Clinical practice guidelines (CPGs) are dense, deep documents—300 pages or more,” admits Michael J. Goldberg, MD, chair of the Guidelines Oversight Committee. “By themselves, they are not necessarily usable. They are difficult to translate into a workable product for day-to-day practice.”


Published 2/1/2012
Terry Stanton

Checklists Put Guidelines Into Practice

Electronic versions recognize evidence base and individual judgment

Michael J. Goldberg, MD

But, convinced of the value of guidelines, Dr. Goldberg was determined to find ways to adapt them to orthopaedic practice. To do so, he turned to a simple but increasingly common tool—the checklist. “We’re trying to make guidelines useable, and not just as a doorstop,” he says.

Using checklists in surgery is one way to promote safety, prevent errors, and standardize practices. Following practices first developed in aviation to eliminate avoidable adverse outcomes, checklists require the surgical team to confirm such items as signed consent, site of procedure, and proper antibiotic administration. They also mandate steps such as the timeout.

Dr. Goldberg, who directs the Skeletal Health Program at Seattle Children’s Hospital, believes that checklists can be used to provide guidance on specific procedures and confirm that surgeons are following established, evidence-based practices. He has converted the CPGs on “The Treatment of Pediatric Supracondylar Humerus Fractures” and “The Treatment of Pediatric Diaphyseal Femur Fractures” into procedure-specific tools that enable surgeons to confirm that they are following the guidelines or to indicate why they are not.

The aim of these instruments is to reduce physician variability and encourage the practice of evidence-based medicine, while providing the flexibility that actual clinical situations require and acknowledging the value of physician judgment. The checklists help boil down the unwieldy CPGs to their essences, resulting in easy-to-use tools that have promise for improving outcomes.

The two checklists are simple documents consisting of about a dozen items that must be signed off on, electronically, at three stages of patient movement: before the patient leaves the emergency department; when the patient is transferred from the operating room to the floor; and when the patient is discharged.

Yes and no
The feature that distinguishes Dr. Goldberg’s CPG checklists (Fig. 1) is that they are not a series of mandates.

“We’re all used to the analogy with aviation checklists,” Dr. Goldberg says. “That is not always applicable to medical care. With aviation checklists, you must always answer yes; there is not a “no” answer. And the steps must be done in sequence: you close the door, and then you start the engines, and so on.

“In medicine,” he continues, “a child with a femur fracture is seen in the emergency department, and steps are taken to treat the child—appropriate radiographs, neurovascular check, determining whether it is a pathologic fracture or whether child abuse is suspected—that are done simultaneously or in varying order. They all need to be done, but not necessarily in the same sequence.”

When a surgeon checks off the No box, he or she must then enter the reason that the CPG-derived recommendation was not followed. For example, the supracondylar humerus fracture guideline calls for fixation with lateral entry pins. “But you might have a fracture where you need to use a medial entry pin,” Dr. Goldberg says. “If you click ‘No’ to the item for lateral pins, a text box comes up and you can type in, for example, ‘I used a medial entry pin because it was a badly comminuted or unstable fracture and it needed the medial pin.’ That’s real-life medicine.”

Another example is the entry in the femur fracture checklist calling for the use of flexible intramedullary nailing for children aged 5 to 11 years. “But what if the child is obese or if the fracture is comminuted or the child looks older and more mature than his or her stated age? Doctors need to have flexibility to choose alternative procedures,” Dr. Goldberg says. “Physicians object to a cookbook, must-do-it-this-way approach.”

The checklists not only allow for variation from the guidelines, but by entering surgeon responses into the electronic medical record, they provide potentially valuable information about what surgeons are doing and why.

Clinical practice guidelines (CPGs) are dense, deep documents—300 pages or more,” admits Michael J. Goldberg, MD, chair of the Guidelines Oversight Committee. “By themselves, they are not necessarily usable. They are difficult to translate into a workable product for day-to-day practice.”
Fig. 1 Checklists based on AAOS CPGs and in use at Seattle Children’s Hospital require that physicians provide a reason for any “no” answers.

“We can collect these metrics in real time and see where the exceptions are,” he said. “We ask, are there specific patient factors or surgeon factors that account for physician variation? Because the guideline recommendations are often inconclusive or have weak supporting evidence, checklists such as these allow physicians to determine a preferred evidence-based treatment pathway at their own institutions and then monitor the ‘No’ or ‘Other’ checkbox responses. This teaches you a lot about variation.”

The culture factor
Dr. Goldberg said his institution has a strong commitment to safety and to instituting clinical standards and was quite supportive in helping implement the checklists. Physicians and surgeons were not immediately receptive to the program, which was instituted in August 2011. Nurses, on the other hand, greeted it with enthusiasm.

“In both physician and nurse cultures, people get used to doing things a certain way,” he says. “Doctors often believe that their patients are the most complicated, the most difficult, the most this, and the most that. They are reluctant to be measured and suspicious of having their work monitored. They are used to working a certain way. Some looked at completing the checklists as an unfunded mandate or a data collection burden.”

Thus it was important to demonstrate the benefits of the checklist to the people who would be using it. “This is not a program that can be mandated from the top down,” Dr. Goldberg said. “Micro-communities and individual work units have to buy into it and take ownership, and that has taken a lot of work. The cultural challenge in a very busy hospital, especially in an academic medical center with residents, is moving the patient through; you can’t slow the flow.”

Yet, Dr. Goldberg said, the other prevailing imperative—Do No Harm—can be invoked in support of the checklists. “No one wants to hurt a patient, overlook an important detail, or make a mistake,” he said. “But the pressure for moving the patient through the system encourages workarounds or shortcuts. Thus, systems develop that allow for unsafe processes. ‘Do No Harm’ requires a pause, some stop signs, to ensure everything has been done. At the end of the day, physicians and nurses want to do the right thing, the right way. Checklists like these empower them to do so.”

Room for dissent
As the program was implemented, physicians generally came to embrace it. “It gives them a much better sense that they didn’t miss anything,” Dr. Goldberg said. Although the checklists don’t force surgeons to follow the guidelines, it does ask them to provide a rationale for exceptions.

“Surgeons can dissent, but we want to know why. It’s hard to write, ‘because I always did it that way’ or ‘because I just want to try this new implant.’ So the checklist forces them to be thoughtful. The doctors have accepted that the best of the literature is right there in the checklist, and although they don’t have to follow it, they are being made to think about why they are not. That’s a big step.”

Dr. Goldberg said he is eager to discover what kind of impact the checklists will have. “We believe that standardizing clinical work and using patient safety checklists have both economic and safety benefits. But we must demonstrate that this program of standardized order sets and checklists embedded into the electronic medical record actually does improve quality, reduce medical errors, and lead to better outcomes.

“Are we prematurely patting ourselves on the back? I can’t answer that yet,” he admitted. “I believe it will have an effect, but I don’t yet have the data. We will know more at the end of the year.”

Leadership at Seattle Children’s Hospital believes that such work products should be shared, because their intent is to improve the care and safety of all children treated with these conditions. Clinical pathways are posted on the hospital's website (; to access Dr. Goldberg’s checklists based on the AAOS CPGs “The Treatment of Pediatric Supracondylar Humerus Fractures” and “The Treatment of Pediatric Diaphyseal Femur Fractures,” as well as a non–CPG-based checklist for adolescent idiopathic scoliosis.

Disclosure information: Dr. Goldberg—Journal of Children’s Orthopaedics, Journal of Pediatric Orthopaedics

Terry Stanton is senior science writer for AAOS Now. He can be reached at