Checklist Check-in: 5 Tips to Improve Compliance and Engagement

Is your Surgical Safety Checklist in question format? It should be, according to Elizabeth Kingsbury, MSN, RN, CNOR, an original checklist champion. Here’s how she’s improved compliance and team engagement with Time Out, Sign In, Introductions, and other key safety elements of her hospital’s Surgical Safety Checklist.

Since working on the original team to create the first Surgical Safety Checklist introduced in 2007, Elizabeth Kingsbury, MSN, RN, CNOR, has remained a checklist champion in her own operating rooms at Boston Children’s Hospital.

We know compliance and engagement are two challenges OR teams face with Time Out and other elements in the Surgical Safety Checklist. So, we checked in with Kingsbury to learn about the latest checklist tweaks that are bringing her OR teams together for more consistent and effective safety checks.

Her teams adopted these five approaches to reinforce correct checklist practices:

1. Make the Checklist Format Interactive

Start by writing your checklist in question format, Kingsbury recommended. “Questions give everyone in the room an opportunity to be included and engaged,” she says, which “prevents just one person from taking full responsibility for talking through the safety checks.”

For example: The RN will ask the surgeon, “What is the planned procedure?” The surgeon will respond with the intended procedure, and the nurse will have the surgical consent in hand to verify that the consent matches the planned procedure.

They then end the checklist run-through with this open-ended question to the group: “Does anyone have any additional safety concerns for this patient?”

2. Empower the Team to Require a Hard Stop for the Time Out

Consistently practicing this is very important but difficult for some teams. Empowering the RN to ask the team to stop talking or moving during the Time Out works effectively in her ORs.

So, what if the RN isn’t ready for the Time Out?

If a surgeon calls for a Time Out before the RN is ready, she said the RN can say, “we can start the Time Out as soon as I get the equipment all plugged in and I get the consent.”

3. Use a Handheld Checklist

In addition to displaying their Surgical Safety Checklist as a poster in every OR, Kingsbury’s teams find it works best if the circulator has the checklist and the consent in hand and stands close to the team while leading the checklist.

Don’t memorize the checklist, she cautioned, because “the content is too long, and questions may be missed.”

4. Always Make Time for Team Introductions

Her teams always start the checklist with team Introductions (a formal element of the Surgical Safety Checklist that can easily get skipped) because they have a large staff with many new team members. The only time Introductions are waived is if there is a subsequent surgery with all the same team members.

5. Time your Sign-In Before Induction

Their Sign-In (another critical but tricky-to-time checklist element) occurs as soon as the patient enters the OR and prior to the anesthesiologist starting anything and is done with the patient. “Once the patient is on the OR table and monitors are being applied, we lose the opportunity for full attention to the Sign-In,” she explained. “This was a timing change to our checklist. It took time for team buy-in to practice consistently, however, we have finally reached compliance.”

Use Time Out Day on June 14, 2023, as a good excuse for a “Checklist Check In” with your team. But don’t forget Kingsbury’s ultimate advice: audit checklist compliance year-round.

Please read this joint statement from AORN and The Joint Commission on Time Out Day and how perioperative nurses must be passionate champions for an effective Time Out.