Guide to Perioperative Checklist Design, Implementation, and Integration

Introduction

Checklists have become nearly ubiquitous in anesthesiology, and anesthesia professionals encounter them throughout the clinical experience – from entering the operating room (OR) and running a machine check through the debriefing at the end of the last case of the day. The idea of checklists to promote safety was adapted from aviation, but checklists in healthcare have developed their own unique style and evidence base.

Anesthesiology was one of the first fields in healthcare to use checklists with the introduction of a standard anesthesia machine check checklist in the early 1980s. In recent years, the use of checklists has exponentially increased, with the introduction of the World Health Organization Surgical Safety Checklist (WHO SSC),[1] central catheter insertion checklists, OR crisis cognitive aids, and others. Initial results from implementation of these studies showed improvements in safety culture metrics and patient outcomes.[2–6] However, later attempts to replicate these findings have resulted in trials showing comparable outcomes between groups using the checklists and groups receiving routine care.[7,8] These disparate results suggest that checklists are not merely simple solutions to complex problems but rather complex socio-technical solutions themselves[9] requiring thoughtful design and implementation.[10] To that end, the goal of this commentary is to offer pragmatic advice for clinicians looking to incorporate checklists into perioperative workflows.

Workflow Evaluation for a Planned Checklist

The first step of incorporating a checklist is to decide if a checklist solves the problem being addressed, which involves both a deep understanding of the system and workflow and the capabilities of checklists (Table 1). Making this decision includes understanding what type of clinician support is needed, including cognitive offloading, communication, and information sharing. Checklist fatigue is a risk in healthcare, and implementing a checklist for every problem can make this more pronounced.[11]

Table 1.

Checklists Goals and Contexts of Use with Examples

Goal and Context of Use	Description	Examples
Teamwork and Communication Aid	A tool for promoting team communication, alignment, and information sharing. These can be used for either routine or atypical (emergency) operations. These are analogous to the pre-flight briefings done in aviation.	World Health Organization Surgical Safety Checklist
Cognitive Aid	A tool for off-loading clinician cognitive workload. It can be designed to be used in three manners, which are not mutually exclusive: (1) linear – flowing through a series of steps in order, (2) branching logic – flowing through an algorithm that adapts to context, or (3) sampling for information – using the checklist as a resource for finding pieces of information, such as drug dosing in clinical care. These can support both routine and atypical operations. These are analogous to the classic aviation procedural checklists, such as preparing for landing.	Linear – Anesthesia Machine Check Checklist
		Branching Logic – Difficult Airway Algorithm
		Sampling – OR Crisis Checklists

Once a decision has been made to implement a checklist, one must consider the workflow and system that the checklist will support. Specifically, consideration should be given to understanding how best the checklist can support this workflow without conflicting with other, potentially higher priority, workflows.[12] Introducing a checklist is asking the clinicians to add another step to an already high workload. To minimize this risk, it must be ensured that the planned checklist is not duplicating work done elsewhere.[13] Considering the integration of the checklist into the larger socio-technical system is a recurring theme throughout the design and implementation process.

Checklist Design Features

There are two main design considerations for a new checklist – the content of the checklist and the physical design of the checklist. Adaptation of existing checklists to local context is an important step in implementation.[1] Adaptation is ideally done with a group of clinicians familiar with the daily use of the checklist or the context into which it will be implemented.[1,14] This can provide a sense of psychological ownership over the final product, allowing for a smoother implementation process.[12]

The content of the adapted checklist should link tightly to the institutional workflow. For example, institutions have moved items between sections on the WHO SSC to accommodate team member availability or have adapted the content to match their specific organizational goals, such as in response to recent adverse events[15] or a desire to promote other clinical improvements, such as incorporating elements from the Enhanced Recovery After Surgery protocols into the WHO SSC.[16] Organizations are additionally encouraged to adapt checklists to the resources available at their institution.[1] An emergency checklist informing a clinician to request extracorporeal life support in an institution without that resource available is unlikely to assist in management of the crisis and might decrease clinician engagement with the checklist. The content changes additionally need to be considered in the context of the overall goal of the checklist. If it is a checklist intended to promote teamwork and communication, such as the WHO SSC, the adapted changes should continue to promote that goal in its use.[17]

Considering the physical design of the checklist, human factors studies have described the impact of the physical components of checklists, including the font size and style and the layout on the page, on the cognitive load of users as they scan the checklist for information,.[18] The intended use drives these design considerations. Designers need to understand whether a clinician will be running the checklist linearly or if it needs to support sampling and whether it will be one clinician alone or a team of clinicians utilizing the checklist. These use cases have different design considerations. Successful checklist creation may need to include human factors experts as part of the team.[5,19]

Checklist Implementation

Implementation has been posited to be one of the drivers of the success or failure of a checklist in impacting clinical outcomes.[20] The goals at this stage of the process are to spread the checklist through the perioperative space, promote its use as intended, and create a culture where its use can become self-sustaining.

The literature describing facilitators and barriers to checklist implementation is large, and this is not meant to be a comprehensive review but is rather written to provide a subset of pragmatic examples. Facilitators of successful implementation include training the right people at the right time, changing the physical environment to encourage ease of checklist use, and engaging the support of the key senior leadership.[14,21] However, even with these strategies as part of a comprehensive implementation plan, implementation of a checklist can fail. These checklists are embedded in cultures that might include hierarchies with challenges to speaking up[22] and teamwork norms that are deeply established,[21] which hamper implementation. In the face of these cultural challenges, self-reported audits of implementation are frequently inaccurate, overestimating the fidelity and penetration of the checklist.[20,23] Monitoring implementation success may require more intensive techniques, such as trained observations.[24]

Checklist and Workflow Monitoring

Design and implementation of a new checklist is a continuous cycle of workflow evaluation, design, implementation, and monitoring. The temptation to solve each new problem with a new checklist or by adding an item to an existing checklist leads to checklist fatigue.[25] Longer checklists and more checklists lead clinicians to feel that the purpose of the checklist – to safely care for the patient – is falling behind the need to simply complete more checklists.[14] Checklists should be constantly re-evaluated to assess whether they can be shortened or combined, whether they continue to serve their original purpose, and whether their utility has been impacted by other workflow changes.

One can also imagine a future where the technology in the OR is integrated with the checklists that are implemented. This integration may involve offloading tasks from clinicians onto computers or leveraging the data integration abilities of computers for stronger clinical decision support. Consider the case of checking blood components for transfusion. Users can run a manual checklist, comparing multiple long strings of numbers or names to ensure that they match, or this task could instead be completed with bar code scanning technology, removing a checklist.[26] By using technology to offload clinicians, checklist fatigue decreases and clinician productivity increases, allowing clinicians the cognitive bandwidth to provide better patient care.

One can also envision a future where multiple sources of data in the OR are integrated to allow for smarter checklists that are pre-populated with data that computers can check and report to the clinicians.[25] Anesthesia machine check checklists already pull data from the machine so the clinicians are not required to find each piece of separate information. Checklists in the future might pull data from the electronic medical record, the telemetry, or even the robotic surgical equipment. For example, a “smart” version of the WHO SSC with access to electronic health record data might facilitate the pre-induction checklist by pulling the airway exam from the anesthesia pre-operative assessment. Possible scenarios might be either flagging a potential difficult airway for additional discussion, or, if it was a normal exam, prompting the team to skip the discussion of airway concerns, reducing the administrative burden and allowing more time for a deeper discussion of the abnormal prompts. Alternatively, a crisis checklist might detect an abnormal patient state from the patient sensor data and prompt the clinical team to take appropriate next management steps. Increasing data integration and improvements in decision support algorithms could allow these possible futures to become the reality of checklists in the OR.

Conclusion

Overall, checklists can be a powerful tool for patient safety in the perioperative environment, but they are complex interventions that require nuanced design, implementation, and integration within the system. Despite the effort required to successfully use these sociotechnical interventions, there remains promise in the use of checklists as a patient safety tool and an exciting future to imagine.