Checklists have demonstrated their capability to power proficiency in a myriad of applications, from construction, to manufacturing, to fine restaurants, to political campaigns, to emergency room diagnosis, to project management. In this post, we’ll focus on that ubiquitous tool, and a man who can rightly be called The Checklist Champion.
Instead of the usual case, with the help of Ruby Tomar, we’ll look at a most remarkable book and the insights the author gleans about how to use a checklist to implement sustainable change. We’ll also explore how you can leverage the Project Pre-Check building blocks or build your own checklist to deliver sustainable change.
The book is The Checklist Manifesto: How to Get Things Right by Atul Gawande. He is a MacArthur Fellow, a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and an associate professor at Harvard Medical School and the Harvard School of Public Health. He also leads the World Health Organization’s Safe Surgery Saves Lives program.
Dr. Gawande poses a question many of us have asked over the years – how do seemingly intelligent, knowledgeable, talented and motivated individuals and groups manage to get so many things wrong. In his book, Dr. Gawande refers to the work of two philosophers, Samuel Gorovitz and Alasdair MacIntyre, in search of answers. They suggested a couple of reasons for failure. One is ignorance, where we don’t have the necessary knowledge and skills to do the job. The second is ineptitude, where we do have the knowledge and skills required but fail to apply it correctly. How do we fix that?
The challenges Dr. Gawande faces are similar to the challenges we face managing business and technology change. The best practices he uncovers and the lessons he learns are also applicable to our program, project and change management efforts. Dr Gawande reveals the power of a seemingly simple tool, the checklist, to improve performance, reduce costs, increase returns and save lives in a wide array of endeavours including surgery, emergency room settings, construction, natural disasters, restaurants, finance, investing and many other circumstances.
We have borrowed extensively from Dr. Gawande’s book, extracting directly and paraphrasing liberally to give you a sense of the challenges his team faced and the amazing results they achieved. We thank him for his amazing achievements, terrific insights and generous support.
The World Health Organization (WHO) contacted Dr. Gawande in 2006 to help them develop a global program to reduce the risks of surgery. “Officials were picking up indications that the volume of surgery was increasing worldwide and that a significant portion of the care was so unsafe as to be a public danger. 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.” Dr. Gawande accepted the challenge.
A group of health care specialists from around the world gathered in Geneva in early 2007 to tackle the challenge. They understood the enormity of the task at hand. Some suggested more training. Others proposed incentive schemes such as pay-for-performance programs. They considered a set of WHO standards for surgical care. Dr. Gawande looked for and analyzed examples of successful public health interventions that the group could learn from. He states “All the examples, I noticed, had a few attributes in common: They involved simple interventions. The effects were carefully measured. And the interventions proved to have widely transmissible benefits.”
One of his favorite cases was a public health program to address the perilous rates of premature death among children in the slums of Karachi. The program used hand washing with soap in six different situations where cleanliness would have the most impact. After the first year “the incidence of diarrhea among children in these neighborhoods fell 52 percent compared to that in the control group. The incidence of pneumonia fell 48 percent. And the incidence of impetigo, a bacterial skin infection, fell 35 percent.”
States Dr. Gawande “Thinking back on the experiment, I was fascinated to realize that it was as much a checklist study as a soap study. So I wondered: Could a checklist be our soap for surgical care—simple, cheap, effective, and transmissible?”
His colleagues answered his question in the affirmative with a number of examples:
- The Columbus Children’s Hospital had developed a checklist to reduce surgical infections. After three months, 89 percent of appendicitis patients got the right antibiotic at the right time. After ten months, 100 percent did. The checklist had become habitual.
- A Johns Hopkins pancreatic surgeon showed an eighteen-item checklist that he’d tested with eleven surgeons for five months at his hospital. Likewise, a group of Kaiser Hospitals in Southern California had studied a thirty-item “surgery preflight checklist”.
- University of Toronto had completed a feasibility trial using a much broader, twenty-one-item surgical checklist. Their checklist had staff verbally confirm with one another that antibiotics had been given, that blood was available if required, that critical scans and test results needed for the operation were on hand, that any special instruments required were ready, and so on.
The checklist also included what they called a “team briefing.” The team members were supposed to stop and take a moment simply to talk with one another before proceeding—about how long the surgeon expected the operation to take, how much blood loss everyone should be prepared for, whether the patient had any risks or concerns the team should know about.
These checklists not only helped ensure essential tasks were completed consistently, they helped build teams capable of responding to the unexpected. At Johns Hopkins, after three months use, the number of team members reporting that they “functioned as a well-coordinated team” leapt from 68 percent to 92 percent. At the Kaiser hospitals, after six months and thirty-five hundred operations, the staff’s average rating of the teamwork climate improved from good to outstanding. Employee satisfaction rose 19 percent. The rate of OR nurse turnover—the proportion leaving their jobs each year—dropped from 23 percent to 7 percent. And the checklist appeared to have caught numerous near errors.
Dr. Gawande and his colleagues were convinced. Further testing was warranted.
At the end of the Geneva conference, the participants agreed that a safe surgery checklist was worth testing on a larger scale. The focus was to introduce a practice to significantly reduce surgical risks globally.
A working group was formed. They took the different checklists that had been tried and condensed them into a single one. They added any other checks they could think of that might make a difference in care. They incorporated the communication checks in which everyone in the operating room ensures that they know one another’s names and roles and has a chance to weigh in on critical plans and concerns.
They set up a proper pilot study of the safe surgery checklist in a range of hospitals around the world.
When Dr. Gawande returned to Boston, he told the nurses and anesthesiologists what he’d learned in Geneva. His team agreed to try it out.
It didn’t work out very well. On the first attempt, there was confusion about how the checklist should be administered. It was supposed to be a verbal checklist, a team checklist. Some of the checks were ambiguous. The checklist was too long. It was unclear. Everyone was frustrated, even the patient. By the end of the day, they had stopped using it. Dr. Gawande states “Forget making this work around the world. It wasn’t even working in one operating room.”
So Dr. Gawande went back to the drawing board. He consulted with the experts at Boeing, which has decades of experience developing checklists to address emergency, life and death situations that are trusted and used religiously by pilots world-wide. He also reviewed the experiences, practices and applicability of checklists at a major construction firm, a successful high end restaurant, the experiences, good and bad, from Hurricane Katrina, and checklist use in finance and the investment world. In every case, good checklists, used as an integral part of the organizations’ operations, made a significant, positive contribution.
Dr. Gawande returned to Boston. He and his team applied what he had learned in his research. They made the checklist clearer. They made it faster. They clarified responsibilities. They tested it in a simulation rather than a real surgery. Then they tested it in real life situations one case at a time, in different locations around the world. After each test, they assessed how well the checklist performed and revised it accordingly until they had a checklist that seemed to do the job. The final WHO safe surgery checklist spelled out nineteen checks in all.
The safe surgery checklist on patient care in its final form was tested in eight hospitals around the world. They collected data on the surgical care in up to four operating rooms at each facility for about three months before the checklist went into effect.
In early 2008, the pilot hospitals began implementing the two-minute, nineteen-step surgery checklist. The hospital leaders committed to introducing the concept systematically. They made presentations to all affected personnel. The WHO team supplied the hospitals with their failure data from previous sampling so the staff could see what they were trying to address. They also provided PowerPoint slides and YouTube videos, one demonstrating “How to Use the Safe Surgery Checklist” and one entitled “How Not to Use the Safe Surgery Checklist,” showing how easy it is to screw everything up.
In Dr. Gawande’s own words:
“The introduction of the checklist was rocky at times. There was a learning curve, as well. However straightforward the checklist might appear, incorporating it into the routine was not always a smooth process. Sometimes teams forgot to carry out part of the checklist. Other times they found adhering to it just too hard. The difficulty seemed to be social. Very few knew immediately how to adapt their style to huddling with everyone for a systematic run-through of the plans and possible issues. The nurses seemed especially grateful for the step, but the surgeons were sometimes annoyed by it. Nonetheless, most complied. Most but not all.”
“The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.”
With these kinds of fundamental improvements in patient outcomes, one would think that hospitals and surgeons world-wide would be falling over themselves to adopt the WHO checklist. Unfortunately, that was not the case. As DR Gawande commented “We were thrown out of operating rooms all over the world.” Unfortunately, resistance to change is a universal phenomenon. But Dr. Gawande’s team persisted.
“Perhaps the most revealing information, however, was simply what the staff told us. More than 250 staff members—surgeons, anesthesiologists, nurses, and others—filled out an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.”
“Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care. Then we asked the staff one more question. ‘If you were having an operation,’ we asked, ‘would you want the checklist to be used?’ A full 93 percent said yes.”
“Since the results of the WHO safe surgery checklist were made public, more than a dozen countries—including Australia, Brazil, Canada, Costa Rica, Ecuador, France, Ireland, Jordan, New Zealand, the Philippines, Spain, and the United Kingdom—have publicly committed to implementing versions of it in hospitals nationwide. Some are taking the additional step of tracking results, which is crucial for ensuring the checklist is being put in place successfully. In the United States, hospital associations in twenty states have pledged to do the same. By the end of 2009, about 10 percent of American hospitals had either adopted the checklist or taken steps to implement it, and worldwide more than two thousand hospitals had.”
Not bad for a little nineteen point checklist and some brave checklist champions who weathered their colleagues’ slings and arrows to save thousands of lives. A paradigm shift perhaps?
How a Great Leader Succeeded
Dr. Gawande and his WHO team did an amazing job of covering the change management landscape. So how can you leverage these insights and reap the successes that the WHO team achieved on your projects?
Project Pre-Check is a practice for guiding business, organizational and technology change. It addresses the key components of the WHO effort: a stakeholder model to ensure the right players are engaged and responsibilities are clear, a comprehensive, 125 point best practice based checklist (the Decision Framework) and a five stage process to guide the decision-makers from inception to value realization. Here’s Ruby’s assessment of Project Pre-Check relative to the fifteen best practices WHO leveraged on their project.
The Project Pre-Check checklists are downloadable at no cost at projectprecheck.com.
We talked about two sources of failure up front – ignorance and ineptitude. Checklists can address both. They can help stakeholders identify what they don’t know, and get assistance. They can ensure that what is known and pertinent to the change in question is identified and applied appropriately. Use Project Pre-Check’s three building blocks right up front to conquer both failure factors. Or build your own. But please, USE A CHECKLIST!
And remember, if you have a project experience, either good or bad, past or present, that you’d like to share with others and have examined through the Project Pre-Check lens, send me the details. Thanks.
Ruby Tomar is an action oriented, decisive and results focused Program and Project Manager with 16years of experience in the IT systems. With three patents filed and eight disclosures to her credit, Ruby is process and technology savvy with a strong inclination towards innovation and process optimization. She has worked in automotive, consumer, networking, and telecommunications industries and is an avid reader of technical and management research. She has an MS degree in Software Systems from BITS, India and is currently working as a Program Manager at HP. She can be reached at firstname.lastname@example.org
Drew Davison is the owner and principal consultant at Davison Consulting, a senior consultant at Mapador Inc. and a blogger on Project Times. He is the developer of Project Pre-Check, an innovative framework for launching projects and guiding successful project delivery, the author of Project Pre-Check – The Stakeholder Practice for Successful Business and Technology Change and Project Pre-Check FastPath – The Project Manager’s Guide to Stakeholder Management. He works with organizations that are undergoing major business and technology change to implement the empowered stakeholder groups critical to project success. Drew can be reached at email@example.com.