The Checklist Itself Doesn’t Matter

“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence.…We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” – Chapter 8.

I just finished reading Atul Gawande’s The Checklist Manifesto, which was first published in 2009 and spent some well-deserved time on the New York Times Bestseller List. Written by an attending general surgeon at Brigham & Women’s Hospital in Boston, this book tells the admittedly “unsexy” story of how a simple tool such as a checklist can improve the quality and consistency of outcomes in a wide range of fields: aviation, building construction, venture capital, and (even) medicine. All of these fields are complex systems – involving many moving pieces and players, and an inherent unpredictability of conditions, materials, personnel, and complications. In addition, these arenas assume a certain level of skill and require a high standard of consistency and safety, but errors and complications still plague us. We have reached a point in many fields where the problem isn’t ignorance (we do understand a lot about the world around us) but rather ineptitude (we fail to apply the knowledge that we have consistently and correctly). A checklist can help us improve our “eptitude.”

A significant portion of the book focuses on exploring the rationale behind checklists, theories about why they work, and best practices on implementing (and refining) them in an intended system. At the most fundamental level, the checklist should:

1. be clear and concise, not wordy, comprehensive, or longer than a page;
2. be actionable, not directed at factors that resist influence;
3. address a critical safety step, not every step, just the ones that are important but commonly overlooked or are uncommon but catastrophic;
4. fit the flow of work at natural pause points, not be a hindrance to work but a complement; and
5. help improve teamwork and communication, not simply be a checklist for record-keeping or for one person to perform in isolation.

This last point is especially important, so I’ll say it again:

Checklists are not for recordkeeping. They are intentionally not comprehensive. They are just as much for addressing critical safety steps as they are for improving teamwork and communication. They create a culture where each team member has clarified his/her role and where all team members agree on the end goal and the plan to get there.

Indeed, almost all of the best examples of successful checklists in the book contain an element of getting the right people in the same room at the same time, talking. When an operating room team gets together in the pre-operative “Time Out,” it’s a moment for each member of the team to discuss issues that could affect the health and wellbeing of the patient in front of them. In construction, when the ventilation blueprints and the electrical wiring blueprints don’t match up, the relevant contractors must agree on a new course of action – and must have other affected construction specialists sign off on the blueprint change, too. When both engines fail on an airplane, a pilot, co-pilot, and flight crew who have never before worked together can come together emergency-land a plane on the Hudson River.

I believe that the principles of checklists can be applied even in the health promotion space. Recently, the Vitality Institute convened a working group comprised of representatives from both public and private organizations to determine how best to “make health measureable” for organizations seeking to promote the health of their employees. If our goal is to improve the health of the population by minimizing risk factors and reducing rates of chronic disease, then we should have a way of measuring this work and evaluating progress towards that goal. The selected metrics should be material (i.e., valid for the health condition being measured), measurable (i.e., have well-defined, objective criteria for assessment), and understandable (i.e., simple for non-health professionals to use).

I suggest that to enhance this task, we should take a page from Atul Gawande’s playbook. There are many examples of health metric tools in public use (e.g., HERO Scorecard, Business in the Community Public Reporting Framework, CDC Worksite Health Scorecard), but they fail to satisfy the principles of the Checklist Manifesto. They are relatively long, questionably actionable, address the gamut of problems (not just the critical links), and are largely seen as a hindrance to workflows (e.g., an extra form to fill out).

Instead, I propose that we pay attention to the lessons of the Checklist Manifesto, especially item #5. The best surface measures of an organization’s commitment to health promotion will be few, actionable, measurable, and will belie a strong commitment to the health of the employees. Indeed, there is likely a set of metrics that represent (and require) a baseline level of coordination, team input, and training.

I believe that we can find metrics that can indicate this level of organizational sophistication, if you will. These will indicate organizations that have focused on improving communication amongst members and leadership and that have streamlined health workflows and other processes. Again, it’s not about the metrics checklist in itself – it’s about what the metrics represent: a coordinated, functioning, living, and thriving healthy organization.

This is not an idle goal – organizations that are known to have a strong focus on the health of their employees and well-established health promotion programs consistently outperform the market and improve their bottom line through reduced healthcare expenditures and absenteeism. By identifying ways that organizations can measure and improve their health promotion initiatives, we can ensure that the lives of all Americans continue to improve.

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