Surgery Checklists – how a factory taught a surgeon how to save lives

Surgery Checklists – how a factory taught a surgeon how to save lives It wasn’t so long ago when a new mantra came to dominate the manufacturing industry across the globe. At the time, Total Quality Management (TQM) was viewed as a way to improve the productivity of a process, by involving everyone in the value chain to pay close attention to each detail. TQM recognized the balance between each link in the chain being a potential risk to achieving the desired quality, but that also the resulting TQM culture inspired a positive step-change in consistency that consumer brands could leverage to drive customer confidence and loyalty.

The same concepts, when applied to healthcare, can achieve similar results, as proved by the work of Dr. Atul Gawande, surgeon at Brigham and Women's Hospital and author of ‘The Checklist Manifesto’.

Gawande was all too aware that, with the complexity of modern surgery and as many as 4000 medical procedures being conducted annually, the sheer volume of knowledge required is huge – too much for an individual and so usually delivered by surgery teams.

And by their nature, such surgery procedures often throw up unpredictable events, adding risk to the operating theatre and the patient outcome. So, to try and manage such risk, Gawande sought out an industry whose whole existence depended on dealing with such occurrences.

He went to the Boeing aircraft factory, where they operate over 100 checklists a year to help pilots handle unpredictable situations whilst flying. They focus on ‘critical killer items’ and create lists to help prevent them from happening.Inspired, Gawande started creating similar checklists for surgeons, based on this thinking, including basic things like “introduce everyone in the theatre to each other by name before incision is made” and “make sure an antibiotic is given, and that blood is available”

He also added team communication checklists such as describing to everyone in advance “the objective of the surgery” and “the expected blood loss for the procedure”. He called it “a recipe for making a group of people think ahead, and only afterwards, proceeding.”

Gawande believed such team lists were essential, as today’s operating theatre typically has at least half a dozen people in the room, from biotech to anesthesia. Yet, most patients (and their families) are largely unaware of the human complexity of the operating room, the roles involved, and the people issues that are key to successful patient outcomes.


The results of Gawande’s checklists speak for themselves – after implementing in eight hospitals, surgery complications were cut by 36 per cent and deaths by nearly 50 per cent. (Source: HBR, Jan 2010)

Such checklists are not about a ‘tick box mentality’. In healthcare, as in manufacturing, these simple actions can help isolate risk, improve consistency, and remove error. And at a cultural level, checklists encourage respect and communication for who is the specialist (not always the leader or most senior) and how broader goals and objectives can be distributed for all team members to act upon successfully.

If Gawande’s application of checklists can be successful in the operating theatre, there seems little reason why similar achievements could not be realised in hospital wards, outpatient clinics and even care homes.

Inspired? So how could you or your business use checklists to drive consistency, quality, risk reduction and a focus of what really counts?

If you’d like to give check-listing a try, this pdf download provides a template for creation, developed by Gawande himself, along with Dan Boorman of Boeing.


Further links:

To hear Gawande describe some of the insights above, follow this link to an interview on the HBR website

Boeing also published a document last year on this issue.