Checklists: A prescription for everyday excellence

Adapted by Keith Gillette under Creative Commons BY-SA from Rx symbol by Nevit Dilmen
If you care about quality, you know about the efficacy of checklists. In his New Yorker article and in his best-selling book, The Checklist Manifesto, Atul Gawande, surgeon and Harvard Medical School professor, relates dramatic stories and highlights impressive statistics demonstrating the effectiveness of checklists in preventing mistakes.

Gawande popularized the founding myth of checklists. He tells the story of the WWII B-17 “flying fortress” long-range bomber. Its first test flight ended in a crash that killed the pilot and a crew member because the pilot forgot to unlock the elevator and rudder controls on the complex craft. Rather than cancel production of the plane, military leaders created a take-off checklist. The B-17 became instrumental in the Allies winning the war. Since that early success, a checklist culture has taken firm root in aviation and is a central component of flight safety.

Inspired by such examples, Gawande helped develop a Safe Surgery Checklist in conjunction with the World Health Organization (WHO). Use of this surgical checklist reduced inpatient surgery deaths by 40% and major surgical complications by 36%, as reported in a widely-cited study published in 2009 in the New England Journal of Medicine. More recently, preliminary results from trials of the WHO Safe Childbirth Checklist show impressive decreases in infant mortality.

Humbler examples illustrate the effectiveness of checklists in other contexts. A while ago, I interviewed an Information Technology Director for a mid-sized firm. Let’s call him Sam. Sam’s user support team faced many routine requests and recurring issues. Team members were perfectly capable of dispatching these as they arose, but Sam realized that many of the calls the help desk received were entirely avoidable. Frequently, executives who were trying to start an important business call would summon IT, irate that the videoconferencing equipment was not working properly. Typically, this was simply because other users had unplugged equipment or changed settings from the defaults, but IT still had to fix the problem. After repeatedly fielding help desk calls from angry executives (including one quite uncomfortable call directly from the CEO), Sam decided to take a different approach. He built a checklist and instituted checklist-driven morning rounds with his staff to test every piece of teleconferencing equipment in every conference room every day.

Sam also deployed checklists in another area of recurring quality problems: configuring computers for new employees. In a corporate environment, getting a new computer in a useful state for an employee takes much more than unboxing it and plugging it in. Even in only moderately complex environments, there can be hundreds of steps that need to be followed in order to accomplish the myriad customizations in network settings, security profiles, printer connections, and application installations required for full functionality. Many of these tasks can be automated, but in smaller organizations, setting up automated installs frequently takes more time than it saves, especially when a particular configuration profile would apply to just a few employees. In Sam’s company, with so many precise, manual steps to follow, errors occurred frequently. These were easily fixed, but led to frustrated users and wasted time for his team. Sam developed checklists for workstation setups and instituted a procedure for sign-off by two technicians, one who followed the appropriate checklist to configure the new computer, and one who audited the work following the same checklist on the same computer.

These checklist-driven interventions reduced help desk calls 75%. That 75% reduction represents an enormous elimination of wasted time in Sam’s company, freeing those executives, employees, and IT staff for productive pursuits. Moreover, it represents an equivalent decrease in everyday frustrations, promising that Sam’s coworkers may be a bit happier at work, which may also have spill-over effects on productivity, not to mention personal satisfaction.

While Sam’s checklist protocol may not prevent deaths or allow pilots to defend the world from fascism, it’s nonetheless an accomplishment in everyday excellence to be applauded. Though the stakes were not as high as life or death, the same tool—the humble checklist—provided significant improvements in outcomes. In fact, while there are many quality management techniques for mistake-proofing, I think there are several factors that make checklists especially well-suited to such everyday applications:
Simplicity 
Checklists are easy to create and easy to understand. While future articles will cover the nuances of checklist best practices, if you can make a list, you've mastered checklist basics. Their simplicity relative to other quality management tools generates few barriers to use and may lead to better adoption. It’s doubtless better to have a basic checklist widely deployed than the perfect process management system held up in planning due to endless analysis or sloughed off due to burdensome complexity. 
Flexibility 
Checklists have applicability across many domains and use cases, from personal ticklers to mission-critical standard operating procedures. As lists, they can equally well capture either salient inspection attributes or step-by-step sequential procedures, making them applicable to both auditing as well as process documentation, at least for linear processes that do not involve complex branching or recursion. However, even those more complicated cases can be treated with thoughtfully-designed nestable checklists. 
Maintainability
Checklists are easy to update, so they can be quickly revised to scaffold processes that may be undergoing rapid iterations due to changing environments, process improvement, or innovation initiatives.
These characteristics were no doubt among those that made checklists effective in the examples that Dr. Gawande chose, as well as benefits that prompted him to make checklists his prescription to effect better medical outcomes.

Human life may not be on the line for Sam’s company—or yours—but isn’t the promise of fewer mistakes and better outcomes motivation enough to consider how checklists may benefit your work? I’d love to hear other stories about effective (or ineffective) uses of checklists in your pursuit of everyday excellence. Please share yours in the comments following this post or send them to me directly using the contact form on the About page.


A version of this article also appears on my startup's blog.

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