Proactive Checklists

When implementing new technology, organizations often miss their biggest opportunities for improvement, by attempting to translate existing processes directly into a digital format. Before writing a checklist, the process which is being measure should be understood and reconsidered.

There is a natural union between a process map and checklists. By combining these tools, technology can distribute checklist tasks according to a process map and organizational roles. If the process map were to be updated after a QI Physician identifies a method that better guarantees patient safety, then the technology could respond by promptly updating its workflow.

To fully redefine a process requires role analysis. With regard to the process of providing timely prophylactic antibiotics, could pharmacists own a portion of a pre-op checklist? Currently, the pharmacy appears to maintain a responsive role, waiting on doctors to request drugs. However, we already know these drugs need to be ordered when the surgery is scheduled. Could we provide pharmacists with a view of scheduled surgery and allow them to proactively confirm the need for antibiotics?

We might imagine the pharmacist could initiate a conversation with the surgeon to determine if the case will use standard antibiotics or does it require a variation? Once informed, the pharmacy could proceed with filling the orders and coordinate with anesthesia to deliver the antibiotics and transfer leadership of the checklist.



Process reorganization achieves its best results when its implementers consider the new methods to accomplish tasks that are possible using technology. Implementers may find that such considerations are easiesr when they analyze a process using a Hierarchal Task Analysis method. This way, they can focus on the tasks which must be accomplished, rather than a sequence of events which may no longer be required.

During a pre-operative timeout, before surgery commences, many items read out from the checklist may have been better to ask an hour ago. However, an hour ago each member of the surgery team couldn’t have predicted where they would be. It’s unlikely that they would have been in the OR, anxiously waiting their turn to affirm that their task was completed. More likely, they were across the hospital, out of reach of a paper checklist. How do we construct a checklist which takes flight, to reach them where they are, allowing their tasks to be affirmed, even when they are away?

Ultimately, the surgeon takes responsibility for the patient. In this role, they need to be informed of key milestones and prompted when milestones haven't been achieved on schedule. What type of checklist allows the surgeon to make use of the critical moment, rather than tally the score only after the patient has been intubated? How can we transition from a checklist which avoids mistakes before the first incision, to a checklist that is present along the way, ushering the patient towards a successful outcome?

After these revisions, a surgeon might receive a report that details accomplishments and notes tasks that may have been overlooked. We've connected the checklist to the process, and distributed ownership of the checklist across the organization, based on appropriate roles. So, rather than ask people if they finished a task they completed earlier, the surgeon knows to thank the nurse, Michele, for ensuring blood products are on hand. It’s a pleasant way to make a final confirmation that the system has worked for this, individual patient.

Some of the most valuable decisions a clinician makes regard judgments of evidence and choices to adopt new practices. Such decisions require high level cognition and make full use of their medical expertise. After those decisions are made, faithful execution is best achieved by a team and may be best managed by a process and checklist that the physician has previously defined.