Tag Archives: checklist

Checklists: Make money as well as save lives

It’s been about a year since I posted about how checklists can save lives, so it must be time for another entry, right?

There’s an article in the Financial Times on ‘Airline pilot’ protocols in finance. that talks about checklists. It cites a study performed in the late 90s on venture capitalists. It identified several different types of VC based on how they evaluated potential startups. Some came to snap judgments, others based their decision on the technology, ignoring the people, etc. One type — the so-called “airline pilots” — used checklists to help them decide. The study’s conclusion was that this type of VC was far less likely to have to fire the founders down the road: 10%, rather than the 50% average of the rest of the VCs.

The article above is an excerpt from this book (affiliate link warning): The Checklist Manifesto: How to Get Things Right

Checklists are a way of making mistakes only once. In a very few fields that might not apply; I can’t imagine a painter running down a checklist that says:

  • Use at least 10% red.
  • Paint the subject in 3/4 pose if it is a woman, face-on if it is a man.
  • The subject should cover 60% of the field of view
  • etc.

But of course a painter might have a checklist for how to promote art: how to get it in galleries, how to encourage reviewers, how to reach customers.

In many circumstances people tend to have strong resistance to using a checklist, but in others most people have no problem with it. You probably don’t have a checklist for going to work, even though that likely has more than five steps (the number to put in a central venous catheter), and you’ve probably forgotten your gloves/keys/umbrella/paperwork more than once. But you’ve almost certainly followed a checklist when making dinner. What’s the difference between the two? For starters, you may have followed a checklist/recipe, but have you ever written one down?

In the end I think it comes down to convenience and ease of use. I’m going to look at the alternatives for the iPhone and see if any of them are up to the task.

1. Make a Checklist. 2. Save Lives.

What’s the value of a checklist, and how detailed does it have to be to provide value? The answer is surprising: a checklist so simple it seems unnecessary can save thousands of lives. Simple checklists consistently applied can pay big dividends.

Why Would You Need a Checklist for Five Steps?

Putting in a central venous catheter can be risky: according to an article in the New Yorker magazine, four percent of them become infected after ten days. That’s eighty thousand people a year in the United States, and five to twenty-eight per cent them die, depending on how sick they are to begin with. Survivors spend an extra week in intensive care.

There are five simple steps a doctor should follow to help prevent infections:

  1. Wash their hands with soap.
  2. Clean the patient’s skin with chlorhexidine antiseptic.
  3. Put sterile drapes over the entire patient.
  4. Wear a sterile mask, hat, gown and gloves.
  5. Put a sterile dressing over the catheter site.

Pretty straightforward. So simple it seems unnecessary to make such a list. Tying your shoes involves more steps, and you don’t have a checklist for that. You could memorize five steps in a minute, and after practicing once or twice you would likely expect never to violate those simple principles of patient safety.

But a one-month study at Johns Hopkins Hospital showed that doctors were skipping at least one of those five steps in one third of the patients they worked on. Johns Hopkins is one of the best hospitals in the world. It is consistently ranked as the very best hospital in the United States, and even there only two-thirds of patients were receiving the full treatment prescribed in a simple five-step checklist. Peter Pronovost ran the study, and set out to see if he could improve the quality of care given by implementing a checklist.

In the first year, following the checklist dropped the rate of ten-day line infection rate from eleven percent to zero. In another fifteen months, only two infections occurred. During the course of the study it’s likely eight lives were saved, and two million dollars. Studies with other simple checklists showed similar results. A similar study run in hospitals across the state of Michigan led to a decrease of infections of sixty-six percent within just three months. By the end of the eighteen month study infection rates at the average ICU in Michigan was better than ninety percent of other hospitals in the U.S. Over the course of the study the Michigan hospitals saved over one hundred seventy-five million dollars, and fifteen hundred lives. Details can be found in a New Yorker Magazine article.

Taking it to England

Now surgeons in England and Wales will be using a pre-surgery checklist to make certain a few small details: Is this the right patient? Is this the right limb? Has the patient had the right drugs? And sixteen others. Just taking these basic precautions is expected to save hundreds of lives annually and cut down complications dramatically. In a trial run, the checklist reduced the death rate following surgery from 1.5 per cent to 0.8 percent.

Simple and Effective

A checklist can be valuable in several ways. First, just by creating it you force your team to consider what the right thing to do is. (Hint — if you can’t agree on the steps in the checklist, you have a bigger problem to deal with) Second, you create a standard that everyone is expected to follow. Putting it in writing emphasizes that. Third, you provide a reminder to those who, caught up in the moment, might need help to remember all the steps.

Checklists can be applied in almost any field. Pilots use them all the time: before taking off, before landing, etc. Lawyers use checklists to help decide the legality or illegality of something. Shopping lists and recipes are checklists. There are whole web sites devoted to checklists.

So follow this simple checklist to get started:

  1. Pick a procedure to make a checklist for. Be sure to pick a simple one for your first time.
  2. Define the checklist.
  3. Decide how you will track compliance.
  4. Decide when you will re-examine the procedure, the checklist, and the compliance stats to improve the checklist’s effectiveness.

You see what I did there?