Checklist method ticks all the boxes

Managers in different fields are discovering the merits of implementing checklists, from landing an aircraft on the Hudson river in New York to saving lives in hospitals

AFTER HE landed US Airways flight 1549 on the icy waters of the Hudson, Capt Chesley Sullenberger was lauded as a hero for guiding his 155 passengers and crew to safety. But what about the role of his co-pilot, Jeffrey Skiles, and his checklist?

The events of January 15th in New York might have resulted in casualties were it not also for Skiles’s faithful execution of his emergency engine-failure and water-ditching checklists. Gary Klein, a cognitive psychologist, says such lists are vital to those who make critical decisions under pressure.

“The Hudson river pilots didn’t have a half-hour to decide what to do with the engines. Instead they need a checklist that has been compiled by people who have seen these situations before and considered the ways to respond.”

Lists of repetitive yet critical steps in stressful situations are familiar to airline pilots, firefighters and wedding planners. Now managers in sectors including finance and healthcare are also beginning to be persuaded of the merit of low-tech prompts that require no more than a sheet of A4 and a pencil.

Klein, chief scientist of Applied Research Associates, a software supplier to the US military, says checklists are more than just a memory aid.

“They are a safeguard against interruptions and they help teams co-ordinate. If you can trust everyone on your team or crew to follow the checklist, it makes everyone’s actions predictable.”

Klein's work has many fans, including Blink and The Tipping Pointauthor Malcolm Gladwell. To date though, his most successful adherent is Peter Pronovost, a critical-care researcher at Johns Hopkins University in Baltimore.

Intensive care units in the US put five million intravenous lines into patients each year. After 10 days, 4 per cent of those catheters become infected. Infections are costly to treat and can be fatal.

Why, wondered Pronovost, were infections so common when doctors knew how to prevent them? Having read Sources of Power, Klein’s book on decision-making, he realised that because most doctors are so busy, making hundreds of critical decisions daily, they find it difficult to remember important yet repetitive infection-control procedures.

He took one set of guidelines and extracted the half-dozen strongest interventions that were the easiest to implement. Then he reworded them from vague, conditional statements into a checklist – six simple steps that included “wash hands” and “put sterile dressing over the catheter site once the line is in”.

However, Pronovost guessed the checklist on its own would not be enough, so he asked the nurses in Johns Hopkins Hospital to observe doctors’ actions after the checklists were posted. If doctors missed a step, nurses were instructed to remind them.

“Checklists clarify and make explicit what the expectations are, but you also need to create a culture that allows and encourages cross-checking.” Pronovost prescribes different types of checklists according to the nature and risk-profile of the task (see panel). The most basic is a series of read-and-do actions completed by just one person.

For more risky or critical tasks, though, he says a checklist should be constructed along “challenge and response” lines, with a second person verifying that each item has been completed. And for team-based tasks, one person can read out the items, with each responsible team member verifying completion of their specific task.

After two years, his checklist was judged to have prevented 43 infections and eight deaths at Johns Hopkins. Within the first three months of rolling out Pronovost’s checklist across the state of Michigan, the infection rate in more than 100 intensive care units had decreased by two-thirds.

Last summer Pronovost received a call from an unexpected source. Tom Kalaris, chief executive of Barclays Wealth, had read of his successes in the New Yorker and wanted to know if checklists could be applied to investment management. “We strive to make each of our processes as foolproof as we can,” says Kalaris. “When I read about the checklist applied in hospitals and cockpits, I saw an instant applicability.”

Since inviting Pronovost to London to present his ideas to 150 senior executives and managers, Kalaris says checklists have been deployed in several areas, including payments and credit operations. Opening a new account at Barclays Wealth, for example, now takes just 24 hours – instead of, previously, five days.

“The checklists are helping us make significantly fewer errors and eliminate duplications, yet conceptually they’re so simple and not difficult to implement,” says Kalaris.

Investors can already buy Warren Buffett, Peter Lynch or John Templeton investment strategy checklists. In the light of the subprime meltdown, though, Pronovost believes checklists could have helped to prevent lenders and borrowers taking unnecessary risks.

Some argue such claims are overblown. Andrew Clare, professor of asset management at Cass Business School in London, says: “Banks certainly have page upon page of complex procedures to follow, but would a simple checklist have stopped them lending to an 18-year-old who had been in work for only two months? I don’t think so.”

At Barclays Wealth, Kalaris believes checklisting has some role to play in risk management. “It’s fanciful to say one thing could have stopped the whole industry from making a mistake,” he says, “but a checklist gives you the fact-based power, wherever you are along the assembly line, to say ‘this isn’t right’ and to hit the stop button.”

Proper order: how to create a list

The science of developing checklists is immature, admits Peter Pronovost. “But in essence, standardise what you need to do, create a checklist and then, when things go wrong, learn from them.”

Seek out relevant guidelines or an evidence summary – if one does not exist, tap into the ”wisdom of crowds” by canvassing views from diverse sources.

Compile a list of potential actions.

Select those with the strongest impact and the lowest barriers to use.

Translate each action into an explicit, concise and unambiguous behaviour.

Use simple, direct and unambiguous language.

Insert a “challenge and response” if a second person needs to verify that each item has been completed.

Keep it short – if necessary, separate the process into sub-steps and create a checklist for each one.

Review it often – checklists must be dynamic and evolve in light of new evidence.