Two unique sources demonstrated a strong link between the use of a project checklist and effective team building in January 2009: the US Airways incident in New York and the release of a study on medical checklists. The January 2009 Special Article of the New England Journal of Medicine highlights the surprising results of a medical study involving the use of checklists. Research physicians proposed that since approximately half of all surgical complications are avoidable and that there is a strong body of evidence linking effective team building to improved outcomes, a project checklist may help decrease medical errors and improve patient safety.
The researchers did not anticipate as dramatic an impact as was demonstrated in their research. During the course of the study, death rates dropped from 1.5% to 0.8%, and serious complications fell from 11% to 7% – a 47% and 37% improvement, respectively. The project checklist is only now being recognized as a powerful tool in healthcare while they have long been in use in the military – particularly in military aviation, where the tools and techniques developed in this low tolerance for error environment have highlighted the value of the project checklist in performance improvement as well as in effective team building initiatives.
‘Plan-Brief-Execute-Debrief’ Encourages Effective Team Building
Brigadier General Charles “Chaz” Campbell, now retired, spent a considerable portion of his career in the U.S. Air Force in the cockpit of a frontline fighter aircraft. During his career, he logged over 3,700 hours in high-performance jet fighters. And in all those flights, Chaz flew without an essential piece of gear for any pilot just twice – his flight checklist. “Those two times I forgot my checklists,” says Chaz, “I was a nervous wreck even though I knew by heart every step represented in the checklist. Despite that knowledge, the distraction resulted in significantly reduced performance.” Chaz continued, stating that “the medical community is one of the few professions that has recently adopted standard procedures. They have now condensed those procedures into checklists much like military aviation. Most organizations don’t invest the time to develop standards and project checklist initiatives and suffer from the lack of execution discipline that results.”
In addition to demonstrating the value of a project checklist, the study also reinforced the links among project checklists, such as briefing and debriefing, that play a part in effective team building strategies. “To implement the checklist,” reports the study, “all sites had to introduce a formal pause in care during surgery for preoperative team introductions and briefings and postoperative debriefings – effective team building practices that have previously been shown to be associated with improved safety processes and attitudes and with the rate of complications and death reduced by as much as 80%.” Proper briefing and debriefing to encourage collaborative and effective team building, as evidenced in the Plan-Brief-Execute-Debrief cycle, are critical processes in successful military aviation missions, as is the project checklist.
“The act of opening a project checklist,” says Chaz, “speaks to the individual and the team, sending the message that there is a deliberate intent to be disciplined. This intent is often a self-encouraging step that results in improved performance. This occurs in addition to eliminating the obvious errors of omission for which the project checklist is designed.”
The Role of a Checklist and Effective Team Building in the Medical Industry
The Joint Commission and other patient safety groups have been incorporating tools that military pilots use not only to reduce errors, but to improve OR and ER team performance during surgery. The U.S. Air Force learned firsthand in the 50s and 60s that as pilots transitioned to much faster jets from propeller-driven aircraft without proper planning, briefing, and debriefing procedures, more pilots were dying in training than in combat. Even in the super-high-reliability of modern day aviation, we can see, for example, the US Airways accident in the Hudson River and the importance of checklists and good standard operating procedures. Captain Sullenburger would likely say that in his training and preflight briefings, emergencies, just like the one he encountered, had been planned, briefed, and previously executed in his simulator training and visualized in his head many times before. Think of the impact these simple principals would have in business, or as we are now seeing, in saving lives in our hospitals.
Checklists have long been a tool in military and commercial pilots’ professional bag-of-tricks to foster both effective team building and personal reliance. “When you step into the cockpit of an F-16, there’s only one seat,” says Chaz, “and when you realize that it’s all up to you to make the right decisions, that there’s no one else to lean on when something goes wrong, a checklist provides a powerful sense of security and allows you to focus on the mission.” The project checklist is becoming widely recognized as a powerful tool in many different professions. Some of the principle benefits are obvious. A checklist helps make sure that you perform all the critical steps in a process. But, as Chaz knows, checklists have a much greater, little understood, value.
Mutual Support: The Value of Process Planning
That value is related to both individuals, as in Chaz’s reassuring psychological need for his checklist and effective team building. When teams are seriously committed to referencing a project checklist, a discipline of proper execution arises. To encourage effective team building initiatives, teams are often tasked with objectives that contain both routine operations and innovative ones. The routine operations, which can often be numerous and critical to success, may be taken for granted as ‘handled’ by ‘them,’ and the finger pointing ensues when the team fails to attain its objective. Part of the surgical project checklist study included a concept Chaz calls Mutual Support. Chaz explains, “Mutual Support is simply looking out for one another and requiring that team mates speak out when something is missed or someone makes a mistake. Verifying each other’s actions and holding each other accountable during any effective team activity is an important part of the proper use of a project checklist. So, when you are one pilot supporting a team of other pilots on a mission, you watch out for each other and maybe even use your checklist to help someone else.”
“In a crisis,” he says “genius in innovation isn’t always useful. What is absolutely critical to success is doing the things that we know from experience and collective wisdom to be the right things. Developing a good project checklist and using it properly is a great way to make sure we always do those right things.”