The importance of checklists in healthcare and law enforcement

Importance of checklists

During the second-ever demonstration flight of the B-17 bomber in 1935, the crew forgot to disengage the flight control gust locks, which caused the plane to stall and crash, killing two of the crew.

The plane was already considered one of the most complicated planes to fly, and this raised the question about whether pilots would have to memorize more and more steps just to be able to fly it.

After the accident, Boeing came up with the idea of a checklist as a way to display everything a crew needed to do before they could take off. The list was sequential, easy to understand, and easy to follow. They could see that each item was done before they moved onto the next item. It has become a requirement for all pilots to use even today.

The checklist was created because of that fateful day on October 30, 1935 (October 30 is even National Checklist Day), and has been in widespread use ever since.

The practice has, of course, extended to other branches of the military, law enforcement, manufacturing, businesses, and healthcare. Even people who just want to remember what to pack for a vacation or following a recipe have used checklists.

Checklists in healthcare are commonly used in emergency medicine, surgical procedures, housekeeping, safety inspections, home visits, and mental health risk assessments. Checklists in law enforcement often focus on equipment, procedures, and even interviewing victims of crimes.

Of course, as one Norwegian study said, ". . . a checklist is a tool, not a goal in itself." The point of the checklist is to solve a predefined problem. 

Basically, if you need to remember a lot of steps that have to be completed in a particular order, checklists are going to be your best bet. It's especially helpful if they're part of your regular policies and procedures manual, and that your staff is trained on them and uses them on a regular basis.

Checklists in healthcare

How do medical checklists help healthcare organizations improve patient safety?

According to a 2009 press release from the Harvard Medical School, "A two-minute checklist confirming safe delivery of anesthesia, prophylaxis against infection, and other basic safety items reduced complications and deaths after surgery by one third in eight hospitals around the world.

"Overall, the rate of complications went down from 11.0 percent to 7.0 percent while the inpatient death rate fell by more than 40 percent."

The study was performed as part of the World Health Organization (WHO) Safe Surgery Saves Lives campaign. Their surgical safety checklist has 19 questions divided up into groups – before anesthesia, before incision, and before the patient leaves the operating room – and they need to be answered by the nurse and patient or the regular surgical team: a nurse, anesthetist, and surgeon.

The point of the checklist was to reduce errors and increase teamwork and communication in surgery. It has been used around the world, and copies of the checklist are available in English, French, Spanish, Arabic, Portuguese, Russian, Farsi, Norwegian, Chinese, and more.

Hospitals and healthcare facilities might use other medical checklists to prevent other adverse events, like adverse drug effects, bloodstream infections, fall-related injuries, hospital-acquired pressure ulcers, and venous thromboembolisms, just to name a few.

Checklists in law enforcement

Checklists can also be used to help improve outcomes for law enforcement officers and agencies. They're often a requirement in different departments for each officer to use before they head out for their shift.

Is your flashlight operational? Is your TASER functioning? Do you have your cuffs? Is your radio charged? Is your firearm cleaned and oiled?

These are just a few items that every officer has on his or her checklist. But there are also checklists for other parts of the job, not just the patrol officer heading out on the beat.

How do checklists help law enforcement improve outcomes?

Checklists can be used by police officers to help complete reports, interview victims, process suspects, and assess incidents.

For example, the International Association of Chiefs of Police have created checklists to determine what kinds of information an officer should gather in cases of domestic violence, non-lethal strangulation, protection order violations, sexual assault, and stalking.

The checklists can ensure that the officers' reports of those crimes will capture the important details in order to provide as much information to the prosecution. They can also be used as a training tool for rookies and police academy cadets.

Other forms of law enforcement checklists can include:

• A police patrol gear checklist to help you ensure that your equipment is all functioning properly.
• A field training officer (FTO) checklist will show field training officers all the things a rookie or new officer needs to learn during the first months on the job. (The Long Beach, California police department has a very thorough police FTO checklist.)
• A police officer equipment checklist is a bit different from a patrol gear checklist because these may be items kept in a go bag or the trunk of their vehicle.
• A police vehicle maintenance checklist is usually checked whenever a vehicle is checked out before and returned after each shift. Of course, if your department has a take home vehicle policy, you may need a different checklist.
• The IACP report review checklists, which we mentioned above, are part of the IACP's Police Response to Violence Against Women.

How to create an effective checklist

You can ask 10 people how to create an effective checklist and you'll get 11 responses. Checklists are as varied as the individuals who create them and use them. Someone may create a standardized checklist, such as the patrol gear checklist above, but it will have to be changed and updated because the list may have been created in Minneapolis, but it needs to be modified for a department in Miami.

Here are a few items on our Creating an Effective Checklist checklist.

• Learn from past mistakes. Is there a problem this checklist needs to solve? Understanding why you need the checklist will help you make it.
• Dig into your policies and procedures manual. Chances are, you're looking for a way to more easily remember things in the procedures manual. Use it to make sure you've got all the steps.
• Keep checklists manageable. A 12-page daily checklist is not manageable in the least.
• Keep checklists simple. It should be precise and easy to use during difficult or emergency situations. Don't include the whys or hows of a task. Just list the task. "Check flashlight" is better than "Check flashlight by turning it on for 3 seconds and turning it off again."
• Break down large projects. "Maintain vehicle" or "clean the operating room" are too large and unspecific. Do you just hose the thing down and call it done? Of course not! There are so many smaller tasks that go into each of those large projects, it would be hard to know if you missed something or not with that single checklist item.
• Don't bundle multiple items. Don't list items like "Check TASER and flashlight." What do you do if only one works, or you don't check both at the same time?
• Group tasks. Don't scatter them throughout the checklist. The WHO surgical safety checklist breaks tasks into three groups: Before Anesthesia, Before the Incision, and Before the Patient Leaves the OR. Keep your tasks organized by group as well as chronologically.
• Test the checklist. Nothing is perfect the first time, so test the checklist with your colleagues, ask for feedback, and make the necessary updates.
• Review your checklists and update regularly. You update your policies and procedures on a regular basis, so you should do the same with your checklists.
• Work with a colleague. Find someone who does these same tasks and ask them to double-check the checklist. They may find something you missed.

How checklists integrate with your policy management system

In your policies and procedures manual, you no doubt have many different multi-step procedures that explain how healthcare workers should do things like clean a room where a patient has died or prevent central-line related infections. Or how law enforcement personnel should transport a prisoner or engage in a high-speed pursuit.

There are steps, lists, decision trees, and instructions that explain what actions need to happen during routine tasks in order to achieve a successful outcome.

Your departmental checklists are basically just shortened versions of those bigger standard operating procedures. Rather than making your staff carry around a multi-page document, or keep the procedure open on their mobile devices, consider creating an electronic checklist using a task manager app or just a PDF of the checklist.

Checklists should integrate with your policy management system in that they will not only reflect the procedures they represent, but any training on these procedures should also apply to the checklists as well. People who are trained on the procedures are also trained on the checklists.

And if you can provide 24/7 access to the policy manual and training content to your staff on any kind of device – laptop, tablet, mobile phone – then they can have a better understanding of what their checklists mean and how they work.

As you update procedures and checklists through a regular systematic review, you can also send out notifications to your staff asking them to review the updates, and then require signatures of your staff to show that they have reviewed and understood these new updates.

Depending on your accreditation requirements, you can also use checklists as proof of compliance. With the right policy management software, you can map your checklist to the related requirement in your standards manual. This feature greatly simplifies the accreditation process, saving you money, time, and stress.

Final thoughts

Checklists are an important part of organizing and completing tasks in a particular order. They're used in healthcare and law enforcement, as well as the military and business world. Making checklists a regular part of your employees' responsibilities will go a long way in cementing critical procedures in their minds and ensuring they make fewer mistakes that could harm a patient or civilian. That, in turn, reduces your risk of liability and improves outcomes with the public.

If you want to learn why checklists are an important part of policy management, and how effective policy management makes for effective employees and companies, visit the PowerDMS website for more information.