Checklists in Clinical Practice; Revisited

by Shadi Samawi

“Checklists turn out.. to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction – in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains.” –  Atul Gawande, The Checklist Manifesto: How to Get Things Right

In a previous blog post last year, I talked about what I believe to be an important driver for clinical excellence; the use of systematized checklists. In that post, I highlighted the main idea behind checklists and how they can help in the systematic and consistent application of clinical workflows in a precise and reproducible manner, ultimately increasing clinical efficiency and improving the quality of patient care.

That post generated many requests and inquiries from colleagues around the world asking for a follow-up post with further examples of checklists. In today’s blog post, I would like to introduce a few more checklist examples I personally implement in my practice for different parts of my clinical workflow, while explaining my rationale behind them.

Of course, the nature of any checklist, its specific points and sequence of order are directly influenced by how you personally manage workflow in your own particular practice and by what overall results you’re aiming to achieve, and these can be different from clinician to clinician. I personally encourage staff to develop their own Sub-checklists which would allow them to easily and consistently perform the necessary steps for implementing our Main (Big Picture)-checklists which – ideally – should be co-developed together from the start.

Involving the staff in brainstorming, developing and constant updating of these clinical checklists ensures they feel directly responsible and attached to the workflow and consequent results, ensuring the maximum clinical speed and efficiency on a daily basis. Regardless of how these checklists are developed, the important thing is to have a system for everything you do in practice.

Types of Clinical Checklists

There are several categories of checklists (systems) that can be created that encompass all the various aspects of running a daily orthodontic practice. These can include – but are not limited to – the following:

  1. Clinical Treatment checklists for various procedures; e.g. Bond-ups, Follow-up appointments, Debonding, etc.
  2. Patient Workflow checklists; e.g. New Patient Workflow, Phone Follow-up workflow, Payment & Financing workflow, etc.
  3. Procedural checklists; e.g. Orthodontic Instrument Sterilization workflows, Inter-appointment Dental Unit preparation, etc.

I detailed my personal Orthodontic Patient Follow-up appointment checklist in my previous blog post, as an example of a checklist I implement in practice on a daily basis. In this post, I’ll highlight a couple of examples from the checklists mentioned in the list above, for the benefit of those interested. Feel free to try to adopt these examples in your own practice or modify them to suit your particular workflow and/or needs.

Example 1: Bond-up Appointment Checklist

  1. Dental Unit cleansed, surfaces dis-infected and ready at least 10 minutes before scheduled bondup (Part of the dental assistant’s checklist, but double-checked by clinician)
  2. New Orthodontic Bonding Kit and consumables re-instated. (Part of the dental assistant’s checklist, but double-checked by clinician).  The Bonding Kit includes a disposable plastic dental tray with all instruments required for Direct Bonding procedures including 10 bracket bonding tweezers, 4 molar tube bonding tweezers, probe, Graduated Perio probe, Bracket bonding height gauge , polishing paste, orthodontic adhesive and bonding agent and acid etching agent, applicators, Dry-Angles and the Nola dry-field retraction system.
  3. Patient’s pre-treatment study models, clinical photographs, X-rays and electronic note file are ready chair-side (Part of the dental assistant’s checklist, but double-checked by clinician)
  4. Patient greeted and seated, with apron and protective eye wear.
  5. A brief summary and recap of the upcoming procedure is presented to the patient again and re-assurance of a smooth, painless workflow emphasized to dispel anxiety.
  6. Polishing performed, dry-angles followed by the Nola retractor instated and patient re-instructed on what is required of them till the end of the session.
  7. Drying, etching and application of adhesive to initiate bonding.
  8. Bonding is started in the lower left quadrant, to lower right, then upper left, then upper right (according to workflows mentioned in my ebook From Good-to Great: The 4 Keys to Mastery of Orthodontic Finishing).
  9. Bite-raising and/or wire insertion performed to finalize procedure.
  10. Progress clinical photographs (if needed).
  11. Patient remains seated in chair with mirror, while the dental assistant explains, demonstrates and re-emphasizes required Oral Hygiene instructions, brushing techniques and emergency protocol should any problems arise during the first 1-2 weeks post bond-up – in presence of parent/guardian, if it’s a child/teenager patient. A written Oral Hygiene instruction booklet and 1st-time OH gift kit also given to patient.
  12. Patient escorted to reception to book and note-down their follow-up appointment on appointment card.
  13. Detailing progress notes of current stage and next planned step for the next appointment in the patient’s electronic record file.

The above is a simple, basic workflow for the bond-up appointment, and although most of it may seem straightforward – which it is! – however having this protocol/checklist written down in step-by step format not only emphasizes the sequence of events in both the clinician and assistant(s) mind to ensure nothing is overlooked, but it is also an invaluable training tool for new dental staff when first starting out.

Example 2: Debonding Appointment Checklist

The Debonding Appointment Checklist is actually initiated on the last visit prior to the actual debonding appointment. On any given visit, once the patient is determined to be ready for debonding, the following protocol is initiated:

  1. Both upper/lower arches are fixated with stainless steel ligature underties. they are left fixated for a period of 4-6 weeks prior to the debonding appointment.
  2. Two successive Debonding appointments are pre-arranged through the reception desk:
  • The first appointment (in 4-6 weeks):
    • Debonding and teeth cleaning and polishing. Further Incisal recontouring done if required.
    • Upper/lower impressions + Bite registration taken for final study models and removable retainer fabrication.
    • Patient congratulated and quick review of pre-treatment clinical photos for comparison with final esthetic and functional result (Celebratory step!).
  • The Second Appointment (1-2 days later):
    • Final Clinical Photographs.
    • Fitting bonded retainers in either or both upper and lower arches.
    • Fitting removable retainers and instructions.
  1. The first retainer check-up appointment in 3 months scheduled and noted in patient’s appointment card at reception.

Again, the above protocol is specific to how I personally do things, however it can be slightly modified from patient to patient, depending on the individual case requirements. For example; on some occasions, I fit any bonded retainers right before actual debonding, especially in cases that had any kind of localized or generalized spacing, particularly in the anterior area. Also, you will find that certain steps such as Fitting bonded retainers have their own sub-checklist or sub-protocol, which is also written down and constantly updated as new techniques and materials are incorporated into that particular procedure.

“Good checklists, on the other hand are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything–a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps–the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.” Atul Gawande, The Checklist Manifesto: How to Get Things Right

You can practically create tens – if not hundreds – of clinical checklists for your clinical needs, but it’s important to emphasize that the number and scope of these checklists should not be overwhelming so as to produce the exact opposite results of what a checklist is intended to do in the first place! It is easy to get carried away and over-complicate things. As Albert Einstein once noted; the best advice I can give is to keep it simple, but not too simple.

If you’ve found the idea of clinical checklists and Systems Thinking useful, or you already implement such protocols in your own practice, I would love to hear your thoughts about this important topic.  You are more than welcome to share your comments, questions and even your own sample checklists in the comment section below, which would help us all improve our own checklists in the process.