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Andre Metzger

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Three Instances Where Checklists Have Worked--and How

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.)