Checklists and How You Manage Them


Thinking back to a letter-to-the-editor that I mentioned last week, this is such a critical point, I wanted to think and write about it again, especially since it was in the comments and not everyone sees that.

It's not the checklist itself that's important – what matters is how it is managed.

A checklist, or any form of standardized work, is useless if it is not followed consistently or, in some cases, 100% of the time. Errors might be rare in certain fields, but we don't want to be on that one plane where the pilot fails to go through the pre-flight checklist (because they are feeling rushed or out of arrogance), leading to catastrophic results (such as the Northwest Airlines Flight 255 crash that happened during my childhood in Detroit because the pilots didn't follow a checklist).

As hospitals are adopting checklists (or “standardized work” in the terminology of Lean), I'm sure much effort will be put into the writing of the checklists. Ideally, the checklists will be written by the people who actually do the work, rather than being copied from another site or being handed down from a manager or a single expert. Hopefully, people working in the process will be taught to understand the value of a checklist, rather than just being told to do it.

So if we have a checklist in place, how do we make sure it is followed 100% of the time? Again, creating “buy in” by involving people and selling the idea of the checklist is important. That is leadership's job. It is important for managers to “audit” the use of checklists, but we cannot watch people 100% of the time. Hence, the need to create that buy-in so people will do the right thing, in all circumstances, when not being watched.Leadership must make it clear that ANY team member can call a true “time out” if a surgical procedure, for example, is about to go forward without the checklist being used. Leadership must support and stand by staff members, particularly junior ones, who take what might be a courageous stand against, let's say, a powerful surgeon who doesn't want to do the checklist.

vWhile we don't want to “hound” people constantly, it is important that leaders check frequently to make sure the checklists are being used. We want to avoid a situation like one where a hospital leader, before Lean, explained (somewhat tongue in cheek) that “this process is so critical that nobody ever checks to make sure it's happening.”

As President Ronald Reagan famously said, “trust, but verify.” Leaders, or other designated observers, must check in to see that checklists are being followed (at the time they are supposed to be used), or we must verify the paperwork quickly after the fact to see if the checklists have been followed. Some direct observation is important to make sure that the checklists aren't just a “tick the box” exercise that is done without thinking. We have to make sure the “spirit of the law” is followed, not just the “letter of the law.”

Here is a recent story from the BBC about a hospital that has new rules requiring that physicians not wear long sleeves and that, if they wear ties, they be tucked back. These rules are in place to make it easier for physicians to wash their hands and to help them avoid touching a dirty tie during the day. Again, hopefully these rules were developed with the participation of the physicians and that they were sold on the idea, rather than having it dictated. At least one physician is helping lead the effort, apparently:

Consultant physician Dr Chris Uridge told BBC News: “We roll our sleeves up, take off any rings, bracelets and wrist watches.”If you've got cuffs and watches it inhibits good, effective cleansing – it's as simple as that.”

Good stuff – they are measuring the results (although there are other changes happening in parallel – how do you prove it was this change that reduced infection rates? It seems like it would help, though. It also sounds like they are explaining why, a good Lean practice that is in keeping with the “respect for people” principle.

Now my question for this scenario would be, “who is monitoring or verifying that these practices are being followed?” The reaction of administrative and clinical leaders when they see someone wearing long sleeves that first time will be critical. If they look the other way, then they effectively have no standardized work.Leaders must be strong enough to question people when they are not following standardized work. This doesn't mean they should yell at someone. Especially early on when a new method, it's good to gently reinforce the importance of the new standard, making sure people are aware and they understand why it's important. If you don't hold people accountable, the standardized work becomes discretionary and you'll lose the potential benefits that would come from everyone following the process.

Asking, rather than yelling, is key because there may be certain circumstances when it was best for the patient to NOT follow the standardized work. For example, a truly urgent situation in the emergency department might require swift action, where the risk of stopping to do a time out (time delay) is worse than the risk of a mixup that could occur from not following standardized work.

Even with standardized work, people need to be able to exercise professional judgment. But we have to be careful that someone isn't choosing to not follow standardized work “because I didn't feel like it.” There's a difference between having a legitimate reason or not, as explained in the case of Geisinger Health System and their cardiac surgeons' checklists.So as hospitals implement checklists and time out processes, the same question applies. Who is going to verify and hold people accountable?

Can leaders truly lead and sell people on ideas instead of being dictatorial and mandating?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Excellent thoughts. As “checklists” get rolled out, I’m afraid people will think they are “easy” or a “silver bullet.” We need people to be leaders, implementing stuff like this (*really using it*) isn’t easy, as you point out.

  2. I think something that is also critical with checklists is somehow documenting WHY we are checking this point. Too often, something is started, because of a certain set of conditions in the past. However, years later, you review the checklist to improve it, and see a check which looks redundant or uneccesary, and having a field where you can see the WHY of a check.

  3. Right on target.

    I’ve been doing a bit of research on the use of checklists across industries (think pilots in the cockpit prior to take-off, surgeons preparing for a patient surgery, etc.), and I ran across an article in Fast Company magazine from March, 2008, which mentioned a checklist created by Dr. Peter Pronovost of the Johns Hopkins University School of Medicine.

    Authors Dan and Chip Heath say: “The checklist contained straightforward advice. Doctors should wash their hands before inserting in IV, a patient’s skin should be cleaned with antiseptic at the point of insertion, and so forth. There was no new science and nothing controversial-only the results were suprising.”

    Apparently, after implementing this checklist, Michigan ICUs virtually eliminated line infections, saved $175 million by not having to treat associated complications, and they saved about 1,500 lives (over an 18 month period). So, how did Michigan ICUs (perhaps others, but not noted in the article) get medical staffers to implement and actually use this checklist?

    The Heath brothers address this: “Provonost learned to fight the resistance by appealing to a value they all shared-patient health.”

    In other words, he found common ground, built trust, and reached agreement and consensus as today’s true leaders do. Not by issuing edicts and commands but by expressing and sharing values, and engaging those around them with purpose and confidence.

    The Heaths continue: “He (Pronovost) would bring doctors and nurses together and ask ‘Would you ever intentionally allow a patient’s health to be harmed in your presence?’ They’d say ‘Of course not.’ Then he’d hit them with the punch line: ‘Then how can you see someone not washing their hands and let them get away with it?'”

    So, yes, leaders can, and indeed must, lead without issuing edicts and mandates. Our challenge is to find and develop such leaders in all industries and organizations, and at all levels. It’s not just about Dr. Pronovost, it’s about all the doctors and nurses on every shift around the clock, and their personal leadership in the Gemba.

    Adam Zak

  4. The leadership aspect will become even more important as EMR’s are further developed. The movement now is to build the checklist into the medical record.

    But I have seen several situations where people just blindly click through the checks in the medical record. I think it is important for the healthcare industry to realize that a quality EMR is just as useless as a quality checklist if the leadership is not prepared to hold people to the standard.


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