Checklists – They’re Not All In Your Mind
"Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so, [like using checklists]."
- Douglas Adams
The first few generations of electronic medical records were geared to replace parts of the paper charts that preceded them. Sections often replicated the tabs of paper charts with electronic equivalents. In recent years, parts of EMRs have transcended the original paper chart roots, to include direct support for task lists. Tasks like signing verbal orders, dictated transcription, or addressing orders with “automatic stop” criteria. As was pointed out by
Jim Walker recently, the bigger game transcends EMRs and tasks, and moves to reliable, collaborative processes.
In the last decade, we entered the realm of using EMRs to address patient safety. One of the promising areas is automating checklists. If you aren’t familiar with Peter Pronovost’s checklist work, there’s a great
New Yorker article by Atul Gawande from December of 2007 . Here’s a quote about the impact in ICU care:
The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
That brings us to My Garage. For several years, I’ve started a formal talk by asking the audience what they do each morning, between the time they lock their home behind them, put their car into gear, and start their drive to work. I encourage two people to walk through their routine for the larger audience.
Their responses have typical components, as well as atypical. That’s nice because it keeps it fresh for me! It often goes like this: I open the car door, put in my briefcase and lunch. I turn on the radio and make sure I have my cell phone. Then I open the garage door, drive to the street, press the remote control to close the garage door, and I’m on my way.
The lists vary from person to person of course, and someone in the audience always enthusiastically wants to add something that wasn’t mentioned. They’re into it! But, in the years I’ve done this exercise, dozens upon dozens of times, no one has ever said that they check their fuel gauge. I like to point out that, if you have a driving and refueling routine and don’t share your car with others, you may not need to check. If you have a low fuel alert/alarm, it may be less critical. I’ve yet to meet anyone who uses a written checklist before their daily “take-off.” I certainly don’t. I sometimes use a mental checklist, and I definitely have routines that make skipping the checklist stuff work out okay … almost all the time.
Gawande pointed out that in aviation, when planes reached a certain level of complexity, written checklists became clearly required. The “My Garage” exercise simply points out, among other things, that we don’t like to use checklists.
The central importance of written (or electronic) checklists for personal, executive function has been extremely well elaborated by David Allen, in his popular book and methodology known as
Getting Things Done. Incidentally, his book and seminars are chock full of tips related to checklists, from strategic to tactical, from brainstorming and mind mapping to simply using checklists to
dramatically lower toxic anxiety that arises from expecting your brain to remember everything you need.
My understanding of checklists became complete when I put together two thoughts:
we all need to be able to create, as well as eliminate checklists with comfort on an individual basis; and
using checklists can represent the highest level of disciplined management, as well as the lowest (for example, when the items of a check list can and should be built into a workflow such that the checklist is used as an invisible byproduct of doing the job; also known as the concept of forcing functions).
Conclusion and Lessons?
Checklists are central and crucial to healthcare delivery. They’re also explicitly or implicitly embedded in almost every EMR screen. Whether they’re signature queues, inboxes, flowsheets, medication administration and reconciliation screens, etc. Those screens are either explicitly checklists, or being used by providers as triggers for mental checklists associated with delivering care.
Well utilized EMRs are customized and evolved to support care processes. As a result, the creation, evolution and elimination of checklists is an important discipline to develop and plan for.