Checklists in Healthcare – Five Challenges and Their Mitigation

How to enhance the efficacy of healthcare checklists using a ‘mobile first’ approach?

Checklists are used in both medical and non-medical industries as cognitive aids to guide users through accurate task completion [1]. They have proven effective in various aspects of performance improvement and error prevention, in both clinical and administrative scenarios. Checklists used for healthcare are intended to drive patient safety, but large-scale implementations have revealed variable outcomes, suggesting that these tools are not as simple or effective as hoped [2]. Studies have found that the variance may be due to a mix of technical and socio-adaptive elements [3], and that local contexts may either augment or undermine the implementation’s outcomes.

We look at five common challenges and how a ‘mobile first’ approach could help overcome these.

Challenge #1: Poor Checklist Design Undermines Change Management

The successful implementation of healthcare checklists requires well-thought checklist design combined with good change management. According to research, poor checklist design, characteristics of the organisational culture, and variable processes are all factors that affect the adoption of, and compliance with, checklists. These may result in variable end outcomes. [1-5]

Checklist design, a resource-intensive task, is key to ensuring compliance. Customising checklists to changing requirements is often a challenge, and the process of change can be variable and expensive in the paper world. The challenges to change management to initiate these new behaviours can result in poor implementation and compliance.

Mitigation Offered:

Using a digital checklist on a mobile device offers many advantages, including better access to patient data, integration with a future computerized decision support system, flexibility, customization of content, and dynamic display of information [5]. It is important that the checklists are customised to meet the needs of each hospital and unit, and at Medanets, we always customise the checklists according to the needs and wishes of the customer.  Through its Admin UI, the Medanets solution allows using objective data-derived elements to evaluate the true impact of safety interventions, thereby facilitating constant quality improvement cycles.  This helps you plan targeted change management efforts.

Challenge #2: Physical Access Impedes Compliance

Situations in clinical work vary, and sometimes time is short. A paper checklist will not always be at hand. If the checklist needs to be separately retrieved to the situation, this can impede compliance [2]. Moreover, the paper process takes time, which can be a barrier to use the checklist [6].

Mitigation Offered:

Medanets’ solution allows you to digitise your checklists and get instant access to all your checklists at the point of care (POC), or remotely, bringing the checklists into the users’ workflow. It provides patient context to the checklists and brings crucial information to POC, supporting decision making. The interoperability with the EHR allows some of the components of the checklists to be auto populated, which drives efficiency. When the checklists are presented within the clinicians’ workflow, alongside with contextual patient information, their use becomes more meaningful, improving efficiency.

Challenge #3: Variable Accountability of Individual Team Members

In a traditional model, the accountability of individual participants to the checklist process is variable. Typically, one person leads the situation where a checklist is used: he or she calls out different items and documents the compliance to different components. The team members’ responsibilities may be unclear.

Mitigation Offered:

The digital checklist process brings a federated approach to checklist accountability. A mobile application that facilitates multi-part contribution to the checklists simultaneously promotes teamwork. All team members can participate in completing the checklists, according to their defined responsibilities, using their own devices.

Challenge #4: Checklist Fatigue

As checklists prove valuable in healthcare and more of them are introduced, clinicians may experience ‘checklist fatigue’, whereby they become overburdened with completing these lists [1]. The fatigue is often a result of poor design, which, in turn, results in an onerous and time-consuming process.

The lists are only as good as its users: a fatigued user, or someone not educated on the purpose of the checklist, can cause more harm than traditional checks in place.

Mitigation Offered:

Careful selection of checklist topics and consideration of clinical judgement in the content design process can help avoid these potential downfalls.

The Medanets application has a workflow-based approach to checklists, which educates and guides the user as to the ‘why’. This may help avoid fatigue to this useful tool.

Challenge #5: Communication Lapses

Whilst studies have found that communication failures declined by two thirds after the initiation of a surgical briefing, other studies have shown that the person conducting the checklist is ultimately responsible for resolving the problem and redirecting the team [7]. Studies have also shown that there are important limitations to the use of standard checklists as a stand-alone patient safety measure because of multiple factors. Miscommunication was among the key factors affecting outcomes [3; 5].

Evidence suggests that teamwork and effective communication are important factors to successful implementation [3; 5], and checklists can facilitate teamwork.

Mitigation Offered:

Access to crucial clinical information at POC on mobile minimises chances for miscommunication. Medanets application offers agnostic EHR interoperability to drive automation in checklists, which minimises communication lapses. 

REFERENCES:

[1] Development of medical checklists for improved quality of patient care: https://academic.oup.com/intqhc/article/20/1/22/1786984

[2] Back to basics: checklists in aviation and healthcare: https://qualitysafety.bmj.com/content/24/7/428

[3]The problem with checklists: https://qualitysafety.bmj.com/content/24/9/545

[4] The Checklist Conundrum: https://www.nejm.org/doi/10.1056/NEJMe1315851

[5] Comparing the Effects of Paper and Digital Checklists on Team Performance in Time-Critical Work: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800573/

[6] WHO Surgical Checklist in Dermatology: Compliance, Barriers, and Attitudes: https://pubmed.ncbi.nlm.nih.gov/30893152/

[7] Use of the Surgical Safety Checklist to Improve Communication and Reduce Complications: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417373/