The Power of the Checklist

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Of all the Lean tools in use throughout industry and health care, procedural checklists have received perhaps the least media attention prior to Atul Gawande’s feature article in The New Yorker on December 10, 2007. Gawande, a respected physician and author, spotlights the remarkable power of checklists to improve the reliability and consistency of medical procedures, and to deliver much improved patient outcomes at lower cost.

For all its technological advances, modern medicine still requires physicians, nurses and technicians to keep track of an ever-growing list of critical tasks and steps. There is so much going on in a surgical suite or intensive care unit (ICU) that it becomes risky to rely on human attention and memory, no matter how well-trained the team members. Gawande’s article focuses on the dangers of infection from contaminated lines for life support and medication. ICUs nationwide put five million lines into patients a year, and four percent of them become infected, causing complications, excess cost, and in some cases, unnecessary mortality. How can such a mundane and routine procedure go wrong, when everyone knows how to do it correctly?

The challenge is not so much in defining the process as in executing it perfectly in the high-stakes surgical setting. Gawande recalls the story of the prototype B-17 bomber’s first test flight in 1935, which crashed with the Army Air Corps’ finest test pilot at the controls. Why? The conclusion was simple: “Too much airplane for one man to fly.” With the program in jeopardy, engineers wrote detailed checklists for the flight crew, and the plane went on to fly 1.8 million miles without another incident. By the end of World War II almost thirteen thousand B-17 Liberators had flown successfully, and checklists have been universally used in aviation since.

Gawande then describes the work of Dr. Peter Pronovost in addressing the problem of line infections. After establishing the best procedures with his ICU team, Pronovost asked nurses to observe a month’s work, and found that for more than a third of patients, at least one crucial step was missed. Next, with nurses authorized to intervene and enforce the checklist procedures, Pronovost tracked a whole year’s outcomes. The number of new infections dropped to just two, and the team calculated that forty-three infections and two deaths had been prevented in the one hospital, along with $2 million in costs. A further benefit emerged: the checklist as a neutral authority allowed all ICU team members – physicians, nurses and techs – to speak up promptly and freely when something was amiss, taking personal dynamics out of the mix.

Pronovost later went on to implement checklist projects in the state of Michigan, with noteworthy success. More recently, an article in The New England Journal of Medicine reports results of a major study in eight diverse hospitals worldwide, concluding that checklists in surgical suites reduced deaths by 45% and serious complications by 35%. Despite increasing attention to the effectiveness of checklists in Health Care, the rate of adoption in the United States has been noticeably slow. Gawande implies that in the technology-driven world of medicine, checklists simply may not have the glamour and appeal of a new and expensive drug or instrument. He goes on to quote Pronovost: “The fundamental problem with the quality of American medicine is that we’ve failed to view the delivery of health care as a science.”

That comment of Pronovost’s takes us right to the heart of the Lean philosophy: to define, and optimize, the delivery or execution of value-adding activities. All the heroics of a brilliant surgeon are wasted if a contaminated instrument sneaks onto the operating tray.

Creating effective checklists for any process is a challenging task, but one which generally provides unexpected benefits, whatever the industry. The team or task force must think through and agree upon on the one best way to accomplish each step in the process, defining quality check points along the way. There is always plenty of expertise in the room; this process gets it out on the table, refines it, and makes it visible for everyone.

Perhaps like highly-trained physicians, some manufacturing and engineering experts are reluctant to see their high artisanry “reduced” to the level of a checklist. What they find, however, is that with the basics now managed so reliably, they can confidently turn their skills, judgment and insight to the higher-level and creative work which truly adds value. This is where the Lean Management philosophy really begins to pay the big dividends.


“The Checklist: If Something So Simple Can Transform Intensive Care, What Else Can It Do?”, Atul Gawande, The New Yorker, December 10, 2007.

“A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” Haynes, Alex B., M.D.,, The New England Journal of Medicine, January 29, 2009. 

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