Increase Effectiveness with Checklists

Atul Gawande is an accomplished scholar (Mac Arthur Fellow), a staff writer for The New Yorker, and a Harvard professor, in addition to being a well-respected surgeon. He is also an astute observer with a curious mind. In the world of surgery, infection kills more people than the operations. Gawande thought there must be a way to increase survival rates. He stumbled on the effectiveness of the checklist, not a to-do list, but a step-by step form that is brief and effective even under the most critical situations.

Like many great problem solvers, Gawande stepped out of his field to see how others handled both routine and emergency situations, and then figured out how he could apply their systems to hospital predicaments. He consulted onsite construction supervisors who had to lead numbers of specialized teams to work together, and in sequence, to build what none of them could have done alone. He spoke with an aviation specialist whose charge was to create emergency action plans for pilots worldwide. Then he reexamined what was happening in his world of healthcare in the most sophisticated and impoverished settings.

It is humbling but essential to admit that the knowledge required to save someone’s life, or most other important workplace initiatives, is greater than what any one professional or profession could know or handle. Problems are extremely complex; requiring many types and layers of specializations, there’s an opportunity for a number of things to go wrong.

What the author found was that in each industry there were essentials and if imperatives were followed to the letter and consistently, the chance of success greatly increased. In the case of infection prevention, sometimes more than doubled. So if there are five, six, ten things that must be done—something as simple as insuring you are cutting into the correct side of the body—why can’t everyone just do it? In come the saboteurs—boredom, repetition, hierarchy, fear of confrontation, blaming, and the big one, lack of communication. Gawande’s response was to have checklists.

Here are a few essentials of a checklist:

1. Information must be simple and brief, measureable and transmittable, and effective.
2. The team must communicate, not merely obey, or do their piece. In the operating room (where previously most members of the team did not even know one another’s names), it means individuals introduce themselves, name their role, and state their perspective concerning the case. In construction, it’s every trade sitting at the table to discuss needs and problems. With this simple practice the “activation phenomenon” engages. That’s when people feel a sense of participation, and therefore responsibility from the beginning, not only at a critical moment.
3. All team members have the right to alert another (regardless of rank) when a certain procedure is not being followed.

When creating a checklist it’s important that it be:

1. Brief: Ideally one page with five to nine items (about all the memory can handle).
2. Easy to Use: Even in the most challenging situations--in operating rooms it is pasted to the wall. On airplanes they are in binders.
3. Address Only Critical Steps: What to do if the plane loses altitude, not how to fly a plane.
4. Practical: Sets priorities, forces people into actions they already know, helps manage complexity.
5. Read-Do: Meaning it tells you what steps to take, or Do-Confirm making you confirm you addressed something. Situation and experience determines format.
6. Full of Pause Points: Places where you stop, assess, and make sure everything else is still okay.
7. Language of the Profession.
8. Forgettable Items: But not tasks that never are overlooked. Remind nurses to count sponges not to use sponges.
9. Field Tested: Under very similar conditions—like a simulator in a pilot training center or beta tested in the field.
10. Mandatory: No optional use or redesigning.

Think of the many areas where you could develop a checklist and make your life safer, easier, and more predictable. Is it tech failure? (What to do when your hard drive crashes) Health Problems? (If you or your child is really not feeling well, what to look for and do?) Family Emergency? (Who calls whom, where are the healthcare proxies, and who is in charge of what?) Workplace Emergencies? (Weather issues, security problems, and accidents.) Wouldn’t it be easier, under these circumstances to pull up a sheet then try to figure out, in sixty seconds, what you are forgetting?

I could go on and I’m sure you could as well, but if your Office Emergency Manual, Employee Handbook, or Important Documents file is anything like the ones I’ve seen over the years, you know the opportunity for checklists exist. And, with the few simple guidelines I have provided above, you can begin the task of creating a few and mandate yourself and your team to follow them.

(c) Jane Cranston.