Sunday, 16 October 2011

The Checklist Manifesto

A study conducted to analyse why people fail to perform in complex situations identified two major influencing factors -Ignorance and Ineptitude.

Ignorance - The lack of knowledge. This could be due to lack of experience or it could be in rare, complex or unfamiliar situations.

Ineptitude - The lack of application. In other words, the skills and expertise to solve a particular problem are available and are known, but we either fail to apply them or apply them inefficiently.

The former requires more research and it's attributed to the lack of training. For the latter, there is already enough training and expertise in place, but we still fail to apply it successfully. But, why?

In health care, vital signs are measured to assess the most basic body functions. Though the number of vital signs to be measured may vary according to the situation, the four basic ones are body temperature, pulse rate, blood pressure and respiratory rate. In most cases, when three of the vital signs are normal, the fourth one also tends to be normal. When we begin to notice that most of the times the fourth sign is good, we stop checking it when the first three signs are good. And this is not just in health care. Here's another example.

A few years back when I was living in Hyderabad, we were using a padlock for the main door of our apartment. This lock was broken. But it was broken in such a way that you could actually make it look like it was locked even when it was not. Just press it and it would hold together nicely. To unlock it, all you needed to do was just pull it down and no key was required. Though we knew how risky this was, we used this lock whenever we forgot to handover the key to the last leaving housemate. We used it a couple of times and never had any issues.
In the initial days we warned ourselves not to keep using it, but as the days passed, nothing bad happened and we slowly ignored the risks and took it for granted. Everything was good except for the day when our house was robbed! The robber didn't even have to break the door to get in. You could call it carelessness, stupidity or whatever, but the loss is a loss.

Then, there is this human memory which is fallible by nature and a simple fact that many of us don't want to accept. How many times have we been surprised by or surprise others with this question, 'how could you forget such a simple thing?'. It's typical of how our memory is. Our memory cannot retrieve everything whenever and wherever we want. The more we learn, the more information the brain has to store and the more it stores, the tougher it gets to retrieve something quickly, especially in a highly pressurized environment. So in adverse situations, sometimes the brain fails to retrieve or remind us even the most basic stuff. These are some typical examples of being inept.

Experts in various industries started realizing that to tackle ineptitude, just skills and expertise alone would not be sufficient. It requires something more than that.

Dr.Atul Gawande an endocrine surgeon at Brigham and Women's hospital in Boston who has done some extensive research in this area believes that the answer could be 'The Checklist'.

In the field of medicine, checklists are not completely new. They have been used on and off at different levels - for example, some nurses maintain a checklist to ensure that all the vital signs are tested. Dr.Peter Pronovost, one of the early advocates of checklists in the intensive care unit has reported that his checklists have saved 1500 lives and $100 million in the State of Michigan over a period of 18 months*.

In spite of these results, checklists are not popular and not widely accepted. That's possibly because of the way we define what checklists are for and who should be using them.

Ask yourselves a question, 'who do you think should be using a checklist in the real world?'

Was your answer just amateurs like beginners in a profession or for some one in a learning curve; or did it also include some one with extensive experience and specialization like a 'chief surgeon in an hospital who has some 15-20 years of experience in surgery' or 'a pilot with some 20,000 hours of flying experience' ?

If your answer didn't include the latter, then ask yourselves why you thought that an experienced professional would not need a checklist. If your answer did include both novice and experienced alike, then have you ever used or are using a checklist currently? If not why? Answering these questions would probably explain why checklists are not popular and why they are not widely accepted.

We often think checklists are silly. For the experienced, checklists are just a waste of time and its embarrassing to have one.

Few years back, when I was a Senior Tester I failed to test a basic business condition in the application. When the issue was escalated, I had no reason to explain why I had missed it. I just forgot to include the condition in the test case. As simple as that. Thinking about it now, I realize a checklist could have prevented it.

One might wonder what if we failed to include an item in the checklist itself. For this, Gawande insists that the checklist should be discussed with all the stake holders, optimized and made sure it is efficient. Moreover a checklist should neither be too long nor too short. It should be apt to the situation. When more than one pair of eyes are involved in preparing a checklist, chances are less for making mistakes in the checklist itself. Of course there will be exceptions and that's why Gawande suggests that the checklists should be inspected often and made sure they are relevant to the current situation.

During his research on checklists, Gawande observed that checklists have actually been in use for a long time now in other major industries like Aviation and Construction. The Aviation industry in particular has extensive checklists that are well organized and followed effectively. Gawande explains how emergency checklists helped experienced pilots to ditch the US Airways Flight1549 successfully in the Hudson river, saving all 155 on board resulting in the incident to be known as the Miracle on the Hudson .

Eventually when Gawande started working with the WHO on an initiative to improve safety in surgical processes around the world, he put forth the idea of using a checklist that could potentially save millions of lives without requiring the invention of any new medicines or technology. The Surgical Safety checklist was tried in 6 hospitals around the world to see how effective it would actually be. The outcome of the study indicated that, 'Postoperative complication rates fell by 36% on average and death rates fell by a similar amount'. More information on this study can be found here.

Below is the 2009 edition of the Surgical Safety checklist from the WHO. Some of the questions like - patient name and identity, operation procedure would sound so basic. But the reality is, even in the most advanced hospitals these basic things are often missed.

Dr.Gawande has observed multiple instances where checklists have repeatedly saved lives, even in the most improbable situations.

One such case was reported in this article 'The Checklist' - the scintillating story of a three year old girl who almost drowned in an icy fishpond in Alps.

The article published in 2007 in 'The New Yorker' was the forerunner of this book - 'The Checklist Manifesto'. An interesting and worthwhile read.

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