Checklists

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PS1 is exploring the idea of using checklists to encourage the safe use and proper care of tools in the workspace.

Elements of good checklist design

Have a clear purpose. Know what the checklist is for, so that you can prioritize items when deciding what to cut. Give the checklist a simple title that reflects its purpose.

Focus on the critical few. Checklists should include steps that are both easy to miss and have real consequences if missed. If you have included a step that is one but not the other, consider whether it belongs. Prioritize based on the severity and likelihood of a bad outcome.

Keep it short. Conventional wisdom is that checklists should contain between five and nine items, take no more than 60 seconds to run through, and fit on a single page. These are guidelines, not rigid rules. Some checklists can be longer, but many should be even shorter. Unwieldy checklists won't be used.

Use simple and exact language. Test the language of a checklist by reading it out loud.

Make it easy to read. Avoid clutter and unnecessary colors. Use mixed case. Use a sans serif type face and large font size. Use dark letters on a light background. Include a clear title.

Test, iterate, and review. Involve actual users of the checklist. If possible, have them participate in its creation. Perform a trial run and observe the process. Note any ambiguity or problems and refine. Include the date of creation on a checklist and set up a process to update over time based on feedback.

Identify the pause point. People refer to checklists at a natural break in activity, such as when starting a task, after completing a task, or when new circumstances arise. Understand the pause point when the checklist will be used. Usually this will be before using a tool, but it could be, for example, after performing an initial set-up.

Understand the type of checklist you are creating. A DO-CONFIRM checklists is one where individuals or teams come together to confirm that a set of critical steps have been completed. A READ-DO checklist is more like a recipe; people check off tasks as they go. Pick the type that makes the most sense for a given situation.

When appropriate, foster communication. If more than one person is involved in a process, a checklist might require team members to confirm their mutual understanding of the situation. This is often more important than any other process point.

Name the owner. Determine who is responsible for checking off items. If there is only one person involved, this is obvious. But if a team is involved, make sure to identify an individual who owns the checklist and ensures that it is completed.

The Checklist Manifesto

The Checklist Manifesto is a book by Atul Gawande that advocates for using simple checklists to reduce error rates and improve outcomes in complex domains such as healthcare, finance, aviation, and construction.

Complexity as a source error

There are two sources of error: ignorance (lack of knowledge) and ineptitude (failure to apply knowledge correctly). We often judge errors of ineptitude more harshly than errors of ignorance, but perhaps we shouldn't. As we come to understand more about our world, errors are increasingly due to the overwhelming complexity we face. Attention and memory are bounded. As expertise grows increasingly specialized, even experts have trouble staying on top of everything they need to know, and communication becomes both more important and more difficult.

Checklists as a possible remedy

Checklists have a long and successful track record as a tool for managing complexity. The first test flight of the B-17 "Flying Fortress" was expected to be a triumph. The flight crashed. Most on board were killed, and Boeing nearly went bankrupt. The machine marked a turning point in aviation, when planes finally became too complex to be easily mastered by a single person. But some dedicated pilots tamed the complexity with a simple tool -- a checklist -- and the B-17 went on to become a key to the American victory in World War II. Just as importantly, checklists became a fundamental tool in aviation, which relies on them to an astonishing degree to handle an incredible range of scenarios, both routine and exceptional.

Checklists show up in various guises in other complex domains. Years ago, large construction projects were managed by a single Master Builder. But Notre Dame didn't have air conditioning and plumbing and elevators. Now large construction projects tightly choreograph the work of hundreds using an enormous set of detailed checklists, which help to make sure critical tasks are accomplished on schedule. Checklist also perform another key function: they enforce communication between all parties. Problems can't be predicted in advance, but checklists help to make sure that issues are surfaced and resolved.

The proper role of checklists

It is natural to view checklists as a tool of centralization and control. After all, they prescribe a rigid, uniform process. But good checklists can actually facilitate autonomy and empowerment. Particularly in fluid situations or crises, it often makes sense to push decision-making down the hierarchy to the people best able to react quickly to changing conditions. At the same time, some degree of coordination and dissemination of knowledge helps to make everyone's efforts more effective. Instead of enforcing process, checklists can be used to enforce communication and knowledge-sharing in otherwise chaotic situations.

Good checklists don't attempt to replace human decision-making, but rather support it by automating critical but rote tasks, allowing people to focus on the areas where expertise plays a more important role. The value of checklists has been demonstrated even in complex domains such as finance and surgery where judgment is most crucial.

Checklists are not a substitute for expertise. They work best as aids to memory, augmenting human judgment rather than replacing it. Happily, this means checklists do not have to be detailed recipes to be effective. The emergency checklist for engine failure in a single-engine airplane, for example, has only six steps, and the first one is, "Fly the airplane." In the initial panic over a lost engine, pilots often run into trouble because they neglect the basic elements of aviation. This three-word reminder doesn't tell them how to fly the airplane, it simply focuses their attention on the most important matter at hand. Likewise, your checklists don't need to hold the user's hand. They just need to make sure the critical steps remain top of mind.

References