The Checklist: A Global Tool That Works

By Kay Temple

At the core of many infection prevention strategies is an elegant and simple tool: the checklist. Infection prevention actions in healthcare settings were listed as one of four recent objectives proposed by the Centers for Disease Control and Prevention (CDC) to tackle the morbidity and mortality associated with infections caused by drug-resistant organisms. These infections cause 23,000 deaths among the 2 million people who acquire them each year in the United States alone.
Over the past decade, infection prevention efforts have had significant impact on other infection categories, such as healthcare-associated infections (HAIs). Checklists have been a big part of this success. A decrease in HAIs was noted as one of the major 2013 public health accomplishments by the CDC. Since 2008, there has been a 44 percent decrease in central line bloodstream infections (CLABSIs) and a 20 percent decrease in the occurrence of surgical site infections (SSI).

The use of checklists in medicine is adopted from the aviation profession where checklists are routinely used for accident prevention. The event leading to their creation was an accident in 1935. Several pilots were killed when an experimental bomber stalled during a test flight due to a pre-flight failure to unlock part of the aircraft's wings. Recovery of the wing's air lift power was impossible and the aircraft crashed. Newspaper headlines claimed the aircraft was "too much for one man to fly." But the surviving pilots felt otherwise. They brainstormed how to prevent that simple step from ever being forgotten again. Their solution was dubbed a "checklist" and it included pre-takeoff action items for a pilot's review. Checklists are still in daily use today for many phases of an aircraft's operation. Current Federal Aviation Regulations (FARs) mandate checklist use that "must be designed so that a flight crewmember will not need to rely upon his memory for items to be checked."

According to the Agency for Healthcare Research and Quality (AHRQ), a checklist is defined as a list of specific actions performed in a given clinical setting to ensure no step is forgotten. Checklists help prevent the most common errors in healthcare, referred to in behavioral psychology terms as "slips" which occur most often when performers are fatigued, unable to concentrate or distracted.

The checklist first gained attention when Peter Pronovost, MD, PhD, embraced its use to improve outcomes in intensive care settings.  Pronovost led Michigan hospitals in attaining a remarkable and sustainable decrease in central line infection rates by using a simple checklist for insertion and maintenance. Their data, published in the December 2006 issue of the New England Journal of Medicine, is now known as the landmark Keystone Initiative. The study gained national attention when The New Yorker magazine published "The Checklist" in 2007. Atul Gawande, MD, MPH, a practicing surgeon, researcher and staff writer for the magazine, was enamored of the checklist's power and wrote "the still limited response to Pronovost’s work may be easy to explain, but it is hard to justify."
That limited response did not last long.

In 2004, the Joint Commission had released the first version of  its "Universal Protocol" to prevent "wrong site, wrong procedure, wrong patient" surgeries. This protocol was essentially a checklist of  three principal components: a preprocedure verification, site marking, and a "time out," another time interval where another verification is performed. By 2008, the World Health Organization, with Gawande as one of the innovators, formally published the Safe Surgery Checklist. In 2009, the Joint Commission modified its National Patient Safety Goals (NPSG) and in regard to the handwashing goal, suggestions for monitoring handwashing HAIs resembled a checklist.

The CDC provides "national leadership in surveillance, outbreak investigations, laboratory research, and prevention of healthcare-associated infections." Its robust website of continually updated information includes numerous checklists and prevention guidelines for an extensive list of inpatient and outpatient healthcare-acquired infections.

Checklist successes have even caught the attention of Congressional members such as Rep. Russ Holt of New Jersey. Holt, a physicist, read Gawande's stories and felt compelled to follow through. With six other congressional members, Holt co-authored a 2010 letter sent to the administration of the Centers for Medicare and Medicaid Services (CMS) and AHRQ requesting them to "further investigate the success of medical checklists to increase research and dissemination of this life-saving health care tool." Most recently Holt led the creation of the Medical Checklist Act of 2013. The bill is now in the Subcommittee on Health of the House Committee on Ways and Means for further action, according to Holt's staff. The Act would require numerous healthcare agencies to further checklist research, including using information technology to assist implementation.

Today, checklist protocols are prevalent across the globe, according to authors Diana Soule McDowell and Sara A. McComb authors of "Safety Checklist Briefings: A Systematic Review of the Literature," published in AORN (Association of periOperative Registered Nurses) Journal.

"I was struck by what an international phenomenon using perioperative safety checklists has become," McDowell says. "Out of the 27 studies we chose to review, 17 countries were included, and not just those countries that are considered industrialized."

Their literature review, limited to studies since 2011, involved pre-procedural briefings structured by checklists. They note that current evidence for surgical safety check lists offers "strong support for their continued use." But, the authors point out the lack of controlled studies. Many studies were based only on pre-post examinations. McDowell and McComb suggest using some caution when reviewing the consistent positive results demonstrated in nearly all studies looking at checklist adherence and outcomes.

The success of checklists is hard to dispute. But McDowell and McComb recommend that the gold standard of randomized controlled trials be used in testing when new checklists are designed and implemented.

"We will not be able to create a study with and without a checklist," McComb says. "We are past that. But, we need to design more rigorous testing of tools that we think may make jobs more efficient and easier."

In addition to proven checklist successes, McDowell also feels that intraoperative and perioperative infection prevention and safety is optimized by a multidisciplinary perspective.

"From my experience working on facility and system committees, all of these infection prevention measures are a team sport which goes well beyond operating room checklists," McDowell says.

And so thinks the Institute of Healthcare Improvement (IHI).  The IHI began emphasizing teamwork in 2001 when it created care improvement processes based on the "bundle concept." Bundles, according to the IHI white paper "Using Care Bundles to Improve Health Care Quality," are a "small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually." Development by a multidisciplinary care team is one key element in bundle design guidelines. The bundles infection preventionists know best are the "ventilator bundle" and the "central line bundle."

The checklist and bundles are also part of infection prevention strategies being embedded into many organizations' electronic medical records. These tools are becoming part of daily progress record prompts and order sets, making their use, in a sense, almost mandatory. Though the voices of the stakeholders that support checklist mandates are few, this use of medical record electronic technology may satisfy those involved in that conversation.

It goes without saying that infection prevention efforts are first centered in patient safety and quality care delivery. Money is also a factor. Since reimbursement for hospital-acquired infections is tailored by the government and third-party payors, healthcare organizations will need to focus even more on prevention processes involving the checklist: a cost-effective solution to many HAIs.

Despite its simplicity and elegance, checklists can't be part of every prevention process. Healthcare organizations must also consider the limits of checklist benefits. AHRQ points out that checklists are successful only where "gold standard" safety practices are well-established and solutions for problems solved by standardizing behaviors. Mistakes, or "attentional" behavior errors, can only be remedied by training, supervision, and decision support.

Lastly, checklists have proven to work best in organizations that have a culture of safety supported by organizational leaders who prioritize safety in daily care routines.

Drawing from aviation's safety culture again, many healthcare organizations have created their own version of "Cockpit Resource Management" (recently renamed as "Crew Resource Management" or "CRM") in order to create a culture of patient safety. Safety goals become more attainable when the traditional hierarchy of supervisors and subordinates is set aside and all members of a care team can communicate concerns and suggestions, especially for prevention processes associated with HAIs.

The aviation experts who birthed the checklist in 1935 to handle the increasing complexity of modern aircraft  would likely not be surprised to find checklists still used by their profession. And perhaps those same experts would be pleased to discover that the high tech world of modern medicine values their checklist tool as a simple and unique way to help keep patients safe.

Kay Temple is a writer for ICT.