Hospital checklists work really well -- except when they're not used

This is why TeamSTEPPS was developed. Any surgery team member should be able to speak up. They endanger their license and the patient when they don’t.

When will the tyranny of doctors end?

I think this is the crux of it. Medical schools aren’t teaching by the checklist, but aviation schools are. Military aviation even more so. The fighter pilot I know is like a human algorithm. But surgeons and doctors seem to trust their perception of their own expertise over everything else.


This can be valuable as an iterative process-improvement effort as well:

It is often the case that you want the checkbox’s implicit “yes or no; and the correct answer is yes” to be true of the real world, because this implies that you’ve done a reasonably good job of nailing down the task; but it can be hard to reach that point from the very start.

The various “yes; but…” or “no, because…” or “this step delayed by…” or “doesn’t step Y make this step irrelevant?” answers are part of the dialog that (hopefully) moves your process toward a state where you better understand the problem/task; and have cleaned up the circumstances surrounding it so that your new checklist is more realistic and requires fewer free-responses in the margins or on attached page and (more importantly) your process is simply better because all the things you classify as ‘checkbox, someone just has to do it’ can simply just be done (at least the vast majority of the time) and anything that is likely to require special care and attention and a more detailed writeup/test data/etc. is called out as such.

In my own experience at work I’ve seen a number of process dysfunctions cleaned up by people paying attention to the checkbox items that consistently draw acrimonious free-text comments; or which spend atypically long times hanging open because they (often unnecessarily) involved drawing someone else into the task and then hounding them for feedback/signoff.

These cleanups were also accompanied by a nontrivial management shakeup; so it’s not like the checklist was what spurred action by speaking truth to power, man; but it was a useful source of data when power decided that it wanted to get a fresh look at the truth on the ground and adjust accordingly.

While, in rereading them, my earlier comments may have seemed a bit negative about checklists; I’m really not: they are valuable tools for ensuring that everything gets done even in the face of cognitive load and assorted distractions(I certainly use them myself, especially for stuff that can’t be scripted; which is essentially just having a machine checklist for me); but they have to be used as a ‘sensory’ tool for guiding organizational adaptation to the real world as it exists, potentially including changes that might not be thought of as directly ‘in scope’ for the task being checklisted and changes that go much further up the food chain than the person filling out the checklist if they are to be genuinely valuable rather than mostly just supervisory.

(In that vein, while he certainly deserves more than a bit of the ill-regard he has picked up, this is one thing that Taylor and ‘scientific management’ did seem to grasp; albeit in a rather paternalistic and controlling sort of way that sacrificed workers as an information source: the idea that the labor doesn’t understand how best to do the job and needs scientific managers for that sure doesn’t sound nice; but it does explicitly articulate a duty on the manager’s part to understand how best to do the job and aligns responsibility and power: the manager must be able to provide instructions that, if followed sincerely but without any particular initiative, give the desired result.

As noted, ‘scientific management’ squandered worker engagement and is hardly an exemplar; but I just thought of it because, more so than a lot of checklist initiatives that are less willing to come out and say unpopular things, it does have the virtue of being relatively clear about its assumptions; and about aligning power and responsibility: can’t just kick out an unrealistic checklist then flog the peons until productivity improves when it is specifically your job to tell the peons their jobs; and where your understanding and codification of the process is such that, were the workers to decide to “work to rule” that would actually be optimal; rather than a disaster.)


I don’t disagree with this but in this case it really isn’t de-skilling. A checklist isn’t a substitute for training or experience. It doesn’t make you good at surgery, and it doesn’t teach you how to do surgery. It is a tool for an expert to make sure that you do the repetitive parts of your job correctly, especially the preparation parts. In the same way, having a checklist to remind you to verify that there is fuel in the plane before takeoff does not take away from the ability to actually fly the plane.

I definitely make checklists for myself for repetitive processes I do at work. Some of them are just lists of rote steps, some of them are more like signoff lists with a series of things to verify before sending something to production.


It’s more thn that. In surgery, I think a major part of the point is that the whole TEAM has done all the parts of their jobs correctly. These are not just ‘ticklists for surgeons’ they are checklists for surgical teams - not least because some members of the team may differ from operation to operation.


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