Monday, June 27, 2011

The Power of Using Checklists

book cover Checklist Manifesto

Checklists save lives. Dr. Atul Gawande makes that very clear in his fascinating book, The Checklist Manifesto: How to Get Things Done Right.

Gawande focuses mostly on airline pilots and medical teams (ICU and surgical). Builders of skyscrapers and other complex structures, and managers of investment funds, also get some attention. (Van Halen and David Lee Roth make a brief appearance, too.)

Aviation checklists have proven their worth for many years now. Manufacturers like Boeing have become experts in creating effective checklists: precise and practical, and tested in flight simulators. Airlines then make customizations; Gawande tells us that "when airlines merge, among the fiercest battles is the one between the pilots over whose checklists will be used."

Such checklists aren't exhaustive, covering every possible issue; they focus on the "the killer items — the steps that are most dangerous to skip and sometimes overlooked nonetheless." When Gawande spoke to Daniel Boorman of Boeing, he learned that "even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading."

Unfortunately, the surgical checklist developed by the World Health Organization — Gawande was a key player in developing this list — has had much success, but has yet to gain anything close to complete acceptance. I just checked my own area, and many hospitals are actively using the checklist — but many are not. Gawande mentions how he started using the checklist himself, thinking it wouldn't be all the useful in his practice. "To my chagrin, however, I have yet to get through a week in surgery without the checklist's leading us to catch something we would have missed."

Checklists, Gawande argues, don't turn the users into "mindless automatons." Rather, a well-made checklist "gets the dumb stuff out of the way, the routines your brain shouldn't have to occupy itself with ... and lets it rise above to focus on the hard stuff." Both the aviation and the surgical checklists also help build the sense of teamwork needed to effectively deal with emergencies.

While many of us don't work in the complex environments that Gawande describes, checklists can still be useful tools. Reading this book made me appreciate them all the more.

Related Posts:
Organizing for Travel: The Packing List
Checklists: Chore Charts
8 Tips for Getting (and Staying) Organized When You Have Memory Problems


Lauren said...

Great post, Jeri! Think I'll have to pick up the book, too.

Even I'm guilty of underestimating the power of an effective checklist.

Chip & Dan Heath also highlight the power of checklists in relation to implementing change in Switch: How to Change When Change is Hard. Found this article on Fast Company which features Atul Gawande specifically- small world!

MarySees said...

Thank you so much for this post, Jeri! I knew how beneficial checklists are, but now I know they are crucial!

MarySees said...

A surgical checklist could include: Check and double check that you are operating on the correct body part!

I've read horror stories where doctors removed the wrong kidney, leg, or eye! How many people could have been spared untold pain and anguish by a good surgical checklist?

Julie Bestry said...

I was fascinated by Gawande when I first heard him interviewed on The Daily Show and then promptly forgot about the book. Thanks for the reminder, Jeri. I'm going to add it to my book list right now!

Jeri Dansky said...

Lauren, thanks for the Fast Company link! And Julie, thanks for the pointer to the Daily Show. I think you'll both enjoy the book; it's very engaging.

MarySees, confirming the procedure and the site are indeed included on that World Health Organization surgery checklist.

JustGail said...

I think many of us think of checklist as a long, painfully detailed, formal sheet to literally check off boxes. It does NOT need to be that - even something as simple as a sticky note with "before doing task c, do steps a & b first". Back when I first started running some tests in an engineering environment, I kept leaving out something. Finally I tweaked the startup script to ask - Did you do this, Did you do that, etc" and I had to hit a key to continue after every question. Some thought it was rather odd, but it saved me much time from having to re-run tests. I can't imagine not using one when someone's live is at stake, such as the pilots, or the medical field. Anyone can have days where their thoughts are elsewhere and miss 1 critical step.

Cynthia Friedlob said...

Very interesting! Not long ago I had to learn how to manage a website designed by other people that uses a complicated content management system that was new to me. There are so many tasks that I do infrequently that I decided to make checklists so I wouldn't have to try to remember the unfortunately unintuitive procedures. Saved the day for me many times! I've used checklists in other situations, too, and they've been invaluable.

Lee said...

Jeri, The first checklist that impressed me many years ago when I was in college, and it was related to healthcare, was the Apgar Scale. It is a 5 point scale (to me, a checklist) that was developed in 1952 by Virginia Apgar, an anesthesiologist, to determine the effect of anesthesia on a newborn. Each characteristic was given 0, 1, or 2 points, and the total gave medical personnel a picture of the baby's overall health and any areas of immediate concern. It was given immediately after birth and again at 5 minutes after birth.

The characteristics were later renamed to form an acronym of APGAR - Appearance, Pulse, Grimace, Activity, Respiration - making them easier to remember. The scale is still used today. She was later honored with a US postage stamp. Wikipedia and other sites have a more detailed explanation.

When I recently read that a docor was proposing that checklists would a beneficial in healthcare, as if it was a new idea, I wondered if he didn't realize that the Apgar had been in use for almost 60 years.

Thanks for a great post on a much needed subject.

Lee said...

Perhaps I should have a checklist to use before submitting comments, with one of the points being "check spelling 3 times". Somehow "docor" slipped past me.

Jeri Dansky said...

JustGail, the idea that checklists don't need to be "painfully detailed" - and in many cases work MUCH better when they are not - was one of the eye-openers for me. Gawande writes about consciously leaving some items off certain checklists because experience showed that no one EVER forgets them. Checklists need to be brief, he says, or people start "shortcutting."

Here's another quote: "It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals."

Jeri Dansky said...

Lee, the author of this book was not saying checklists are an entirely new idea in the medical arena - just that they aren't widely used, and that doctors tend to be resistant at the beginning.

He doesn't mention the Apgar Scale - great story, thanks for sharing it! - but he mentions how nurses started recording the four vital signs back in the 1960s - a form of checklist, even if that's not what it was called.