The Power of a Checklist: How to Stay Disciplined and Avoid Stupid Mistakes

In today’s world, we have more information and knowledge than ever before. Most of it is readily available and easy to access – all it takes is a quick search on Google or Wikipedia and you can pull up a fact about nearly anything.

Yet with this burst of knowledge has also come increasing complexity and confusion. We know more than ever before, but we don’t always know how to apply it and how to make the most of it. We have trouble putting this knowledge into action – making sure that it is useful and practical.

In many ways, the information age has made us a lot less practical and less wise with the knowledge we know. We know so much now that we get easily distracted, we lose sight of the basics, we miss the essentials, and we make mistakes when we know we know better.

According to Atul Gawande, a surgeon and public health researcher (who explores how to maximize our use of knowledge in his book The Checklist Manifesto: How to Get Things Right):

“Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult to not be infuriated.”

Mistakes when “we know better” are often more painful than mistakes we make when we have to make a guess and just try our best. These mistakes are super important to avoid for a person like Atul Gawande, because as a surgeon a simple mistake could make the difference between life or death.

How do we not get lost in this ocean of information? How do we make the best of the knowledge we have, while still leaving room for the unexpected? According to Dr. Gawande, the power can be found by making a simple checklist.

In a huge public research project funded by the World Health Organization, Dr. Gawande tested the effects of a simple checklist on reducing central line infection rates during surgery.

The project was tried out in 8 different hospitals from different countries with different sizes and budgets to see if the checklist helped reduce infection rates regardless of what type of hospital it was (including rich or poor).

The checklist was incredibly small and simple, it included commonsense steps like “1) Wash your hands with soap, 2) Clean patient’s skin with chlorhexidine antiseptic, 3) Put sterile drapes over the entire patient, 4) Wear a mask, hat, sterile gown, and gloves, and 5) Put a sterile dressing over the insertion site once the line is in.”

All of the steps were no-brainers that have been taught in schools and training classes for years. Yet when one of these simple steps is accidentally passed over, it can lead to severe increases in infection rates, additional hospital care and financial costs, and – in a worst case scenario – death for the patient.

Surprisingly, once the checklist was implemented, all hospitals showed a significant reduction in infection rates. The results of the study were published in the New England Journal of Medicine:

“In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. Most ICUs – including the ones at Sinai-Grace Hospital – cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now – all because of a stupid little checklist.”

Of course the potential power of the checklist isn’t exclusive to doctors and medicine. Atul Gawande describes other popular examples among pilots, chefs, architects, and investors.

According to Gawande, the first industry to really harness the power of the checklist was aviation. Once the B-17 Flying Fortress (a 4 engine heavy bomber aircraft for the U.S. military) was designed in the 1930s, it showed that flying an airplane from raw memorization and skill was becoming too complicated.

Once the prototype crashed, a “preflight checklist” was implemented to help pilots during take-off and ensure no basics were overlooked.

Today the aviation industry is filled with different checklists to aid pilots, co-pilots, and flight attendants. Many of these are “routine checklists” that are carried out on every flight, but there are also countless “emergency checklists” in the case of unexpected circumstances (like an engine going out or a warning light blinking).

We often think of a checklist as insulting to our intelligence, but the main purpose of the checklist is to help professionals stay disciplined in their work, follow protocol thoroughly, and avoid simple mistakes when they should know better (because we all make stupid mistakes sometimes).

The Simple Power of Checklists

Here are the key reasons why checklists can be an important tool for cultivating discipline and professionalism:

• Checklists make sure you don’t overlook the basics. – In the book, Dr. Gawande describes checklists as a type of “cognitive net” that protects us from our mental flaws (our limitations in memory and attention). Checklists ensure that we don’t miss the basics, especially when we’re feeling a bit tired or lazy.
• Checklists free up your mental resources for the hard stuff. – Once you have the basics out of the way, this frees up your mind to actually think about the tough choices, including times when something unexpected or unplanned comes up and being focused is particularly important.
• Checklists keep you disciplined and on track. – Checklists encourage routine and following protocol. When we get super familiar with something, it’s easy to do it half-heartedly and slip up. It’s when we become too comfortable in what we know that a checklist can sometimes be most useful.
• Checklists save you time. – Since the basics are in front of you, you don’t have to mentally run through them and this can save you critical amounts of time. This is especially important in a time-sensitive situation like emergency surgery or landing an airplane.

While checklists aren’t necessarily the most sexy or exciting thing in the world, they can be very valuable tool in reducing “stupid mistakes” and raising our overall standards in whatever work we are doing.

How to Create Your Own Checklists

There is such a thing as a “good checklist” vs. a “bad checklist.” Here are healthy tips and suggestions on how to create and improve your own checklists:

• Focus only on the absolute essentials – The goal of a good checklist is to convey the essentials without going into too many details. Checklists aren’t designed to be “how to” guides, they are essential reminders. A good checklist only needs to be 5-10 items.
• Keep it simple and practical – Use language that is easy to understand and precise. If your checklist takes extra time to read or understand, then it’s not serving it’s proper function. Checklists are designed to make things easier and efficient.
• Define your “pause points” – An important question to ask yourself is, “When should this checklist be used?” “Pause points” are a specific time when you (or a team) need to stop to run through a set of checks before proceeding to the next step (this is similar to the concept of mindful nudges).
• Decide whether it’s a “Do-Confirm” or “Read-Do” list. – A “Do-Confirm” list is checking something you already did (like a preflight checklist a pilot runs through before they can take off). A “Read-Do” list is when you do the items as you go along (like cooking a recipe, you follow as you go step by step).
• Be willing to revise and update when necessary. – Once you create your checklist, don’t hesitate to go back and change things in the future. Often you need to experiment with a checklist before you start getting ideas on how to improve it.

This last step is probably one of the most important to remember. Your checklist doesn’t have to be “set in stone” – it should be susceptible to changes and experimentation. Even in Atul Gawande’s research project, hospitals were often encouraged to change their prescribed checklists to fit their specific needs and preferences.

The “No Brown M&M’s” Clause

One of the most interesting stories shared in The Checklist Manifesto is about Van Halen and their lead singer David Lee Roth.

At their prime, Van Halen was known for being a big arena rock band which included an intricate live show with lots of technical gear and specific instructions to follow. Touring from state to state, bands usually have a “rider” to let stadium personnel know how to set up their live equipment. It essentially functions as a checklist.

David Lee Roth would include one weird “step” within this checklist where he’d ask for a bowl of M&M’s in his dressing room; however, he wanted all the brown M&M’s removed. He explains his reasoning below:

“So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. ‘When I would walk backstage, if I saw a brown M&M in that bowl,’ he wrote, ‘well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error…guaranteed you’d run into a problem.’ These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.”

Asking for no brown M&M’s may seem like a super trivial and painstaking detail to follow, but the test was important to David Lee Roth because, if followed successfully, it shows that the stadium personnel are serious about their job and getting the details right.

As you can see, in many situations checklists can be used to encourage a high level of professionalism and discipline. How often do you use checklists in your own life? How well do they serve you?

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