Improving Team Performance With Checklists and Mutual Support

As a 31 year veteran of aviation and fighter operations, I have been engaged and intrigued with the relationship of core aviation operations concepts and their ability to improve team performance in other industries and environments. The renowned surgeon and author Atul Gawande has been a great stimulus for thought in supporting the viability of these core ideas, heavily leveraged in the military aviation environment. Tools such as a 1. Collaborative Planning prior to any mission or activity, 2. a Pre Execution Briefing that reinforces the plan and the team’s reliance on each other, 3. Teamwork expectations during the mission, and finally, 5. the value of Debriefing the activity with an eye toward improving future results, have all provided tremendous results in the aviation community.

In his book The Checklist Manifesto, Gawande references research that indicates the use of a checklist in the operating room environment can dramatically reduce major post surgery complications and deaths.

Gawande does a marvelous job of expanding the power of these concepts with industry studies in commercial high rise construction and also the financial services industry. Additional medical research indicates that the simple step of following the checklist direction to complete a pre operative briefing also results in a significant decrease in operative and post operative issues. I love the stories and I fully believe the noted concepts are a credit to the improvements that Gawande and the World Health Organization site. However, as an expert in the field of aviation planning, briefing, execution, and debriefing I believe that the significant root cause concepts that underlie the success of these tools are perhaps missed, or at least underappreciated.

The World Health Organization recommends that prior to commencing surgery each surgical team conduct a briefing, or in their vernacular, a “time out.” If I can now fast forward to the additional use of a checklist during surgery, I want to point to how these two actions collaboratively relate to each other and ultimately result in an increase in positive surgical outcomes. In military fighter aviation, a pre mission briefing is required in most non emergent situations. Any fighter pilot will attest that if this pre mission briefing is skipped or minimized, then it is often an early indicator of poor mission performance. The question is why is this so? Why does the lack of completion of a somewhat routine and mundane pre mission briefing point to marginal results? The answer is that the briefing serves not only as a vehicle to share important mission information but also as the starting focus point of the mission. This focus point results in a message to the team that we are expecting disciplined and accountable action from each member of the team in order to accomplish the mission. In contrast, the lack of this briefing, especially if specifically required by rule, is the first step in lack of focus and lack of discipline by the team.

Now let us consider the use of the checklist during the surgical operation. Again, there are complex outcomes beyond just sharing critical information. Indeed, in most cases, given the experience of the team, most team members would pass a test that was probing checklist knowledge. The checklist then serves two purposes: first, it ensures that critical information or action steps are followed. This is important because we know that under pressure we can all become task saturated and make simple errors yielding undesired outcomes. Having critical information in a checklist takes the pressure off of our “memory” with regard to critical information and frees our cognitive brain to think and react more creatively and with agility. The next purpose of the checklist, pointed to but in my opinion not fully developed by Gawande is that the checklist is an empowering and enabling tool for anybody on the team to “speak up” when they sense or see a checklist step being missed or skipped. Standing behind the authority of the checklist, the youngest, least experienced member of any team is more empowered to stop action and point out that a step in the required checklist had been overlooked.

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The outcome of having an overlooked step acknowledged and accounted for is the desired effect of the checklist. However, I believe it is very shortsighted to think that the simple act of having the checklist in the surgical center will direct the team to this success. In fact, even in the days of sky rocketing aviation losses, we had checklists; but because the culture of the organization was not addressing the perceived infallibility of the “Captain’s” decisions we still suffered double digit aviation accidents and losses. It was not until we changed this culture of Inappropriate Professional Courtesy that we began reducing errors by enabling the team to react to and prevent mistakes before they occurred.

This is the intersection of briefing and checklist use. In the briefing, conducted as required; the Leader (Flight Lead, Captain or Surgeon) MUST set the stage and expectation that in today’s mission we will follow the plan (checklist); and if anybody on the team becomes aware that we are not following the plan (checklist), then they are empowered…expected, to speak up and thus stop an ensuing team error. The importance of this discussion is enhanced with the introduction of “standard” critical communication terms. In fighter aviation, this communication briefing might be in the following typical format: “now that we know the plan… If anybody in the flight (on the team) sees us do something Dumb, Different (from the briefed plan or expectation) or Dangerous, then they are to say on the radio “Knock it Off.” At this point, we will suspend progress until we understand the problem and take the required corrective action.” ANYBODY in the flight is expected to do this! In military aviation, we refer to this general concept as providing Mutual Support and is practiced by all successful teams. This idea of Mutual Support, whether from a four ship of fighters, a crew on a multi crew aircraft or a civilian surgical team is the concept that dramatically improves our performance.

What happens if “Knock it Off” is directed by somebody on the team and the subsequent review discovers that it was miss called? This is handled in the debriefing after mission completion when we review the mission and discover lessons learned. Inevitably, if Knock it Off was directed, even in misassessment; there is a great deal to be learned…not to mention reinforcing the old adage: “better safe than sorry.”

In conclusion, the briefing and the checklist are critical arrows in the quiver of success. However, these arrows must be coupled with leadership that embodies & promotes “It’s not who’s right, it’s what’s right.” A leader, surgeon or fighter pilot who communicates this core concept to the team, and then empowers the team to provide mutual support in the accomplishment of the mission will dramatically improve team performance.