The case for using checklists …’s good KM

Pilots have been using checklists forever (well since World War II) and surgical teams are now starting to use them routinely.  Why…because they codify good practices.  In the words of the World Health Organization (in the downloadable speakers kit)

Currently, hospitals do MOST of the right things, on MOST patients, MOST of the time.

The Checklist helps us do ALL the right things, on ALL patients, ALL the time

I’d like to make the case that checklists should be a vital part of a KM program… they are one of the simple things that we as KM practitioners/advocates can help develop and implement in organizations that will have a profound impact on business outcomes.  If they are so important to pilots and surgical teams…is there a case to be made for their use in other professions as well?

What do checklists have to do with KM?  Can something as simple as a checklist help apply good practices across an organization? And if they can is there a role for the KM practitioner or advocate to help develop and apply checklists across an organization?

Aren’t checklists kind of like a grocery list…something you use so you don’t forget the simple things…like picking up the milk…or in the case of an airline pilot, putting down the landing gear (or not…if you are going to do a water landing)?

Yeah—that is what they are – they are lists so that you don’t forget the simple things – things that in the case of airline pilots and surgeons save lives.  Or in the case of construction superintends insure that no major steps or critical pieces are missed in a construction project.

It turns out that check lists are vital in a number of professions…helping everyone from the novice to the expert make sure they don’t skip the simple things…that can make a huge difference in the final outcome. But it also turns out that they are not used nearly as often as they could or should be.

Dr Atul Gawande,  a surgeon, associate professor at Harvard and a staff writer for the New Yorker, may have never heard of KM – or be able to define KM – but in his recent book The Checklist Manifesto – how to get things right, he lays out a very effective case for using checklists (and in effect KM) to ensure that what an organization knows is both captured and applied.  But…what he taking about is not the expertise of a neurosurgeon …or the expertise of a pilot of an airliner…but the routine things that if done consistently make a big difference in the outcomes.

In the book Gawande, who is one of best story tellers I have encountered in some time (a good trait for a KM type person), sites numerous statistics and tells great stories that demonstrate the value of using checklists for the simple things – the things that should be done routinely at the start of every procedure – such as making sure you are removing the right (and not the left) kidney (there are between 1500 and 2500 wrong side surgery incidents every year in the US) or the patient has been given the right anesthetic at the right time (giving antibiotics within one hour before incision can cut risk of surgical site infection by 50% – but in eight evaluation sites around the world nearly half the patients did not get the antibiotics timely) or the surgical team is communicating with each other (communication is the root cause of nearly 70% of the events reported to the Joint Commission…an accrediting agency associated with quality care initiatives).

So how can checklists make a difference?

In one hospital where they instituted a check list to reduce the incidence of central line infection, simply introducing (and using) a check list in the ICU reduce the infections  from 11% of the patient population to 0%.

In a World Health Organization (WHO) pilot study a surgery check list was instituted in eight hospitals around the world, four in high income countries (US, Canada, UK, New Zealand) and four in low to middle income countries (Philippines, India, Jordan and Tanzania.; The check list was simple…divided into three parts, before anesthesia, before incision and before patient leaves operating room.  In total only the check list has only 16 questions…and takes only a couple of minutes to complete.

After the study, which involved over 4000 patients, major complications for surgical patients fell by 36 percent and deaths fell 47%.  Without the check list 435 patients (just over 10%) would have been expected to develop serious complications – but just 277 did.  The check list “spared more than 150 people from harm…and 27 from death.”  And then there is the dollars that were saved…

But not only does Gawande look at the value of checklists in the operating room –he also looks at a variety of other professions.  For example….why do pilots…with 10’s of thousands of hours of flight time go through a checklist before every flight?  Why did the copilot on US Airways 1549 (Sullenberger and the Landing on the Hudson) immediately start going through the check list for engine restart, then for a water landing when the pilots realized there was a problem less than 90 seconds after takeoff?  Why do construction superintendents of major projects have massive checklists (also known as master project schedules)?  It is because they make a difference.  It is because they help even the experts make sure they apply good practices that have been learned over time.  And it frees up your mind from thinking about the routine stuff and lets you focus on the more complex….

But what does this have to do with KM?

A checklist is a simple way to codified practices (hopefully a good practices) and make them easily accessible, and if done properly easily usable by others.  Isn’t this one of the fundamental things that we do as KM practitioners – allowing the effective sharing and use of knowledge across an organization.

Near the end of the book Gawande talks about how we are all “plagued by overlooked knowledge (one of the domains of KM practitioners and advocates) and how checklists can help overcome this syndrome.

We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors.  For the most part, we have imagined that little can be done by working harder and harder to catch the problems and clean up after them.  We are not in the habit of thinking the way army pilots did as they looked upon their shiny new Model 299 bomber a machine so complex no one was sure that human beings could fly it. (this was the first multi engine bomber – and it crashed the first time it was flown…the pilots got together and said…okay…it’s complicated…so let’s create a list of the key things we need to do before and during flight.  This was apparently the origin of the pilots check list.)

They to could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot.  Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a check list.

And so can we.  Indeed, against the complexity of the world, we must.  There is no other choice.  When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination.  We know the patters. We see the costs.  It’s time to try something else.

Try a check list.

How to create the check list

But how are checklists actually created?  How many people have the expertise to create an effective checklist?  In the case of Gawande, he clearly has the inclination and the ability to create and help others apply good practices.  I think that if you read some of his writings you will see that in fact he is a very natural practitioner of KM….even though he and his colleagues may not think of it in those terms.  But how many people are like Dr. Gawande?  How many people have the expertise, the time or the inclination to help an organization use and apply the checklist?  Isn’t this a key role for KM practitioners?

In some cases creating a check list is easy…we have a mountain cabin and every time we leave there are a few things we want to make sure we do.  We created a list based on what we routinely did when we left.  At first we created a “winter list” (we really didn’t want the pipes to freeze if the heat went out), but then discovered that we needed a summer list as well.  Ok…that was easy—think about what you actually do and what you should do, write it down and put it someplace easy to find.  Now the last thing we do as we walk out the door is check the list.

In talking to David Allen – well known management consultant and author of Getting Things Done, it turns out that David routinely uses lists (one of his mantras is….you can only remember a few things…so get them out of your head by writing them down…that way you free up your mind to think about the important things).  One example of a list he uses is his packing list for travel. Several people have seen the list and asked if they could have a copy.  When asked how he created such a great list, he said…”every time I forgot to pack something, I just added it to the list…”  So creating checklists can be easy.

But they are not always that easy…

In many cases it’s necessary to do more than have a person or two compose a list.  It’s valuable to say…what do we know about a particular process…or what are the issues we are facing in a particular process.

In the case of the WHO they know that approximately 234 million people are operated on each year, and that over 1 million of these individuals die from complications.  And they know that at least half are avoidable with the checklist.  But as you read Dr Gawande’s story you will see, not surprisingly…it wasn’t possible for one person to sit down and put together a check list – no matter how good they are.  What was happening in US operating rooms was different from what happened in the UK, or in India or in Tanzania.  It took a team coming together…and then piloting both the check list and the procedures for implanting it to come up with something that was effective in hospitals around the world.  And still if you look at the WHO material…you will see the statement “The WHO’s checklist is not intended to be comprehensive, and additions and modifications to fit local practice are encouraged. Click here to see how others have done just this.”

In some organizations you may already have processes that can help you create checklists. For example, when I was at Unocal and then working for an Aerospace company we routinely ran retrospects for projects.  The retrospects were facilitated meetings conducted with a team that had just completed a project or phase of a project.  The intent of the retrospect was to capture advice from the team based on what they had just done.  The retrospects generated great advice that was based on the experience of the team that just did the work.

Initially, we captured this advice in document that summarized the recommendations and discussed what actually happened that generated the advice.  And for the most part the documents sat in a folder – largely unused.  Then we decided to start creating checklists.  The checklists were simple and actionable.  We put the check list on the web…and indexed to make it easy to find.  And…we then linked it back to the more complete document in the event people wanted more information…or wanted to contact the people that had created the document and the check list.

Other organizations such as the Army routinely use AAR’s (After Action Reviews) that may similarly be used as starting points for checklists and for information that can be used to update the checklists.

What makes a good check list?

Gawande talks at length about what makes a good check list.  And we have some experience of our own.

The checklist of what makes a good checklist

  1. Keep it simple…this is not about reminding the neurosurgeon how to do neurosurgery or the pilot how to fly the plane.  It’s about making sure that the fundamentals are taken care of.
  2. Keep it short…if it takes more than a few minutes to complete, people won’t do it
  3. Use events such as After Action Reviews (AAR’s) or retropects to help create the checklist…as well as to periodically update it.
  4. If possible establish metrics to assess the effectiveness of the checklists.  In a hospital…where everything is tracked this is much easier to do than in other organizations,  but it is still worth trying.  If you can’t get metrics, collect stories, as Gawande has done, about the effectiveness of checklists
  5. Finally – it gets used in the organization.  This is a matter of culture – and of sharing the stories about the difference using check lists make.

I’d love to hear stories about how KM people are fostering the use of checklists in their organizations and their practices…what’s working and not working.

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