Quality Improvement on the Frontline: Lessons from Implementing Surgical Checklists in Health Care

Quality Improvement on the Frontline: Lessons from Implementing Surgical Checklists in Health Care

Article Highlights:

  • Although checklists are relatively easy to create, bringing them into practice is difficult.
  • The following six rules can aid in the effective implementation of a checklist: Follow the workflow, keep things simple, build your tool with a multidisciplinary team, test before your tool touches a patient, train, and engage everyone individually.

Dr. William R. Berry
By William R. Berry, MD, MPH

A little over a year ago, I was privileged to give a short presentation to 2014 ASCO Quality Care Symposium attendees. In fifteen minutes, I tried to summarize what I have learned about improving the quality of care that we provided patients through the use of tools like checklists. I had a terrible cold, and I am not certain that I delivered the message particularly well, but when I was offered the opportunity to present my thoughts to a similar audience here, I seized it.

I have been helping health care teams implement the World Health Organization (WHO) Surgical Safety Checklist in operating rooms around the world for the last decade through the Checklist Dissemination Program. In that time, I have observed remarkable successes and more than a few failures. For certain, implementing a “simple tool” like a checklist is anything but easy. Although checklists are relatively easy to create, bringing them into practice is difficult. I have had much time to reflect on why that may be, and this exercise has led me to develop a set of rules for how best to bring even simple change to frontline clinical practice.

To begin any quality-improvement project you need a goal, a process to reach that goal, and something to measure your progress toward that goal. For the WHO Surgical Safety Checklist, that includes making the operating room safer, implementing the checklist, and monitoring checklist performance through observation and coaching. With that established, onto the rules.

Follow the Workflow

Checklists require that you take the time out of your busy routine to actually read them and carry out the actions that they prompt. In checklist lingo, that time is a called a “pause point.” Without a natural pause point in someone’s work, the checklist cannot be used effectively. There are two ways to use the pause point. One is to use it as you do the work to actually trigger the actions. We call that a “read, do” checklist; you read, and then you do. The other is called a “do, confirm” checklist; you do everything you think you need to do, and then you use the checklist to confirm you didn’t forget anything.

Both of these approaches could work, depending on what you are trying to accomplish with your checklist. For example, when assembling a child’s bike, the “read, do” checklist makes sense. It keeps you from putting the wheel on only to find that you needed to put the fenders on first and having to take everything apart. For many things in health care where there are fairly practiced routines, the “do, confirm” approach might make more sense. The team gathers the equipment needed for a procedure and stops to review the equipment checklist before they begin to ensure they have everything.

However, if you need to stop to use a checklist and you don’t have the time to stop, the checklist will probably not get used. You have to respect the workflow and use it to your best advantage by looking for those pause points. This principle applies beyond checklists, too. The change you are trying to make will be easier to implement if you can build it into an existing workflow. If you fight the workflow, you will likely fail to implement the change.

Keep Things Simple

Humans are capable of performing incredibly complex tasks, but they don’t learn to perform complex tasks instantly; they begin at a simple level and gradually move toward more complexity. Anyone who has taken piano lessons knows that you start with single notes and then move to one-handed scales before graduating to a Bach concerto. With checklists in health care, we are not ready for Bach. We are still figuring out how to best use these powerful tools that can help us remember critical steps and prepare to perform increasingly complex procedures. We need to keep them simple because we need to start simple, and for most instances stay simple.

Checklists are best used to prompt discussion of important information that should be verified and discussed for every patient, every time. Every checklist item should be scrutinized using these six questions:

  1. Is this a critical safety step at risk of being missed?
  2. If this safety step wasn’t completed, would the team notice?
  3. Was this item discussed when all relevant team members were present?
  4. Is a checklist the best way to ensure this action is completed?
  5. Can something be done about it?
  6. Will this item help someone on the team?

You want your checklist to be sparse and clear instead of dense and complex. That rule works, too, for how we create tools for use with patients, checklist or not. We strive for simplicity and clarity to the point of elegance.

Build Your Checklist With a Multidisciplinary Team

The original WHO Surgical Safety Checklist was created by a large group of international experts from virtually every specialty that impacts care in the operating room, including nurses, anesthesiologists, biomedical engineers, surgeons, technologists, administrators, and patient advocates. There were many reasons for that approach, but the most important was the need for broad perspectives to ensure patient safety in the operating room, regardless of location. Different specialties view the operating room in different ways, and all viewpoints are important. For example, nurses realize surgeons don’t always know their names, and the nurses believe that knowing names is critical to creating a culture of safety in the operating room. Surgeons may not think of that on their own. In the end, the WHO Surgical Safety Checklist became a powerful tool well-suited for operating room teams.

Surgery is performed in teams, so tools for surgery should be made by teams. The WHO Checklist Dissemination team strongly believes this, which is why we first ask hospitals to build a multidisciplinary surgical team before implementing the checklist. Our rule is that if a group is going to use the checklist, that group should be involved in the creation, testing, and implementation process. That rule works for any process change; use a multidisciplinary team to do the work from the very beginning, and pick your team strategically to include those who are respected by others and who will champion the work.

Test Your Checklist Before Using it With Patients

Many of the changes people try to make in health care are planned behind closed doors, and project teams assume what they believe will work will actually work in reality. The Checklist Dissemination team feels strongly that testing the checklist in use with clinicians is a critical and necessary step that is often skipped.

Have you ever bought a new television and were completely confused by the remote? Chances are it wasn’t tested with end users. The first step in testing a checklist is to try it without patients in what is called a “tabletop simulation.” It works as follows: Take your checklist, give everyone on the team a role to play, and then actually try the checklist out. This gives you a chance to identify problems while there is still an opportunity to fix them.

We call that “iterative testing,” which means test, change, repeat test. The testing doesn’t stop when you introduce the checklist in the clinical environment. Here, the principle is to start small and build slowly—one clinician, one patient, one time—and expand from there. Testing small allows you to make mistakes small. Nothing destroys an implication effort faster than a poorly functioning tool implemented at full scale that needs to be retracted, repaired, and reintroduced. This testing approach works with any change, not just checklists.

Don’t forget to test the checklist with enthusiastic and supportive teams. Testing with naysayers rarely changes their minds, and they may hold a grudge against your checklist if it doesn’t work perfectly.


The WHO Checklist Dissemination team recently brought together a group from many different industries that use checklists as part of their everyday work. We had someone from the nuclear power industry, a former senior forester, and a couple of airline pilots, surgeons, and anesthesiologists. What became quickly apparent was a major difference in the amount of training time that each sector devotes or can to devote to training, particularly safety training.

Health care is clearly time challenged. Resources are limited, as is time spent away from frontline patient care. That said, training is important. The first time someone uses a new checklist or tries out a new process should not be during actual patient care. For example, just this last weekend, I went to a restaurant that typically has great food and great service. But the service was challenged this time because the restaurant had transitioned from paper orders to tablets orders. The food took forever to arrive; the waitress made two mistakes, kept apologizing, and was clearly uncomfortable and anxious. She was obviously practicing on us and hadn’t been well trained. Fortunately, it was a quiet afternoon, and my party and I were forgiving diners.

Proper training, however, could have helped avoid the situation. We make this mistake all the time in health care, and particularly with the implementation of checklists. The health care team is given no training, and then leadership is surprised when the team is anxious, pushes back, or are noncompliant with the new great idea. Be creative. Find the time, and train your change.

Engage Everyone Individually: The One-On-One Conversation

Leadership tends to communicate change through emails, posting a letter on a wall, or saying something in a meeting because those approaches are easy. Have you ever looked around during a staff meeting and watched what people are actually doing? Their phones are out, their computers are open, and most individuals are clearly not paying attention. Emails, wall postings, and meeting announcements are useful, but we can’t and shouldn’t count on them to get an important message across, and we shouldn’t expect people to buy in and change their behavior based on those types of communication.

Early on in doing the WHO checklist work, I worked with a hospital where the surgeons were the first on board with the Surgical Safety Checklist and had complete buy-in—not what I usually observe in these situations. I asked how they did it, and the answer was simple, with two parts. They took the time to talk to each surgeon individually (made office appointments, in fact), and they asked the surgeons for their help in making the checklist work.

After all, most of us were drawn to health care out of a desire to help people. Taking the time to talk directly with someone demonstrates how important you think the change is, and asking them for help seals the deal. The impersonal approach is cheap, and you get what you pay for. We extend this rule to every group that will be touched by the Surgical Safety Checklist, and if you are really creative, you can combine one-on-one training with this conversation. Don’t forget to ask for their help and to say “thank you” at the end.

For a successful improvement project, start with a goal, a way to achieve that goal, a way to measure your progress, and then follow the six simple rules of effective implementation:

  1. Follow the workflow
  2. Keep things simple
  3. Build your tool with a multidisciplinary team
  4. Test before your tool touches a patient
  5. Train
  6. Engage everyone individually

The next time you want to change a process, make the investment, spend the time, stack the deck, and stick with it. Success will follow.

About the Author: Dr. Berry is the Program Director for the Safe Surgery 2015 initiative based at the Harvard School of Public Health and the Deputy Director and Chief Science and Implementation Officer of Ariadne Labs: a joint center for health system innovation at Brigham and Women’s Hospital and the Harvard School of Public Health.  He is also a Surgical Consultant to the Risk Management Foundation of the Harvard Medical Institutions.   He also serves as the Boston Project Director of the Safe Surgery Saves Lives initiative with the World Health Organization’s Patient Safety Program.

Additional Resources:

  1. Project Check. projectcheck.org. Accessed February 12, 2016.
  2. Ariadne Labs. ariadnelabs.org. Accessed February 12, 2016.