Psychological Safety: Checklists

Checklists

I read Atul Gawande’s “Better” some time around 2008 and absolutely loved it, so when he published “The Checklist Manifesto” in 2009, I grabbed a copy immediately. The Checklist Manifesto describes the power of checklists in reducing human error and increasing effectiveness across various industries, especially in complex and high-stakes situations such as surgery, aviation, and construction. Gawande makes the point that making mistakes is human nature, and proposes that checklists can help mitigate errors and improve performance. He gives the example of the WHO Surgical Safety Checklist, which led to a significant reduction in complications and deaths in operating rooms worldwide. It was Gawande’s Checklist Manifesto that in part catalysed my own interest in Human Factors. 
 

At the time, I was heading up tech at a large event venue, and we began to implement checklists for certain scenarios, such as pre-event (making sure everything is ready for the show), doors (when thousands of people are let in), and large on-sales (when tickets for a major event go on sale and typically sell out in a few minutes). The introduction of checklists for these situations didn’t just improve our outcomes, but also reduced anxiety and stress, and allowed team members to spend their cognitive capacity on more germane problem solving. In event season, there could be as many as six large events and multiple on-sales each week, and it was easy, if the same steps are taken day after day, for someone to forget a critical task that could result in disaster.

Here’s another example of a successful checklist. The B-17 bomber was far more complicated to fly than previous aircraft, and the initial prototype crashed because pilots were overwhelmed by the increased number of checks and tasks. After the creation of a checklist for crew, alongside ergonomic improvements, the B-17 proved incredibly safe and nearly 13,000 aircraft were built.
 

But most of us aren’t flying new, complicated aircraft, so how do we know if a checklist is likely to be useful? Here are several criteria where a checklist could be a powerful tool: 

1. Where the event is repeatable, and the same tasks or checks must be executed each time.
2. Where time pressure exists to complete the tasks.
3. Where it is likely that there are distractions (noise, light, other people etc) that can draw operators attention away from the tasks
4. Where the tasks are critical to health, safety, performance or quality.
5. Where the operator may not be an expert in all aspects of the tasks.
6. Where the event is an unexpected critical failure or disaster.

If a scenario meets some or all of these criteria, it’s likely that a checklist will aid in execution – assuming, of course, that the checklist is well designed and aligns with the work as done, not simply as imagined. At the venue, we did this by making sure that tasks were rotated around team members, so everyone had a chance to test and feed back on the checklists, and we continuously evolved and improved them  – which included removing tasks to ensure the checklist didn’t just grow and grow, becoming burdensome and ineffective. As tasks evolve and become more complex, the checklists used for them should as well.
 

There is a dark side to checklists, however. When a checklist becomes a tool for compliance rather than performance, not only does its utility decrease, but it becomes the antithesis of what it was intended to do: it actually increases the burden upon practitioners, rather than freeing them. Compliance checklists align more with Safety I, whilst performance checklists align more closely with Safety II. Compliance checklists can actually harm outcomes, by removing the capacity for people to make decisions about how the work is done, particularly in situations where the checklist doesn’t make sense, increases cognitive load rather than reduces it, or endows a false sense of safety. “Nothing threatens safety so much as the complacency induced when an organisation thinks that a problem is solved” – this is an excellent paper on checklists in healthcare by Charles L Bosk: Reality check for checklists. Thanks to Jonathan Cohen MD for the link.

Checklists aren’t a substitute for expertise, and of course, you can over-rotate on checklists until they actually become detrimental to performance. Sidney Dekker states in “The Safety Anarchist” that surgeons have complained of “checklist fatigue”. They remarked that if any more checklists would be instituted, they “would need a checklist for all the checklists”. Checklists should empower people and free up their cognitive capacity for problem solving, not steal it.
 

If checklists exist in part to reduce cognitive load, it is clearly folly to create long, detailed checklists, or checklists that are ergonomically poor and difficult to read or use. Checklists must be usable, especially in emergency situations or in difficult environments. Here’s a great article from Gareth Lock at the Human Diver on the ergonomics of checklists, and he also makes the great point that “if multiple people are failing, it isn’t an individual ‘human’ issue, it is much bigger.”
 

Psychological safety and performance-oriented checklists are well associated and mediate each other. The conversations that allow effective checklists to be created and improved over time are more effective in an environment of psychological safety; greater psychological safety results in greater checklists. Conversely, the message that checklists send is “we acknowledge that humans are fallible – we expect you to make mistakes: here is a tool to help with that”. Indeed, having the psychological safety to admit that even as an expert, a checklist might help you perform in your job, is powerful.

Psychological safety at work:

Here’s a paper in the Journal of Healthcare Leadership about the individual characteristics that affect psychological safety and error reporting. As we might expect, previous experiences and cultural norms affect our perception of whether our work environment is psychologically safe.

A fascinating paper here by Clara Wilkins et al: You can win but I can’t lose: Bias against high-status groups increases their zero-sum beliefs about discrimination. The authors find that Zero-Sum Beliefs are reinforced, or increased when people with privilege feel threatened. Essentially this is a paper that, amongst other things, evidences the phrase “When you’re accustomed to privilege, equality can feel like oppression.”

Some interesting findings here from a study by Workhuman: employees who participate in an ERG experience higher psychological safety, and are more likely to be highly engaged, to know their organisation’s values, and to recommend their organisation to a friend. However, employees in ERGs report higher levels of stress and burnout than those who don’t participate. Further, one-third of employees in ERGs report being treated unfairly for their participation in the group, and this increases sharply for Black employees and LGBTQIA+. 

This is a great article about the Ottawa Senators (an ice hockey team) and their team culture, by Ary at Silver Seven, who says they realised on hearing the candid reflections of care shared by D.J. Smith and his players, “oh my god, I’m actually hearing about a team culture that sounds safe“.
 

I love this image from @thegoodhippie on Instagram. Your brain is for having ideas, not for holding them.

And this is exciting news! Amy Edmondson has a new book due out in September: Right Kind of Wrong: Why Learning to Fail Can Teach Us to Thrive. I’m super excited about this and I’ve already placed my pre-order, which you can do over at Amazon or your favourite bookshop 🙂

This week’s poem:

Momma Welfare Roll by Maya Angelou

Her arms semaphore fat triangles,
Pudgy hands bunched on layered hips
Where bones idle under years of fatback
And lima beans.

Her jowls shiver in accusation
Of crimes cliched by Repetition. 
Her children, strangers
To childhood’s toys, play
Best the games of darkened doorways,
Rooftop tag, and know the slick feel of
Other people’s property.

Too fat to whore,
Too mad to work,
Searches her dreams for the
Lucky sign and walks bare-handed
Into a den of bereaucrats for her portion.

‘They don’t give me welfare.
I take it.’