We thank Mary Dixon-Woods for drawing our attention to an interesting article on the use of the fabled WHO surgical checklist.[1] Interesting because the topic is important and because the authors used a step wedge, cluster, experimental design as they introduced the intervention across different surgical specialities in two Norwegian hospitals. Step wedge designs need to avoid pitfalls of all cluster studies related to interaction between intervention and willingness to be recruited. The neat way out of this conundrum is to use routinely collected data and enter everyone in the cluster. That was done here. It is important to control for systematically later time periods in the intervention ‘cells’ of the step wedge and, again, the authors did so. So what did they find in this procedurally satisfactory study? A large and statistically significant intervention effect was observed. This is in keeping with many, but not all, previous studies of the conventional checklist.
My problem lies in the underlying hypothesis; as a previous surgeon I find the theoretical basis for the checklist unconvincing. In other words I start from a sceptical prior that is reluctantly being pulled towards a more optimistic estimate. Also, I fret over publication bias in the social science/service delivery literature, as discussed in a previous post. All the same a sceptic like me cannot ignore these positive results. So how may they work. Firstly, the word “checklist” may be a misnomer. It may just be a convenient focus around which to engender a positive and professional personal and team approach. This could explain why it sometimes works and sometimes does not. The idea here would be that it can’t work when: 1) attitudes are totally hostile, or 2) practice is already very good so there is little headroom for improvement. In that case it would be like any behavioural intervention – it will work among those who are receptive to improvement, but not yet improved. It is also possible that use of the checklist, even in a tokenistic way, will be effective in the very long term. Here I rely on the theory of cognitive dissonance.[2] People who start with ritualistic tokens of compliance are inclined to either stop complying or move their attitudes towards their outward actions, if I understand correctly. Comments welcome.
— Richard Lilford, CLAHRC WM Director
- Haugen AS, Søfteland E, Almeland S, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg. 2015; 261 (5): 821-8.
- Festinger L. A Theory of cognitive dissonance. Stanford, CA: Stanford University Press, 1957.
NIHR CLAHRC West Midlands News Blog 
Checklists work well in the aviation industry: preflight checks are always conducted, and practice is already very good with little room for imporvement. Yet checks and checklist completed.
I suspect that these may have better compliance and prominence as the pilot’s own life is at risk if there is a defect, whilst it is “merely” theirprofession at risk for the surgical team.
Regardless, the flattened heirarchies and focus on safety, implicit in each checklist, serve to focus the provision of action on to the of the client (passenger or patient) instead of focussing on who has the biggest badge. If people were infallible, these checklists would not be required, but the tasks are multi-facted with parts easily overlooked, human facotrs creep in, and so, as you say ” a conveninet focus” has sense. To counter hostile attitudes, perhaps make it a legal obligation such that the team are saying to the world “we consider this to be safe by our collective judgement” – as pilots do – even if you hate the team you are in you’d make sure the safety were good, otherwise you’d be actionable if you filed faulty papers?