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Summer Reading — A Manifesto Of Simple Power

June 4, 2010
by Joe Bormel
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Add This To Your Summer Reading List

For most people, the power of checklists is a concept that's just too simplistic. There are people who are wedded to a perception that checklists primarily zap autonomy. These checklists implicitly represent overbearing, parental control.

At the other extreme, there are people who really appreciate process and discipline. For them, checklists, and I mean really good checklists, are a god send. These two groups of people never have lunch with each other!

The fact is, as Dr. Atul Gawande elaborates beautifully in his book, “

The Checklist Manifesto,” checklists in healthcare are much more than autonomy zapping or a panacea of discipline then one may ignorantly conclude. There are several notions Gawande covers that are both highly relevant to HCIT and not well represented today.

For instance, the idea that there are two different checklist models which address different problems:

DO-CONFIRM checklist


READ-DO checklist

In the first, people work from memory and experience, then the checklist ensures completeness. In the later, people, often in teams such as pilot/co-pilot pairs, work using the checklist more like a recipe.

For more on this concept, just start the book this summer at chapter six,

The Checklist Factory. Here you'll learn how Boeing publishes and revises checklists for every aircraft; they've learned a ton about what works and what doesn't, what pilots need and what they don't. This isn't intuitive stuff. For example, “Do you test your organization's checklists in simulators?”

Another insight in the book elaborates why traditional project management techniques are inadequate when multiple sub-specialists are involved, and what to do about that problem. It's yet a third kind of checklist that has been critical and effective for decades in the construction industry. But that's another chapter and another blog post!

Lots of great stories and a wonderful read (or listen). And, highly relevant to HIT design, build, test, and deployment work. Highly recommended.



Thanks for your comment as well. Your observation about specialization is the subject of an entire chapter of the book. Using specialization alone to deal with complexity only gets you so far. In the chapter on the Master Builder, Gawande points out that in the construction industry, they transcended the idea of a single person who coordinates specialists. That paradigm doesn't scale to the complexities of the real world.

Instead, the solution is a combination of a well-executed detailed project plan, combined with a committal schedule where carefully scheduled, face-to-face meetings ensure adequate review. That committal schedule, commitment to timely team review constitutes it own set of check lists events.

In fact, team activities, like introductions and reviews are some of the most important checklist steps. It's not complicated it's definitely work that you don't want attempted through email!

Thanks for your comment and insight. I didn't really talk about, nor did Gawande, the use of checklists for self-managing the litany of stuff we track in our to-do check lists. Most successful practitioners of one such self-management approach called GTD (see my recent iPad post) are familiar with your observation:

"... Human behavior pulling them back to their previous habits."

The discipline is, like dieting and exercise, to pick oneself up after falling off the discipline horse and get back on it. Accept that, although it's human behavior to slip back to less discipline habits, it's also possible to develop a habit getting back on the horse. The benefit is "Stress-Free Productivity" to borrow a term from David Allen.

Thanks again for your comment.

Joe, Great recommendation. You didn't touch on this directly - there are several examples of where checklists improved safety and lowered costs dramatically. This is so much more significant than a memory aid.

Thanks for your comment. You're making a terrific point, which is that checklists have proven to deliver real benefits, such as reduce avoidable Hospital Acquired Infections (HAIs). There are a variety of quality improvement examples for hospitals, and physicians, as well as public health outlined in the book.

A point that I had in mind when writing this was the role of checklists in developing problem based methodologies for order sets, documentation templates, performance measurement codification and abstracting (aka CDI initiatives).

There's an art and practice to Checklists. Few of us have thought, researched and rolled-out Checklists like Dr Gawande.

Both these checklist types have been essential in almost every aspect of my professional and personal life. It frees my mind to pursue innovation, new ideas, and research. Why clutter my mind when a list with reminders is more effective!

It has been a challenge to institutionalize such checklists in organizations. Very few in my opinion disagree with its importance and sincerely want to adopt such an approach, however human behavior keeps pulling them back to their previous habits. Can you imagine the benefits in terms of quality of care and patient safety if most in healthcare committed to the discipline of creating and following checklists!

As with Girish, I've used both types of checklists throughout my professional career. I consider them to be an essential component for everything from innovation to successful project completion. That aside, your post spawned a thought, which led to a few of questions.

Does all of the extreme sub-specialization in healthcare have any unique implications for checklists? It appears there is a possibility that each type of sub-specialist, presumably with "specialty-specific wisdom," may create complications for healthcare.

After all, in commercial aviation there is probably just one checklist for the cockpit and perhaps a second for the flight attendants. But when it comes to care providers, I could have a GP, a cardiologist, a GI guy, and more! This looks a little complicated . . . or is it?