The beauty of checklists

I enjoyed The Checklist Manifesto by Atul Gawande, a surgeon and New Yorker writer who previously wrote a notable piece about finding that more expensive healthcare wasn’t necessarily better healthcare. He’s written a whole lot more since then.

The premise of The Checklist Manifesto is that a simple (but well devised) checklist is perhaps the best tool we have to make us consistently more successful at managing complex situations – whether that be operating on someone, choosing companies to invest in, landing a plane or building a skyscraper.

The airline industry in particular has learned to rely on pilot checklists – and a culture of always using those checklists – to maintain safety, and their evolution makes for interesting reading.

As Gawande notes, the reason no one died when an Airbus A320 was forced to land on the Hudson river in January 2009 was not only because of skill and professionalism on the part of the pilot. It was because the pilot and crew all used the checklists provided for them for precisely that situation.

Gawande’s interest in checklists grew out of wanting to improve outcomes for surgical patients. He points to data showing that by 2004 surgeons around the world were performing 230 million major operations a year and estimates of complication rates ranged from 3 per cent to 17 per cent.

“Worldwide, at least seven million people a year are left disabled and at least one million dead – a level of harm that approaches that of malaria, tuberculosis and other traditional public health concerns.”

The numbers were sufficiently alarming to prompt the World Health Organization (WHO) to ask him to spearhead a project to tackle the issue. The project group discussed all manner of interventions – guidelines, training, incentives – but ruled them out as too easily ignored, expensive or impractical.

Research showed that simple interventions were often the best in public health. Gawande cites as examples how removing the pump from an infected water well was enough to end a famous cholera outbreak in London in 1854, and how child mortality was reduced in poor districts of Karachi, Pakistan, by supplying free soap and instructions on how and when to wash hands – a kind of checklist.

A checklist had also proved useful in reducing infections at a US children’s hospital simply by ensuring antibiotics were administered at the right time.

So the group came up with the WHO Surgical Safety Checklist and trialled it in eight countries, including here in New Zealand, at Auckland Hospital.

I saw it, or something like it, in action when I sat with my Dad at Auckland Hospital ahead of an exploratory surgery recently. The pre-op nurses worked through a set of forms and questions with him before he was prepared for surgery.

The results of the trial were so positive WHO set about rolling the project out worldwide, and New Zealand is one of the countries to have signed up to encourage its use in every hospital.

Not all have taken it up, but let’s hope they do. A ministerial review in NZ last year found that “44 thousand people admitted to hospital suffer an unintended injury caused in the management of their conditions, rather than the underlying disease – this is a similar rate to other countries. Although most of those people had relatively minor adverse events, about 15% resulted in permanent disability or death.”

In testing his theory about the checklist, Gawande visited building sites, the people who write the pilot checklists for Boeing, venture capitalists and top-flight restaurants. He found examples everywhere of simple checklists improving success rates, with the pilot checklists proving particularly instructive.

He learned, however, that not all checklists are created equal and he picked up tips along the way on writing a good one. Here are the main points:

  1. Identify pause points – the point in a process where the team needs to pause and use the checklist. In surgical checklists they came up with three: before the patient has anaesthesia, after anaesthesia but before incision, and after the operation but before the patient is wheeled out of the theatre.
  2. Decide whether it makes more sense to use a Do-Review or a Read-Do list. The first requires people to do their tasks then stop and review them before moving on. The other requires people to read the checklist and do each task in turn, like a recipe.
  3. Use simple, exact wording and use the language of the profession.
  4. Don’t make the checklist too long. If it’s too complex or takes too long people will give up and throw it away. Not everything has to be on the checklist. Just those things that are essential but that people can sometimes miss in the heat of the moment.
  5. Boeing found the best checklists have 6 to 9 points, are on one page that is sparing in colour and free of clutter, uses a mix of upper and lower case letters and a sans serif font. (Boeing use electronic checklists now too.)
  6. Find the right person in a given scenario to give the job of starting or overseeing the checklist. It may not be the most senior person. In some cases the checklist proved a tool for distributing responsibility and power in a way that made people work as a team and unafraid to speak up.
  7. Buy-in is important and so is working as a team. As part of the surgical checklist operating staff are asked to introduce each other so they know one another’s names. Research had shown that people communicate better if they know each other’s names.
  8. Communicating well is as important as checking for potential infection agents.
  9. Checklists have to be road tested in the real world.
  10. Checklists are not static. They need to be adapted to individual situations and improved and updated over time.

Listen to Gawande in Conversation with Tyler on “why Watson will never diagnose your illness, what George Church’s narcolepsy teaches us about CRISPR, what’s missing in medical education, Michael Crichton’s cultural influence, Knausgård versus Ferrante, indie music, and the thing that makes Gawande ‘bawl like a baby’.”

5 replies on “The beauty of checklists”

  1. “As Gawande notes, the reason no one died when an Airbus A320 was forced to land on the Hudson river in January 2009 was not because of heroism on the part of the pilot. It was because the pilot and crew all used the checklists provided for them for precisely that situation.”

    The checklist didn’t keep that plane from breaking up on landing- the pilot did. Maybe you should insert “not ONLY because of heroism on the part of the pilot…” That would make more sense.

  2. Having a checklist isn’t enough. People also have to understand why it is there, and believe in it.

    My sister was recently in hospital and the nurse dutifully read through her checklist saying things like: “Here’s a silly question. You don’t have any religious beliefs that we have to cater for, do you?”

    Good on the person who created the checklist. What a shame the nurse treated it with so little understanding.

    1. You’re so right about buy-in and belief in the checklist being important. It’s easy to think it’s too simple to make a difference or not required in the first place. Even Gawande says he didn’t expect the checklist to make much difference in his own practice but roadtested it nonetheless and found it helped his team catch a number of problems that could have had dreadful consequences.

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