The Value of Using A Checklist
As many of you know, I have lived and practiced in New Orleans, LA since 1984. When Hurricane Katrina hit the city on August 29, 2005, my family and I evacuated leaving our home, my dental practice, my husband’s law practice and my children’s school behind us with an uncertain ominous feeling of dread as we realized that life as we knew it was about to change forever. Within a matter of just a few hours, the city’s telephone lines, cell towers and electrical power went out – making high tech communication impossible. At much the same time, the levees protecting the city were breached.
A lone agent of FEMA (Federal Emergency Management Agency) managed to get a helicopter ride over New Orleans that afternoon and reported seeing widespread flooding, hundreds of people stranded on rooftops and bodies floating in the water. He filed an urgent report by e-mail because all other means of communication had been lost. The only problem with that was FEMA’s top official didn’t use e-mail and therefore FEMA didn’t even know there was an emergency until TV pictures of the disaster were broadcast the following day. By then, 80 percent of the city was flooded, forty thousand refugees were stranded at the New Orleans Superdome and Convention Center, five thousand people were stranded on an overpass on Interstate 10, hospitals were without power and widespread looting had broken out as people became desperate for food and water. For days, the federal government, the state government and the local government then debated who should respond while the situation on the ground.
Subsequently, when I read the book “Checklist Manifesto” by Atul Gwande, I couldn’t help but think that a simple checklist could have been used to prevent the breakdown in communication, minimize the loss of human life, and avoid the utter confusion about who was in charge at the time. Complex situations such as this arise in every industry today however, the solutions are often complicated and demanding. When you factor in human error, you find that people become paralyzed dealing with complexities and tend to overlook what might be the more common sense and immediate solutions to some of the most basic and urgent problems at hand. Using the commercial aviation industry as his example, Dr. Gwande’s book is a testament to using a checklist for simple, complicated as well as complex eventualities. If you want to make sure that you cover all of your bases in a quick and concise manner, design a checklist to fit every task in your office.
Before a plane can take off down a runway, there are numerous evaluations and diagnostic checks that are required to be performed before the plane can be cleared for take off. Besides the mechanical and engine checks, the overall flight plan needs to be reviewed. In addition to knowing where to go, the pilot needs to determine the best way to get there so that all on board are safe, comfortable and hopefully on time. The details are too numerous to mention, but when you consider the weather forecast, communication with air traffic control, and a complete understanding of how that particular flight will fit into the existing web of other airborne craft you can easily understand how this metaphor can translate into how we practice dentistry. A little knowledge and advanced planning can save time, money and improve the consistency of the outcome of the procedure.
As dentists, we have vast amounts of information that we need rely on, systems that need to function in order to even get the patient through the front door, and vast amounts of attention to detail in every procedure requiring our team to always be on the same page at the same time and in sync with the rest of the office. All equipment needs to be in working order, all supplies need to be available, and we need to be particularly cognizant that there is a human being that we are about ready to treat. It is inevitable that some things will fall through the cracks.
But if checklists are developed and used the cracks will become smaller, less significant, and less likely to make everything fall apart.
Mise en place is a French culinary phrase that means “put everything in its place”. It refers to the setup required before cooking as well as organizing and arranging the ingredients. Dan Charnas, writer and chef, uses the concept of mise en place as a system, a philosophy and an ethical code in his kitchen. As a noun it means that everything is set up and ready to go, But, in addition, he uses it as a verb, extending its meaning to include the preparation process as well as a state of mind for his team. While a checklist may seem like a ridiculously simple concept, it enables a team to be prepared so that the focus can be on the patient and the procedure. In addition if your intent is to embrace a culture of discipline for higher performance and readiness, it is invaluable.
Daniel Boorman is Electronic Checklist-Procedure Manager and Technical Fellow at Boeing, the world’s largest aerospace company. In essence, he is the checklist “Master”. He recommends that each checklist be limited to 5-9 items otherwise it defeats the purpose. Language used should be familiar to the profession and the wording should be simple and exact. In an ideal situation, it should fit on one page. In addition it is important to remember that they are not comprehensive procedure manuals. They are tools that enable you to minimize errors of omission and keep you on task in the moment. They can prevent you from missing a step that is crucial to the outcome of your procedure. In addition, they can provide you with a method to provide a higher level of baseline performance for your team.
If you have not joined our Facebook group, I want to invite you to join me there so we can discuss this further in our forum. I would like to know what you think about implementing checklists in your practice. I am going to open a discussion on our Facebook group page about them. Please let me know if you have any checklists that you would like to share with us. How have they have worked for you to improve your practice? Attached you will find a PDF which is a checklist to develop a checklist. I challenge you to use this simple method to create your first checklist and share it with our group!