As you've probably guessed, I've been reading Atul Gawande's The Checklist Manifesto, which is a well-written exposition of the power of simple checklists in driving efficiencies and performance. Atul uses lots of examples from healthcare (he's a general surgeon), aviation, engineering and construction to show how well-crafted checklists can be transformational in their impact.
I particularly liked a story he told about how establishing a new ritual through the introduction of a simple object had helped change behaviour in one children's hospital. Administering a pre-operation anti-biotic to patients can be a critical factor in preventing post-operative infection which can not only be dangerous but seemingly occurs with surprising frequency. It turns out that the precise time before incision that the anti-biotic is given is critical to making it work – too soon and it will have worn off by the time the operation starts, too late and it won't have time to take effect.
Atul tells the story of how in 2005 Columbus Children’s Hospital discovered that, despite it seeming like a simple process, more than one-third of its appendectomy patients failed to get the right antibiotic at the right time:
'How hard could this be? Even people in medicine assume we get this kind of simple task right 100 percent of the time. But in fact we don’t. With all the flurry of things that go on when a patient is wheeled into an operating room, this is exactly the sort of step that can be neglected. The anesthesiologists are the ones who have to provide the antibiotic, but they are concentrating on getting the patient safely and calmly to sleep—and this is no small matter when that patient is a scared eight-year-old lying naked on a cold table in a room full of strangers getting ready to cut into her. Add in an equipment malfunction (“Is that red light supposed to be blinking like that?”), or the patient’s asthma acting up, or a page for the surgeon to call the emergency room, and you begin to see how something as mundane as an antibiotic can slip past. The hospital’s director of surgical administration, who happened to be not only a pediatric cardiac surgeon but also a pilot, decided to take the aviation approach. He designed a preincision “Cleared for Takeoff ” checklist that he put on a whiteboard in each of the operating rooms. It was really simple. There was a check box for the nurse to verbally confirm with the team that they had the correct patient and the correct side of the body planned for surgery—something teams are supposed to verify in any case. And there was a further check box to confirm that the antibiotics were given (or else judged unnecessary, which they can be for some operations). There wasn’t much more to it. But getting teams to stop and use the checklist—to make it their habit—was clearly tricky. A couple of check boxes weren’t going to do much all by themselves. So the surgical director gave some lectures to the nurses, anesthesiologists, and surgeons explaining what this checklist thing was all about. He also did something curious: he designed a little metal tent stenciled with the phrase Cleared for Take off and arranged for it to be placed in the surgical instrument kits. The metal tent was six inches long, just long enough to cover a scalpel, and the nurses were asked to set it over the scalpel when laying out the instruments before a case. This served as a reminder to run the checklist before making the incision. Just as important, it also made clear that the surgeon could not start the operation until the nurse gave the okay and removed the tent, a subtle cultural shift. Even a modest checklist had the effect of distributing power. The surgical director measured the effect on care. After three months, 89 percent of appendicitis patients got the right antibiotic at the right time. After ten months, 100 percent did. The checklist had become habitual—and it had also become clear that team members could hold up an operation until the necessary steps were completed.'
Another great example of the power of habit in changing behaviour.
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