive behavior or understaffing as well as using checklists will make great strides in patient safety outcomes.  Using them to address a particularly high incidence of error such as with catheter or central line infections.  And in time, maybe implement random uses of checklists throughout a facility for a variety of procedures can become an established practice for refreshing and reaffirming proper techniques and keeping the heirarchy level.

When toxic relationships are a problem, team-building, ‘whole systems’ consulting and effective communication training and practice will help to create more positive cultures, improve toxic relationships and decrease disruptive behaviors.  Medical Improv is another albeit unconventional way to affect toxic elements in your workplace and it is so much fun you won’t even know your doing it!

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2 Responses to Questioning Why “Checklists” Work to Optimize Their Use in Patient Safety Interventions

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