liveonearth (liveonearth) wrote,

Checklists for Medicine

What Sort of Checklist Should You Be Using?
By Justin Fox | Tuesday, February 23, 2010

Like zillions (or at least tens and tens of thousands) of other non-surgeons, I've been reading Atul Gawande's The Checklist Manifesto. It's a wonderfully entertaining and thought-provoking book. (If you want the short version, you can listen to HBR's Katherine Bell interviewing Gawande here.)

Gawande convincingly makes the case that medicine — in particular surgery — shares many traits with two complex, high-skill endeavors: constructing big buildings and flying airplanes. Yet while people working in construction and aviation depend on following checklists to get things right, doctors and nurses so far have not. Gawande thinks this is a big mistake, and in his book he tells the inspiring tale of how he and a bunch of other medical professionals from around the world designed a new surgery checklist that is already saving lives all over, including in Gawande's own operating room at Brigham and Women's Hospital in Boston.

But Gawande also argues for using checklists in other endeavors, from business to investing to law. This went too far for lawyer Philip Howard, who complained in a review in the Wall Street Journal that:

Accomplishment is personal. That's why giving people the freedom to take responsibility is so important. Organizational techniques can be useful — we all rely on checklists informally — but formal protocols can disrupt focus and undermine success in many life activities.

Howard was overdoing it: Gawande never says that all or even most decisions should be broken down into formal protocols. But he also never formally breaks down what kinds of situations call out for what kinds of checklists. He doesn't provide a checklist checklist! So I thought I'd give it a try (although if you've got a better checklist taxonomy, I'd love to hear about it):

1. The most straightforward kind of checklist is the task list: a step-by-step recital of standard operating procedures that must be followed in the correct order. This only works well when it's widely accepted and agreed what the task list should be. This means task lists are best suited for technical endeavors that involve too many details to remember, but not a lot of judgment. Such as preparing a specific dish in a restaurant, or starting up an airplane. There are surely some appropriate applications for them in more general management settings, but Howard is right that — when imposed from above — they can get in the way of getting useful things done.

2. A close relative of the task list is the troubleshooting list. Something goes wrong; what steps do you take to find out what it is and correct it? Again, these work best in technical endeavors: in the book, Gawande describes the checklist Boeing put together to deal with unlatched cargo doors. But one can easily envision simple troubleshooting lists being put to good use in less technical, more judgment-dependent areas.

3. At a construction site in Boston, Gawande encounters what I'll call a coordination list. You have an extremely complicated endeavor that no one person can fully understand, so you set up procedures that force the various specialists involved to consult each other on a regular basis. Again, this seems like something with all sorts of applications outside of construction (and medicine).

4. Gawande describes several value investment managers who use checklists to make sure they always follow certain steps before putting money into a company. This is a discipline list. In a calm, reasoned state of mind, you set down a list of procedures you want to follow to keep you from making bad decisions later, in the heat of the moment. It seems like these can't really be standardized but, in part because they're not standardized, they can be used almost anywhere.

5. The most common sort of checklist is one that Gawande doesn't discuss at all, the to-do list. This is an entirely personal list, meant to be revised monthly or weekly or daily. It's a staple of every time-management regimen going back at least to Benjamin Franklin, who wrote in his Autobiography that he tried to begin his days like this:

Rise, wash, and address Powerful Goodness!
Contrive day's business, and take the resolution of the day;
prosecute the present study, and breakfast.
Question. What good shall I do this day?

Almost all of us try to keep to some such regimen, and the fact that we usually fail at it doesn't make it any less useful (if it's any solace, Franklin wrote that he usually failed to keep to his daily resolutions, too). The question is when it's appropriate to move from such entirely personalized list-making to the more formal checklists that Gawande espouses. Over the past half-century, medicine has gone from a profession built mostly around individual doctors making judgment calls to one in which there is now far too much specialized knowledge and expertise for a single doctor to do all the work or make all the calls (don't tell anybody, but there's a really good article discussing this transformation slated for the April issue of HBR). Hence the need for task lists and coordination lists and troubleshooting lists (the surgery checklist Gawande helped devise is really a combination of all three) that might not have served much purpose 50 years ago.

Medicine surely isn't the only field to have made such a transition recently (although journalism, bizarrely enough, seems to be headed in the opposite direction, with Web-based publishing generally requiring less formal coordination and planning than putting out a magazine or newspaper). So get your checklists out, people!
Tags: discipline, investing, lists, management, medicine, my practice, plans, resolutions, to do

  • Post a new comment


    Comments allowed for friends only

    Anonymous comments are disabled in this journal

    default userpic

    Your reply will be screened

    Your IP address will be recorded