Insights June 2010

The Greatest Checklist

Neil Seeman

In The Checklist Manifesto, Atul Gawande’s panorama of complex decision-making in modern medicine, he showcases the power of the checklist to save lives.  Checklists fight the fallibility of human memory, even among the best-trained clinicians. Few people call checklists ‘innovations’ – since they sound humdrum. Prominent examples include the routine recording of vital signs in patient charts, or a checklist in the Operating Room asking things like: Do we have the right patient? The correct side of the body planned for surgery? The right antibiotics administered?

Every day the mental discipline of reviewing a checklist saves thousands of lives in aviation, building construction and medicine. Checklists should grow organically with new evidence. And as Gawande points out, the checklist, while a useful aid to navigate the extraordinary complexity that pervades modern medicine and aviation and construction, needs more than just tick boxes. Of greater importance is a role for recalibration if, as is inevitable, something emerges that confounds the team (e.g., a cargo door blow-out in mid-flight). And as anyone who has used a checklist (verbal, written or electronic) knows, a checklist’s effectiveness is only as powerful as its precision, simplicity and clarity.

Even a precise checklist cannot fly a plane or perform an operation; nor can a good checklist make anyone follow it. All of which brings me to something complexity theorists seldom discuss: leadership. It is generally a CEO or board responsibility – in law – to ensure that certain checklists (e.g., emergency preparedness plans, risk mitigation strategies) are in place and have been tested. A deviation from the checklist or a lack of sufficient testing of it could bring a company, say, BP, to heel.

But is there a meta-checklist that a leader can follow to make sure that all sub-units of the organization (from the senior executive team to communications to the quality committee) are checklist-savvy? In other words, is it possible – with one beautifully elegant list – to ensure that every committee and every unit in your organization is committed to protocol and to improving upon it? Is there an organizational nirvana where there is a best-practices checklist for everything? Strategy consultants will offer up solutions: Six Sigma training, content management software, company Intranet portals for knowledge management. But I’m talking about something grander: let’s call it “The Greatest Checklist”.

Some companies say The Greatest Checklist lies in über values. The values statement – emblazoned on company letterhead and Websites – could promote values such as evidence-based decision-making and collaboration and compassion for all clients. All decisions in any complex environment, goes this theory, should be consistent with the values statement. OK, but a values statement will only go so far to help you in an unexpected PR crisis – like public fury over executive compensation; or in an unexpected confluence of events, like an electrical shutdown during a G-20 conference in your city. All you know is that the unexpected will surely happen; you need the Greatest Checklist to handle it when it hits.

I am reminded here of the spectacular talk on leadership that Rudolph Giuliani gave at the Ontario Hospital Association’s HealthAcheive conference in 2005. Before 9/11, Giuliani explained at his keynote address, New York City had a rigorous and well-tested checklist to handle a massive fire in the downtown core; to contain major electrical shutdowns; to respond to a skyscraper implosion in Manhattan; and to meet the needs of surging patient demand on the city’s ERs that could flow from a bioterrorist attack. What New York City failed to imagine, a theme seized upon in the 9/11 Commission Report, was that all of these things could happen simultaneously. There was no checklist for that.

The Greatest Checklist, a tool to get all things right all the time, currently eludes healthcare, since there are unexpected shocks in systems far outside the organization that have dramatic impacts on the internal, local operations and outcomes over which the healthcare organization has, at best, limited control. Consider a sudden change in the world price of oil; the global automobile sector’s travails; the hedge fund industry’s demise. The healthcare organization is adaptive and adapting in real-time.

Given this complexity, the Greatest Checklist will only emerge if there is a free, user-friendly intelligent knowledge database at your fingertips (Google); that possesses deep situational awareness (Facebook); gets updated in real-time in response to millions of stimuli (the stock exchange) – and offers elegantly organized, contextually aware checklists to solve unexpected problems. We’re not there yet; but we’re closer than you think. It is called the Semantic Web, the third generation of the Internet. Until then, we need to keep improving upon our humdrum checklists – and practice and practice and practice.


About the Author(s)

Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.


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