Heroic Checklist

Why you should learn to love checking boxes.

Quick, a word-association test. What word comes to mind when we say "checklist"?

Here are some candidates: "basic," "routine," "dull." But what if we asserted (with a great dramatic flourish) that your first associations should be "lifesaving" and "game changing"?

Yes, we really are that nerdy. But we mean it.

The holy grail of checklists may be the one created by Dr. Peter Pronovost of the Johns Hopkins University School of Medicine. Intensive-care units (ICUs) often use intravenous lines to deliver medication, and these lines can become infected, causing nasty health complications. Pronovost, frustrated by these preventable events, compiled a five-step checklist.

The checklist contained straightforward advice: Doctors should wash their hands before inserting an IV, a patient's skin should be cleaned with antiseptic at the point of insertion, and so forth. There was no new science and nothing controversial--only the results were surprising. When Michigan ICUs put the checklist into practice over a period of 18 months, line infections were virtually eliminated, saving the hospitals an estimated $175 million, because they no longer had to treat the associated complications. Oh, and it saved about 1,500 lives.

How can something so simple be so powerful? Checklists are good because they can educate people about the best course of action, showing them the ironclad right way to do something. As Pronovost told Atul Gawande in The New Yorker last winter, his five steps were black and white and backed by solid medical research. You could ignore the checklist, but you couldn't dispute it.

Even when there is no ironclad right way, checklists can help people avoid blind spots in complex environments. Has your business ever made a big mistake because it failed to consider all the right information? Cisco Systems, renowned for its savvy in buying and absorbing complementary companies, uses a checklist to analyze potential acquisitions. Will the company's key engineers be willing to relocate? Will it be able to sell additional services to its customer base? What's the plan for migrating customer support? As a smart business-development person, you'd probably remember to investigate 80% of these critical issues. But it would be inadvisable to remember the other 20% after the close of a $100 million acquisition. (Whoops, the hotshot engineers won't leave the snow in Boulder.) Checklists are insurance against overconfidence.

And overconfidence is worth ensuring against, because we all have a knack for it. In one classic psychology study, the administrators asked the participants to come up with possible solutions for their university's chronic parking problem. Each individual, on average, managed to come up with about 30% of the solutions, which experts compiled for a "best ideas" list. Thirty percent is pretty darn good, but before the individuals saw the list, they had to guess what percentage of ideas they'd contributed personally. They confidently predicted 75%. (Don't we all know people who believe that the world's accumulated wisdom adds only an incremental 25% to their own contribution? Many of you may have married them.)

As much as we need checklists, the troubling truth is that few people use them. In fact, that silence you hear is the sound of thousands of the nation's hospitals ignoring Pronovost's cost-reducing, lifesaving checklist. Their inertia is astonishing. Do you think Sears or T.G.I. Friday's would ignore a cost-reducing, satisfaction-improving checklist?

Well, they might if their corporate cultures got in the way. That's what initially happened to Pronovost. When he proposed putting nurses in charge of managing the checklists, he got an earful. "The nurses said, 'It's not my job to police the doctors, and if I try, I'll get my head bit off,'" he told us. "And the doctors said, 'You can't have these nurses second-guessing me in public--it'll undermine my authority!'"

Pronovost learned to fight the resistance by appealing to a value they all shared--patient health. He would bring doctors and nurses together and ask, "Would you ever intentionally allow a patient's health to be harmed in your presence?" They'd say, "Of course not." Then he'd hit them with the punch line: "Then how can you see someone not washing their hands and let them get away with it?"

People fear checklists because they see them as dehumanizing. Maybe that's because people associate them with the exhaustive lists that let random teenagers successfully run fast-food chains. They think if something is simple enough to be broken down into discrete steps, a monkey can do it. Well, if that's true, grab a pilot's checklist, and try your luck with a 767.

Even if you're sold on the value, beware checklist creep. A checklist doesn't mean huge binders full of obsessive and likely counterproductive ISO 9000-style process documentation. As Pronovost says, "One mistake I've seen in health care is that people will produce these 200-page process guidelines that nobody ever reads." You're not trying to create a high-resolution photograph of the status quo. In fact, if the status quo worked perfectly, you wouldn't need a checklist, you'd need a bonus.

Checklists help us avoid blind spots in complex scenarios. Hospitals have saved thousands of lives by following a simple five-step process for inserting IV lines. Where could your business benefit from a checklist?

Checklists simply make big screwups less likely. "We wanted people to standardize on the mission-critical elements--the areas where we have the strongest evidence," Pronovost says. "And these things that are mission critical, we've got to do them every time."

What does your business have to do every time? Put it in a checklist. You may not save a life, but you'll avoid a painful blind spot.

Read more Made to Stick columns

Dan Heath and Chip Heath are the best-selling authors of Made to Stick: Why Some Ideas Survive and Others Die.

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2 Comments

  • Anonymous

    GREAT ARTICLE!!!! I work for a company called LifeWings that teaches hospitals how to use the same teamwork training and safety tools that have made commercial aviation so safe and reliable. And it works! Hospitals who use our system have eliminated errors like removing the wrong kidney and dramatically improved the safety of their care. Many of them have won awards for the quality of their patient safety.

    If I had a choice, I wouldn't go to any hospital that didn't use our LifeWings safety system.

    We are out there making a difference in patient safety every day. Over 85 organizations use us. Find out if your hospital is on the list. Visit LifeWings at www.SaferPatients.com.

  • Syamant

    A very nice post.

    An example comes to mind, while developing the experience of a bike service centre , a checklist was sought to be designed for diagnosing the bike . The best service advisor could ask only about 15 percent or so questions in a role play situation. The same person when asked to list the questions in a checklist added more in much the same amount of time.

    It turned out to be the best way to get over resistance in implementing a checklist. The downside was that it became monotonous and the rigour was lost at a later point in time. But it was addressed.

    Its important though that the checklist does not become plastic and retains the warmth of the customer promise.