If You Don't Have a Checklist, You Probably Should
"If something so simple can transform intensive care, what else can it do?"--Atul Gawande, 2010
Checklists seem to be all the rage these days. There are checklists for managers, checklists that are industry-specific, and even a book titled The Checklist Manifesto: How to Get Things Done Right by Atul Gawande, MD, MPH, which states that every profession could be more effective if checklists were used for various tasks.
As proof to Gawande's thesis, the book offers examples from several industries where safety is paramount--specifically surgery and air travel--and there is heavy reliance on checklists to ensure that everything is covered and covered correctly. So, do checklists have a place in EMS? Can our operations, safety and perhaps even managerial processes benefit from this approach?
Checklists can be small or large, with varying degrees of complication depending on the specific situation they are being developed to cover. According to Gawande, a comprehensive checklist should be:
- To the point
- Easy to use
- Only a reminder of critical steps
The essence of a checklist is taking all of the actions that go into a larger scheme-- actions that have the potential to vary due to time, person performing the actions, day of the week, the weather and a host of other variables--and putting them in written order so the same essential actions happen in the same format independent of all of those aforementioned variables.
Sometimes a checklist may be essential for an event that is important but not frequently seen, such as your EMS agency's response to a pandemic.
A good example of checklist utilization comes from Wake County (NC) EMS. Chief Skip Kirkwood says that his EMS agency utilizes checklists to ensure that EMS providers "dot their I's and cross their T's" in a number of clinical scenarios, including cardiac arrest management, CHF patients and asthmatics, as well as for determining legal capacity, mental capacity and/or medical or situational capacity. Another example of clinical checklists with a quality assurance bent comes from the Eastern Pennsylvania EMS Council and covers a host of clinical interventions like airway management, CHF patients, seizure management, OB/GYN emergencies, etc.
An extremely applicable checklist comes from the Monmouth-Ocean Hospital Service Corporation (MONOC), a CAAS-accredited EMS agency in New Jersey that utilizes a comprehensive checklist to assist supervisory personnel in investigating motor vehicle accidents in which departmental vehicles are involved. Their checklist specifically prompts the supervisor to address various critical points, such as seatbelt utilization, whether a traffic light was involved, whether the unit was en route to a call or hospital at the time of the accident and weather conditions at the time, and also reminds supervisors to take pictures of the scene.
Another checklist, developed and utilized by Lancaster County EMS providing EMS services in the Charlotte, NC, area, specifically addresses myriad issues that field supervisors can and will face over the course of a shift, where to funnel complaints and where in the agency personnel manual to find information. This list is clearly specific to various supervisory responsibilities and includes both day-to-day realities, such as location of spare equipment, checking the supervisor's unit and overall system status, as well as more out-of-the-ordinary issues like communicating with the media or contacting a PIO to handle media situations, coordinating mutual aid requests, and knowing when to contact administration for major incidents (i.e. bomb threats, major employee injury etc.).
One of the underlying elements that is recurrent throughout Gawande's book is that by looking for the answers to simple, often overlooked questions, we can avoid potentially large mistakes. Gawande counsels agencies to get employees to embrace checklists by assuring they are easy and quick to use, adaptable to a variety of settings and of obvious benefit.
The use of applicable checklists in EMS agencies has the potential to take some of the risk out of what we do. They worked for Sully Sullenberger, the pilot who landed his plane successfully on the Hudson River. I think they can work for your EMS agency as well.
Raphael M. Barishansky, MPH, is program chief of public health preparedness for the Prince George's County (MD) Health Department and a member of EMS World Magazine's editorial advisory board. E-mail email@example.com.