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8 checklist mistakes to avoid

Publish Date: 3/20/2013

It’s no mystery. The key to an effective surgical safety checklist is a smooth implementation that involves team participation and careful tailoring to match the checklist with the surgical setting. But it’s less clear how periop professionals can iron out barriers blocking the road to successful checklist implementation and sustained use.

“A lack of physician buy-in, a poorly planned launch, a tailored checklist that trims out communication—we have found that these barriers can spell disaster for the long-term success of a surgical safety checklist,” explains Lizabeth Edmondson, BA, senior project manager for Atul Gawande’s surgical safety checklist research team based at the Harvard School of Public Health.

As part of their Safe Surgery 2015 initiative, the team is in the third wave of a project partnering with the South Carolina Hospital Association to help South Carolina get an effective surgical safety checklist used in a consistent and meaningful way in every operating room in the state. The team is also applying what they’re learning in South Carolina to help surrounding states and the American Hospital Association's Health Research and Educational Trust begin similar work with widespread, meaningful checklist use.

For the South Carolina project, Edmondson and research team members, including Atul Gawande, MD, MPH, William Berry, MD, MPH, FACS, team perioperative nursing adviser Elizabeth Norton, BSN, RN, CNOR, and team members from the South Carolina Hospital Association are working with OR teams to teach team training and provide coaching for checklist implementation in various surgical settings, including checklists for ambulatory ORs and endoscopy suites.

“This kind of large-scale checklist implementation has helped us find new ways to identify common barriers and mistakes preventing these surgical teams from getting the most out of their checklist,” according to Norton, who also speaks from her experience implementing the Pediatric Surgical Safety Checklist at Boston Children’s Hospital.

Here are the mistakes Edmondson and Norton say every OR team MUST avoid to reach checklist success:

1. Don’t remove communication steps  

When tailoring the checklist, people have a tendency to drop things that relate to teamwork, particularly with physician engagement, Edmondson notes. “Team engagement takes time, but that is where you get the most benefit.”

She advises, when implementing or modifying a checklist, make sure discussion is facilitated, first and foremost. “If you don’t hear every single team member’s voice before the incision, the checklist isn’t right and you can make it better.”

2. Don’t make the checklist a catch-all 

The surgical safety checklist is specific to patient safety, and should not be used for resolving other challenges in the OR, such as efficiency, Norton stresses. “When we talk with teams about refining their checklist we often hear, ‘oh put that on the checklist,’ but it’s not there to catch all problems—a checklist needs to stay specific to patient safety and communication.”

3. Don’t wait to engage physicians and don’t underestimate the power of one-on-one conversations 

“Physician engagement is identified over and over again as one of the toughest barriers to putting a successful checklist in place,” Edmondson explains. She suggests a clear plan for engaging physicians be initiated early in the checklist implementation process.

The Gawande research team has found success with engaging physicians in South Carolina through one-on-one conversations, often initiated by physician peers who champion the checklist.

“It’s been exciting to see how something as simple as a one-on-one conversation melts away resistance,” Edmondson acknowledges. Based on this success, the team has made one-on-one conversations with physicians and other members of the surgical team part of the core recommendations for the Safe Surgery 2015 initiative.

Norton considers such one-on-one conversations—what she calls “sink-side” conversations—to be the key ingredient in her success with the checklist at Boston Children’s hospital.

She cautions, these conversations must happen with ALL members of the surgical team, especially prior to launching the checklist. “No one on the team wants to be surprised with something new—that’s a sure way to lose checklist support.”

4. Don’t skimp on pre-implementation education and preparation  

Edmondson and Norton agree that team building is a critical step in the checklist implementation process. Building a strong group of enthusiastic, multidisciplinary checklist champions builds the foundation for a successful implementation, Norton suggests.

Because the checklist is about changing culture, checklist implementation team members must have the right mix of knowledge and personality to “sell” the checklist by educating extensively, she says. “This education may involve providing the evidence for why checklists work, or it may focus more on how the checklist will tie in to the flow of the procedure—be ready to answer any question or share any information that will help get buy-in.”

5. Don’t forget to “test-drive” the checklist 

Running the checklist in a tabletop simulation is an important step in the implementation process to identify areas for improvement, Edmondson advises. “Test small with one surgical team whose members are enthusiastic and supportive of the checklist, this way errors with the checklist can be identified early on with people who won’t hold a grudge.”

Norton says a checklist “test drive” can also help teams be better prepared for the more challenging aspects of the checklist, such as the debriefing at the end of the procedure.

6. Don’t choose an arbitrary launch date, be flexible 

Avoid the “big bang”—launching the checklist on a predetermined day that can’t be changed, Edmondson advises.

“Without a flexible launch date, we see the one-on-one conversations and engaging start to disappear; all of a sudden people aren’t prepared when the checklist goes live,” she explains. “This opens the door for a less than successful launch and risks future buy-in and long-term checklist success.”

7. Don’t audit. Coach teams, and never stop looking 

Coaching before, during and after the launch of the checklist must be built into the implementation plan. The Gawande team has focused much effort on teaching good coaching skills to checklist implementation leaders in South Carolina. Edmondson cautions against auditing, which can be viewed as negative. “Coaching in a non-punitive way to observe and provide feedback has been key.”

She also cautions against the common tendency to put the checklist in place and then move on to a new quality improvement project. “You can never stop looking and coaching teams to be better.”

8. Don’t worry about those who are against you 

Norton says the best place to start with checklist implementation is in ORs were you have teams willing to try and willing to believe in the value of the surgical safety checklist. “Focus on the group that’s really interested and spend a lot of time with education and team training; gain their support and then move on to the more ambivalent users—eventually those negative folks will jump on board.”

Additional Resources

Access checklist resources from the Safe Surgery 2015 initiative, including:

  • Checklist templates
  • Coaching and team-building tools
  • Recorded webinars to guide users through checklist implementation steps
  • Scripts for one-on-one conversations to gain checklist buy-in

Stay tuned for published research and new checklist implementation tools from Safe Surgery 2015 expected in 2014.

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