Why PTs Should Be Using Checklists | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Why PTs Should Be Using Checklists

While growing up, every New Years Day my whole family, including my parents, three siblings, and myself, would go out for breakfast at the Golden Skillet. The Golden Skillet was your stereotypical diner, from the mediocre coffee to the old men (the “regulars”) always sitting at the counter reading the newspaper. Interestingly enough, one thing I always remember about this experience is our waitresses. It always seemed to be a middle-aged woman with some grittiness to her that showed she might have worked at the diner just a little too long.

“Alright, what would you like?” she would ask us, and then with no pen or order pad, and her arms behind her back, she would proceed to take each of our orders. She would then take our menus and walk away to input the orders.The next ten minutes of the table conversation would consist of “how the heck does she memorize all our orders?” Yet, sure enough, we seemed to always get the food we wanted just as we ordered it.

We always seem to have a fascination with memory. “I can always memorize people’s birthdays” or “I can memorize this many digits of the number pi.” I’m sure the examples are endless, but I don’t want to talk about memorizing things. I want to talk about the easiest way to not have to memorize things: the use of a checklist.

Again, I have received inspiration for this blog post from a nonfiction book, The Checklist Manifesto by Atul Gawande. Besides being an author, Gawande is an American surgeon and public health researcher. His book describes the trials and successes of the adoption of checklists in operating rooms across the world. He also describes the successful use of checklists in numerous industries, most notably aviation and commercial building and construction. At one point, Gawande notes that he cannot imagine a single industry in which checklists cannot provide a benefit. So, let’s look a little further at the benefits of using checklists, what makes a good checklist, and how physical therapists can use checklists for our benefit.

Simply put, the reason for checklists is that humans are fallible and have inadequacies. We miss things and make mistakes. There are limits to our attention span (some more than others) and our memory. Of course, this is okay. The world is complex and the field of physical therapy is no different. Just think about the complexity of the human body, or think of the multiple diagnoses, co-morbidities, tests and measures, and treatment techniques that you’re exposed to or perform throughout the course of day. A checklist offers a simple way to avoid errors and oversight. It helps you avoid problems and make sure the stupid stuff isn’t missed.

What makes a good checklist? Gawande describes the key characteristics of a good checklist include that it is precise, efficient, and practical. It should be to the point and only include the “killer items.” Additionally, a good checklist should only be used as an aid. It should aid the decision-making and skills of the professional. However, most importantly, a checklist needs to be practical, which means that you should practice using it and continuously make refinements to improve its effectiveness and ease of use.

Physical therapists can utilize checklists in a variety of situations. We can have a checklist for initial evaluations. For example, a checklist might include history, posture, strength, ROM, functional mobility, etc. From here, we could have sub-checklists for different sections of the evaluation. What part of the patient history should I absolutely ask and not forget? We can use checklists that are specific to certain diagnoses or patient populations. We can use a checklist for red flags. What are the red flags that I absolutely must ask about for each patient? The same thing can be done for yellow flags and psychosocial factors. There also are the huge lists of contraindications and precautions for different treatments and modalities. Don’t tell me you’ve memorized all the contraindications to electrical stimulation, and for every patient you ask about each one.

It seems clear that physical therapists can benefit from using checklists. There are probably different examples that I didn’t even think of. So, what are the reasons we don’t use them? First we have to consider the mindset of the skilled expert clinician. “I am a knowledgeable and skilled therapist and I don’t need the aid of a checklist, and plus, my patient will consider me less skilled and knowledgeable if he or she sees me using a checklist”…This thinking is flawed. A checklist is not supposed to completely eliminate any decision-making, problem solving, or skilled care. The purpose of the checklist is to take care of the simple stuff, so that you can focus on the complex stuff. If used correctly, a checklist should not turn you into an automated robot or diminish the personal connection with the patient. In fact, a checklist can improve communication with the patient, improve thoroughness, and make sure important things aren’t missed.
“I’ve never used a checklist, and I’ve never had a problem.” 
Another argument against using checklists might be, “I’ve never used a checklist, and I’ve never had a problem.” It’s true that most parts on a checklist can seem unimportant or unnecessary (“Do you have Raynaud’s syndrome?” “Do I have what?”). However, as Gawande notes 49/50 times there is no problem…until there is. The things that are uncommon, but can occur, are the things we are most likely to miss. Following the checklist is the easy way to not miss those things.

We shouldn’t fear the rigidity of implementing checklists. As Gawande notes, checklists “get the dumb stuff out of the way, so you can focus on the hard stuff.” Consider that Steve Jobs wore the same clothing (black turtleneck and blue jeans) every single day. He did this because he didn’t want to expend mental energy making silly decisions such as what to wear for the day. He wanted to use his mental energy creating amazing products for Apple. We should use checklists the same exact way. Let’s expend our mental energy on the tough stuff and keep the simple stuff simple.

Note: This post should really be considered as a synthesis of Atul Gawande’s book, The Checklist Manifesto, with my personal thoughts in relation to the field of physical therapy.

via Luke Pedersen, DPT

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