Using Checklists to Reduce Process Variation and Improve Results

By John Hunter, author of the Curious Cat Management Improvement Blog.

image of the book cover for Checklist Manifesto

The Checklist Manifesto by Atul Gawande is a wonderful book about how to create systems that work.

At the core the Checklist Manifesto is about determining the critical process conditions and creating a system to assure that the those process items are properly handled.

In the book Atul Gawande paraphrases Daniel Boorman, veteran pilot who spent two decades developing checklists and flight deck controls for Boeing:

Good checklists… are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything – a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps – the ones that even highly skilled professionals using them could miss. Good checklists are, above all, practical.

Boorman stated when checklists are made by “desk jockeys with no awareness of the situations in which they are to be deployed. It is critical that checklists be developed at the gemba (where the real work is done) and that they are modified based on experience. A good checklist system integrates continual improvement to adjust checklists based on user experience.

As Atul Gawande states in the book, making a check on a piece of paper isn’t the important part (they even decided to skip doing it when that interfered with the process of work in a surgery environment). What matters is enforcing discipline to assure that the procedures deemed critical to success are followed.

The book also discusses the difficulty of successfully changing behavior. That is true even when that change to how things are done has documented evidence of success (it is usually easy to find excuses why that evidence doesn’t apply if you don’t want to change). Adopting a checklist manifesto is about creating a cultural change that prioritizes effectiveness and discipline.

That cultural change is most often the difficult part to achieve. People just don’t use the checklists that are made available. If that happens in your organization look at whether the checklists are useful (maybe they are poorly implemented and that will hinder adoption). So we (those familiar with Deming principles) know what to do. Pilot on a small scale (and piloting means operating at the gemba), iterate, gather evidence, iterate some more, learn until we are convinced we are ready deploy more broadly (or abandon the attempt). In other words turn the PDSA cycle on the checklist.

A checklist is a form of the mistake-proofing concept, but since they don’t definitely prevent errors I like term mistake-making-more-difficult (though that term hasn’t seem to catch on with others). The core of checklists is to improve processes in order to achieve more reliable and effective results (and reduce errors). One of the ways they do this is by reducing variation. Another, if they are done properly, is to require study of the process to determine the critical items in a process and how those items should be addressed. Checklists also assure that changes (for those items that make it to the checklist, remember only the most critical will) are made explicit to everyone via an updated checklist (though the process to make sure that updated checklist is used everywhere is important and something that is not always done well).

Related: The Checklist (New Yorker article by Atul Gawande)Effective Communication is ExplicitA Lifesaving ChecklistPoor Results Should be Addressed by Improving the System Not Blaming Individuals

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