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August 4, 2015

Why checklists fail—and the three keys to making them succeed

Daily Briefing

    At some hospitals, checklists have resulted in dramatic reductions in infection rates—but at others, they have failed to make much of a difference. In the journal Nature, Emily Anthes outlines the keys to effective checklist implementation.

    Mixed results

    Several studies have shown striking declines in infection rates after hospitals implemented checklists.

    For example, Johns Hopkins Medicine safety expert Peter Pronovost and his colleagues found that when 108 ICUs in Michigan implemented a five-step checklist to prevent infections, the providers reduced their rates of catheter-related bloodstream infections by about 66% within 18 months.

    And a pilot study of eight hospitals— led by long-time checklist champion and renowned Brigham and Women's Hospital surgeon Atul Gawande—of the 19-item World Health Organization (WHO) Surgical Safety Checklist found that the providers'  post-surgery complications decreased by more than one-third, while mortality rates dropped by nearly 50%.

    The checklist proven to improve cardiac surgery program efficiency

    But other studies have told a different story. Both a 2014 study in the New England Journal of Medicine  conducted at about 100 hospitals in Canada and a 2013 study in BMJ Quality & Safety of a British initiative based on Pronovost's efforts—called Matching Michigan—found that using checklists did not lead to significant improvements in outcomes.

    Why checklists fail

    One reason checklist efforts fall short, Anthes writes, is that even if clinicians have a checklist in front of them, they don't always check all the boxes.

    After the National Health Service (NHS) required all treatment centers to use the WHO checklist, researchers at Imperial College London conducted an analysis of procedures performed at five NHS hospitals. They found that providers used the checklists 97% of the time, but:

    • Did not have at least one team member present during checklist review more than 40% of the time;
    • Did not have the lead surgeon present for checklist review about 10% of the time;
    • Only read an average of 66% of the checklist items aloud; and
    • Only completed the checklists about 60% of the time.

    However, the researchers did find that completing more of the checklist corresponded with lower complication rates.

    When the research team interviewed staff at 10 NHS hospitals about their challenges with making the checklists effective, clinicians raised several issues, including resistance from anesthesiologists and senior surgeons, too little initial input from clinicians, and insufficient implementation support. Some also had issues with checklists themselves, calling them redundant or poorly worded.

    Gawande: When checklists don't work

    Three keys to effective checklist implementation

    In interviews with Anthes, experts outlined several steps hospitals can take to ensure checklists deliver results.

    Ensure leadership is engaged. Several studies have found that the difference between checklist success and failure is whether implementation leaders take time to discuss how and why the lists should be used with clinicians. Getting buy-in can require several different approaches, ranging from "pulling on somebody's heart strings" to sharing data, explains Sara Singer, a researcher at the Harvard T. H. Chan School of Public Health.

    Tweak the lists. Experts also say it is crucial for individual hospitals to modify the checklists to best fit within their workflows and instill a sense of ownership and investment. Pronovost says that at the 108 ICUs in Michigan, the checklists were all "95% the same, but that 5% made it work" for the providers.

    Share feedback. Pronovost also stresses the importance of giving providers feedback on a regular basis to increase the pressure on them to improve. He also says a key part of the Michigan ICU's success was holding regular in-person workshops that brought staff from different hospitals together to discuss their experiences, which helped enhance their sense of a common mission (Anthes, Nature, 7/28).

    Pronovost: How to build an infrastructure that supports quality improvement

    Dr. Peter Pronovost, director of patient safety and quality at Johns Hopkins Medicine, discusses the importance of balancing clinician autonomy and accountability.

    Watch now

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