In 1935, Boeing’s Model 299 test plane took off to show off its grandeur as the “flying fortress” for the US Army Air Corps. It was quite impressive with a hundred-and-three-foot wingspan and four engines rather than the usual two. The plane took off smoothly and climbed sharply up to 300 feet, then crashed in a sudden explosion. Two of the five crew members died, including the pilot.
An investigation revealed that the cause of the accident was not a mechanical problem but a pilot error as the pilot did not release the new locking system on the rudder controls. However, what was surprising was that the pilot was Major Ployer P. Hill, the chief of flight testing and the very best of the best at the time. The army pilots could have opted for more intensive training but it was hard to find anyone with more expertise and experience than Major Ployer P. Hill. Instead, they created a pilot’s checklist with step by step checkpoints for the different phases of the flight. With the checklist in use, the Model 299, later named B-17 flew a total of 1.8 million miles without one accident.
We live in a complex environment, a system comprised of intersection of people, technology, and organized structures. We depend on these systems and we are obsessed with having the best components in the system without considering how they work together. We respond and adapt to the constant status changes of the multiple components such as the change of patient status in healthcare, a new parameter in the laboratory, or a change of direction for a group project.
Moreover, we conduct most of our work as a team striving for the best outcome. Donald Berwick stated that every system is perfectly designed to achieve the results it gets. Then, how do we improve when expertise is not enough? Atul Gawande, an endocrine surgeon at the Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School, states in his book, “The Checklist Manifesto” that the volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver safe, consistent, correct care and promotes the use of checklists to overcome our fallibility.
Checklists are used in healthcare as independent checks for a standardized processes. In 2001, Peter Pronovost, a critical care specialist at Johns Hopkins Hospital designed a checklist to prevent central line infections in the intensive care unit. After a year of using the checklist, the ten-day line infection rate went from 11 percent to 0 percent.
The remarkable finding has been published widely and the checklist has been tested in other hospitals as well. Other checklists were implemented and all have been found to establish a higher standard of baseline performance. The WHO Surgical Safety Checklist has been adopted in more than 20 countries and has been named as the biggest clinical invention in 30 years.
Through the use of checklists, not only do we accomplish what needs to be done but the safety culture of the organization is also promoted as teamwork and a checklist becomes something more than the simple act of ticking off boxes. If you need to boost your team’s performance, then check off incorporating checklists today.
Professor Cho Su-jin is a professor of the Department of Pediatrics in Ewha Womans University School of Medicine. She received her Ph.D. in Ewha Womans University.