The Checklist Manifesto

Several years ago a man was admitted to a hospital in San Francisco after being diagnosed with stomach cancer. His prognosis was good as the cancer had been caught early and the man was in good health otherwise. The surgery was going well, the cancer had been removed.

Suddenly the heart-rate monitor went flat-line. No pulse in the patient’s carotid artery, his heart had stopped… Why? After 15 minutes of frenzied effort by hospital staff to revive the man and a hurried review of potential causes of this almost hopeless situation, they realized what happened. The patient had low potassium level on his routine labs. A dose of potassium was administered to correct it. However, they administered the wrong dosage: The concentration was 100 times higher than intended.

Now the operating team understood the problem and did everything they were supposed to do: injections of insulin and glucose to lower the toxic level of potassium, intravenous calcium and inhaled doses of albuterol. The patient’s heartbeat came back, they finished the surgery and he recovered almost as if the whole episode had never occurred!

This story is from the opening of The Checklist Manifesto by Atwul Gawande (2011). An uncommon situation? Studies have found that patients receive incomplete or inappropriate medical care from 30% (stroke) to 60% (pneumonia) of the time. Why do such mistakes occur in health care? For that matter, why do mistakes occur in any organization?

Gawande, a surgeon at Brigham and Women’s Hospital in Boston and author of other books on health care, explains in a very authentic way how he got interested in using a checklist in the operating room to improve outcomes. His book describes his struggles with developing a checklist in the medical field and the tremendous benefits the checklist ultimately had for him and others working in medicine.

He posits there are two main types of errors: Ignorance and Ineptitude. Ignorance occurs when science has given us only a partial understanding of the world and how it works. This type of mistake has existed for millennia for some types of problems, and is very difficult to overcome.

But it is the other type of error which is so frustrating. This occurs when we do have knowledge but it isn’t applied correctly. In business terminology it is sometimes called a lack of execution. At all levels – from front-line supervisor to CEO – the challenge is how to ensure employees will follow procedures.

The answer is provided by Gawande in The Checklist Manifesto: Checklists make a tangible difference in outcomes. And not just in health care, but in a variety of fields. In this New York Times bestseller the power of a checklist is introduced in a fascinating way.

But Gawande goes beyond the application of checklists in healthcare. His research connects the power of checklists in many different situations including the heroic Hudson River airplane landing, Wal-Mart’s response after Hurricane Katrina, and construction of the Russia Wharf building in Boston.

An important aspect to consider when using checklists under complex situations is to push the power of decision making out to the periphery and away from the center. That is, give people room to act and adapt, based on their experience and expertise. This approach was used by Wal-Mart in responding to the aftermath of Hurricane Katrina in 2005.

Gawande discussed a key question: How to make a checklist that is both simple and effective? He found his answer in the aerospace industry. Daniel Boorman, a veteran pilot and technical writer from Boeing, said a good checklist has to be precise, to the point, and easy to use even in the most difficult situations. Checklists do not try to spell out everything.  Instead, they provide reminders of only the most critical and important steps. Other guidelines:

• Define a clear pause point at which the checklist is used.
• Decide whether the checklist is a Do-Confirm (people perform their jobs from memory and experience and use the checklist to confirm actions) or Read-Do (people carry out the tasks as they check them off).
• Keep them short and focus only on the “killer items” (steps that are most dangerous to skip and sometimes overlooked). A checklist cannot be lengthy. A rule of thumb is to keep it to between five and nine items. Ideally, it should fit on one page.
• The wording should be simple and exact. It should use uppercase and lowercase text for ease of reading.
• Test the checklist in the real world, make changes, and keep testing until the checklist works consistently.

Much of the book tells the story of Gawande’s work at the WHO (World Health Organization) to develop a surgery checklist which was piloted in eight different hospitals around the world in 2008. The results included a 36% reduction in major complications and 47% reduction in deaths. At the end of the study, they surmised improved communication was the real key. There was a notable correlation between teamwork scores and results for patients – “the greater the improvement in teamwork, the greater the drop in complications.”

What is the takeaway for LSS practitioners? Checklists are a powerful tool to improve outcomes and increase chances of success. They can and should be part of the deliverables in the Improve and Control Phases of any LSS project.