Surgeon, author, and medical crusader Atul Gawande, in his book, "The Checklist Manifesto", presents theory, research, and personal experience in support of using checklists in complex work situations, such as performing surgery, flying a plane, or building a skyskraper. He writes:
Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, higly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is ofen unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields - from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.
That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies.
Gawande's solution is to use a checklist - the "minimum necessary steps" that must be taken to ensure safety, quality, and success. I would argue that it is not the list of critical steps that makes the difference, but the organizational culture that emerges as a result of using a checklist that makes the difference. In order to use a checklist effectively, employees must work together to identify the items to go on the checklist, requiring a careful and thorough assessment of work processes. Then they must hold each other accountable for completing each of the steps (e.g., nurses must have permission to remind surgeons to use sterile gloves). When something unpredicatble happens they must be able to react as a cohesive unit. Then they must collaborate on reviewing the process and making modifications to ensure safety, quality, and success in the future.
Susan Kistler, Executive Director of the American Evaluation Association, writes this about Gawande checklists:
They provide a means for harnessing variability, lending structure and guidance amid what may be chaos, and controlling risk if not eliminating it. He explains the ways in which checklists can be empowering – providing line workers with the information needed to make decisions and the leeway to act rather than be stymied by a bureaucracy awaiting permissions from superiors. The most ‘a-ha’ moment I had while reading was Gawande’s indication of how checklists might detail not specifically what to do but rather, when the unexpected strikes, with whom to collaborate, connect, and communicate in order to leverage the collective knowledge of a group to respond and resolve.
In other words, checklists in complex work situations are instruments for creating a positive culture, contributing to breaking down the hierarchies and mistrust that are barriers to high performance teams. A checklist is the focus for a shared process for managing the complexity and risk that everyone feels. The tool will only be effective if it is used within a culure in which doctors listen to nurses, architects listen to structural engineers, and captains listen to their first officers.
