Implementation of checklists in health care; learning from high-reliability organisations

BACKGROUND Checklists are common in some medical fields, including surgery, intensive care and emergency medicine. They can be an effective tool to improve care processes and reduce mortality and morbidity. Despite the seemingly rapid acceptance and dissemination of the checklist, there are few studies describing the actual process of developing and implementing such tools in health care. The aim of this study is to explore the experiences from checklist development and implementation in a group of non-medical, high reliability organisations (HROs). METHOD A qualitative study based on key informant interviews and field visits followed by a Delphi approach. Eight informants, each with 10-30 years of checklist experience, were recruited from six different HROs. RESULTS The interviews generated 84 assertions and recommendations for checklist implementation. To achieve checklist acceptance and compliance, there must be a predefined need for which a checklist is considered a well suited solution. The end-users ("sharp-end") are the key stakeholders throughout the development and implementation process. Proximity and ownership must be assured through a thorough and wise process. All informants underlined the importance of short, self-developed, and operationally-suited checklists. Simulation is a valuable and widely used method for training, revision, and validation. CONCLUSION Checklists have been a cornerstone of safety management in HROs for nearly a century, and are becoming increasingly popular in medicine. Acceptance and compliance are crucial for checklist implementation in health care. Experiences from HROs may provide valuable input to checklist implementation in healthcare.