The Communicative Power of The Checklist
Medical mistakes are the eighth leading cause of death, higher than breast cancer, car accidents, and HIV/AIDS combined. Although hospitals cannot completely eliminate medical mistakes, they can develop communication strategies to prevent some mistakes. Atul Gawande offers a simple communication strategy in his latest book, The Checklist Manifesto: How to Get Things Right. His recommendation: the checklist. The checklist is designed to increase and improve communication between physicians, nurses, and patients to prevent errors. The simple act of having a checklist to encourage communication has already had a major impact in medical practice; Gawande reported that deaths and surgical complications dropped 36% when using a checklist.
For several years, communication has been lauded as one of the primary solutions to prevent medical mistakes. But the communicative power of the checklist isn't just for the health industry. Checklists are part of the foundation of aviation and are critical to the success of the airline industry. Pilots are required to learn and use checklists for every aspect of flight, from preparing for take-off to dealing with equipment malfunction. It was a checklist that helped Captain Chelsey “Sully” Sullenberger and co-pilot Jeffery Skiles safely land their US Airways flight in the Hudson River after the plane's engines were damaged by a flock of geese. Construction companies use checklists to ensure that buildings have all the required elements and don't collapse. Teachers provide students with checklists to make sure they have all the required elements of an assignment. Organizations use OSHA checklists to make sure that they have a safe work environment.
Checklists are everywhere and are more than just ways to maintain safety. Checklists communicate a variety of information from work goals and project objectives to people's ability to organize and communicate information. For example, in the recent movie Up in the Air, a young corporate downsizer created an interactive web-based system to lay off workers, complete with a checklist of phrases and information to cover during the downsizing process. This checklist was designed to provide people with all of the information needed to transition out of that position. However, the checklist was not able to account for different responses. What was a corporate downsizer supposed to say if someone threatened to jump off a bridge?
This gets at the crux of using checklists to communicate: Not all checklists are created equal. Just like other forms of communication, checklists can contribute to both failure and success. Developing a successful checklist is more than just putting ideas down on paper. For a checklist to be an effective communication tool, we have to think about a variety of issues: What are the important elements of the task? What could happen? How much time will it take to go through the checklist? How much time will it take to do all of the elements of the checklist? Although these questions seem simple, they require honest and practical reflection. Success is not just the existence of a checklist—we have to make sure that we have communicated goals and objectives clearly in order for the checklist to be a good checklist.
So why are checklists so effective? Why does such a simple communicative tool have such a powerful impact? Gawande argues that society today is extremely complex--so complex that we often have trouble knowing everything that is required in a given situation. Checklists provide us with a tool to negotiate this complexity. The checklist was not the sole reason for Sullenberger's and Skiles' successful water landing; rather, it was a culmination of factors--the checklist, flight experience and knowledge, and ability to work under pressure. All of these elements had to be communicated in a short amount of time. This highlights the power of the checklist: In order to use a checklist, we have to know enough about what we are doing to be able to improvise. Checklists are not hard and fast rules to live by; they are guidelines to help us make sense of the complexity of our lives. An important part of using checklists effectively is recognizing that humans are fallible. One of the underlying reasons for using a checklist is to prevent mistakes, which means that we must admit that mistakes happen. In medicine, this is an especially difficult belief to change because physicians and patients are constantly socialized to believe that physicians are infallible. One reason a checklist may be such a powerful communication tool is becauseit serves as a constant reminders that we do make mistakes and we are willing to try to prevent them.
One of the most powerful elements of the checklist is that it can empower people. Although a checklist may be viewed as a rigid list of rules which must be followed, the ambiguity of situations means that we have to be flexible and creative when using checklists. People have to figure out how to use a checklist to fit their needs, and in some cases, what to do if a checklist doesn't include something. Because checklists cannot include every possibility, we have to be prepared. In some cases, they just provide us with a place to begin. For patients, the checklist can be a way to become more involved in the health care process. A visit to the doctor's office or hospital can be an overwhelming experience and sometimes patients don't know what to ask their physicians. A simple checklist provides patients with a way to ask these questions. Because every patient is different, a checklist is just a way to begin the conversation—patients can adapt a checklist for their needs.
Checklists encourage communication, whether it is between patients and physicians, members of a work team, or between co-workers during a crisis. Although checklists can be powerful communication tools, Gawande points out, “In the end, the checklist is only an aid. If it doesn't aid, it's not right. But if it does, we must be ready to embrace the possibility.” How we use the checklist to communicate is just as important as what the checklist has to say.