http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, Early Online: 1–3 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.916089 GUEST EDITORIAL Revisiting evidence-based checklists: interprofessionalism, safety culture and collective competence Simon Kitto 1,2,3 and Rachel Grant 1 1 Office of Continuing Professional Development, Faculty of Medicine, University of Toronto, Toronto, Canada, 2 Department of Surgery, University of Toronto, Toronto, Canada, and 3 Wilson Centre, University Health Network, Toronto, Canada Introduction In an earlier editorial in this journal on the intended and unintended consequences of checklists for interprofessional care (Kitto, 2010), an attempt was made to raise awareness and encourage interrogation of the problematic relationship between checklists and interprofessional care. The editorial outlined how checklists are driven by the evidence-based medicine (EBM) philosophy of the application of rigorously generated evidence to the building of programmatic clinical sequential steps that can produce optimal outcomes for patients and improve the working lives of healthcare professionals. A proposition was put forward that checklists in and of themselves are insufficient technical fixes to socio-cultural adaptive problems relating to team or interprofessional behavior. The overall purpose of this editorial was to encourage an interprofessional education research agenda focused on developing a greater understanding of how checklists in healthcare might act both as a problem and as a solution to the quality of interprofessional teamwork and collaboration (Kitto, 2010). In response to the seminal surgical safety checklist (SSC) study by Haynes et al. (2009), Canadian researchers have now conducted a study that problematizes the claims of the technical fix capacity of checklists to team-based patient safety problems in the operating room (OR) (Urbach, Govindarajan, Saskin, Wilton & Baxter, 2014). In this editorial, we would like to revisit checklists in light of this new study and other recent work on SSCs. In doing so, we hope to further encourage interprofessional scholars to treat this new ‘‘scientific controversy’’ (Latour, 1987), as a window of opportunity to demonstrate how the field of interprofessional knowledge and practice can contribute to the improvement of the design and implementation of safety science interventions in healthcare. Revisiting the checklist Urbach and colleagues (2014) recent study examined surgical outcomes before and after implementing the SSC at all hospitals in Ontario, Canada, providing surgical services. Their study found that implementation of the SSC, ‘‘was not associated with significant reductions in operative mortality or complications’’ (p. 1029). The authors suggest the divergence in findings from published evidence may be due to a lack of generalizability, or the Hawthorne effect when staff members know their use of the SSC is under observation. Furthermore, the authors note that studies offering substantial favorable findings are often combined with in-depth team training or an expanded checklist. The findings of this study and the authors’ conclusions support the core arguments raised in 2010 that the solution to teamwork in operating rooms and elsewhere requires more than evidence-based protocol implementation (i.e. intense team training and expanded checklists) and that resistance and/or ‘‘work-arounds’’ can occur during their implementation. In the case of the SSC, the latter may even affect the saliency of positive evaluations by quality improvement audit regimes in hospital settings. Further support to these findings that tend to refute the technical fix capacity of checklists protocols comes from a recent Swedish study examining individual checklist item compliance, which found that the SSC time-out was not always conducted as intended (Rydenfa ¨lt, Johansson, Odenrick, A ˚ kerman, & Larsson, 2013). The authors suggest this could be due to variation in healthcare professionals’ perception of the intention of the SSC, the importance of individual checklist items, and/or the necessity of exchanging information. Rydenfa ¨lt, Ek, and Larsson (2014) suggest that the SSC can introduce a ‘‘false sense of safety’’ when other safety checks become obsolete because they are thought to be encompassed by the SSC. They suggest that future SSC research should focus on work dynamics, compliance with and perception of importance of individual checklist items, and the design and implementation of a SSC that is considered to be meaningful by the users. In other words, an understanding of localized safety culture in the workplace is brought back to the forefront as the key to safe surgical and medical practice. Safety culture is repositioned as an essential, rather than the dominant ‘‘objective’’, ‘‘evidence-based’’ approach to the design, imple- mentation, and measurement of compliance to such checklists (e.g. Pickering, Robertson, Griffin, Hadi, & Morgan, 2013; Treadwell, Lucas, & Tsou, 2014). We are deploying the term safety culture in a meaningful way here, containing two distinct but interrelated units of analysis: the value systems of a community of practitioners and patterns of clinical behavior. Seeing safety specifically and deliberately through this conceptual lens is still largely absent within interprofessional literature on checklists, but work is emerging. Correspondence: Dr. Simon Kitto, Office of Continuing Professional Development, Faculty of Medicine, University of Toronto, Toronto, Canada. E-mail: simon.kitto@utoronto.ca J Interprof Care Downloaded from informahealthcare.com by University of Toronto on 05/15/14 For personal use only.