In any given surgical procedure, the number of steps and procedures that must be followed exactly can be huge. The chances of missing one of those steps or procedures climbs as the complexity increases.

In 2007 and 2008 the World Health Organization tried surgical checklists in eight hospitals worldwide. The results were amazing! Complications from infections dropped by one third and death rates dropped by almost half.

By 2012 the UK had rolled out the checklists to nearly 2,000 of its institutions and that is where the mystery begins. Around the world some hospitals and teams were showing large improvements in decreasing death rates, while other hospitals showed no change. In fact, a Canadian study of more than 200,000 procedures at 101 hospitals found no significant improvement.

Here’s a compilation I’ve made from findings of why checklists in organizations succeed and why they fail. I’m sure you’ll be able to identify the people, attitudes, organizations, and cultures as you read this list. It goes from the most practical to the big picture/cultural. Most of these findings are compiled from World Health Organizations or UK’s National Healthcare System, but a couple are from my own experience.

Create and Customize Your Own Checklists Using Excel

Add logos, notes, reformat to your heart's content. These are your checklists. Make them the way you want.

Create your own custom Excel checklists by downloading this Excel worksheet.

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Going from #6 to #1, here are 6 tips to help you make your organization more successful with checklists.

6. Add Warnings, Cautions, and Notes

Checklists can get awfully boring, especially if you have to run two or three back-to-back. Make sure your teams know which items are CRITICAL.

Do This

Military flight checklists always contain icons next to critical action items. This snaps the crewman back into realizing that this one checklist item could be critical to life or property. There are three levels of icons: Warnings, Cautions, and Notes. If you have critical items on your checklist use icons with BRIGHT colors.

	Information - Helpful Information. Icon free at www.iconfinder.com
	Caution - Damage or data loss if these instructions are not followed. Icon free at www.iconfinder.com
	Warning – Possible severe personal injury, loss of life, or equipment damage if these instructions are not followed. Icon free at www.clipartbest.com.

5. Let Teams “Localize” Checklists

Checklists created by a top-level authority may not consider the differences in equipment, skills, and other local conditions. In one case, a surgical checklist from WHO required the use of antibiotics and materials not available in an African clinic. That dislocation casts a spell of doubt on the whole idea of whether the checklists were of value.

Do This

A top-level authority may develop the core checklist, but teams facing special local conditions should have the ability to add their own best practices. These best practices need to be rolled up to the top-level teams for the next edition.

4. Follow and Complete the Checklist

A review of 7,000 procedures in five National Healthcare System (UK) hospitals found that checklists were used 97% of the time, but were only completed 62% of the time. Observers found that the checklists were considered an afterthought by some team members and in some cases the head surgeons were not even present during checklist use.

Do This

Slow down and have everyone consider why checklists are being used – what is their real purpose. They aren’t there to slow down the process. They aren’t there to sully someone’s expertise. They are there because they improve results and sometimes to save lives. 

3. Get Experts Engaged and Promoting Checklists

Interviews in ten National Healthcare System hospitals found that some surgeons and anesthesiologists actively resisted using checklists. Some surgeons felt it was an affront to their professional expertise. (Nurses who were friends of mine have told me cases where the head surgical nurse had to confront doctors to use the checklist.)

Do This

Military units have a Judge Advocate General who acts as an anonymous independent investigator and senior counsel. They are a proxy for anyone finding issues or errors in orders and protocol. Safety issues, orders violating the Uniform Code of Military Justice, etc., can be brought anonymously to the JAG for investigation. In some cases, a JAG-like position may be needed in organizations where failure to follow a checklist could result in injury or death.

2. Don’t Shove Checklists Down from the Top

Checklists passed down from “On High” have a high failure rate. The people most experienced with the job don’t like being told explicit details by someone who doesn’t have intimate knowledge of the work. No one likes getting ordered to follow a mandate. Teams want to be involved and engaged.

Do This

That rebellious feeling that comes up when being ordered by a “parent” never leaves us, even when we are long past teenagers. Instead of having checklists created and mandated by the “High Command”, executives and management can set objectives and broad guidance, then teams can add their real world experience and details that make the checklist work. When they checklist comes from the team (or their own kind) and not forced on them, teams try harder to make their checklist work.

Also, like software, the first version of a checklist is rarely correct. Put a version number on them and make it easy to gather feedback, review changes, and update.

1. Executives Must Promote the Use of Checklists

Don’t introduce the use of checklists as “just another new thing.” Checklists must become an accepted part of the culture. Senior executives must present the case for using checklists – everyone needs to know that checklists aren’t just another idea picked up while reading a magazine on a cross-country flight.

Do This

Executives should talk about the importance of checklists. There needs to be a local checklist champion for each domain that can localize the checklist (more on that later), gather data, and credit winning teams.