Checklists: Conventional or Auditable

When we need to carry out a lengthy or complicated procedure, some of us have learned not to rely on memory to get all the right steps in the right order. We make checklists. We might check off the steps as we go, or after executing the procedure from memory, we might use the checklist to confirm that we got it right. These ways of using checklists — these "usage modes" and others — are what I'm calling "conventional."

We usually make checklists only if the procedure in question is complicated enough, or the consequences of missing a step are severe enough. But if the situation calls for a checklist of any kind, and if a conventional checklist is helpful, taking the next step to an auditable checklist is worth considering.

About conventional checklists

A conventional checklist functions as a reminder of the steps required when we execute a procedure. It also reminds us of the order in which we must execute those steps. There are two fundamental classes of conventional checklists, characterized by how they're meant to be used. [Gawande 2011] [Lau 2023]

READ-DO checklists

When people use a READ-DO checklist, they check off the items in the list as they execute them. This kind of checklist is sometimes called a "do-list."

DO-CONFIRM checklists

With a DO-CONFIRM checklist, people run the procedure often from memory and out of sight of the checklist. At some point they pause and check off the items of the checklist, confirming that they executed all the steps required.

The mental model we have of checklists of either category is planar. That is, we think of checklists as having been implemented on paper or a screen, where what you see is all there is (WYSIATI). Unlike Web pages, and unlike the forms we see on Web sites, conventional checklists have no moving parts, and no background software.

The audibility gap

Conventional checklists are better than no list at all, but they have limited value when something has gone wrong and we want to figure out what happened. Conventional checklists have no memory unless they're printed on paper and we save the paper.

But If the situation calls for a checklist of
any kind, and if a conventional checklist
is helpful, taking the next step to an
auditable checklist is worth consideringeven if we do save the paper, conventional checklists contain only checkmarks. Many cannot reliably provide evidence to post-incident investigators about whether a procedure was followed accurately, or exactly how the team deviated from prescribed procedure, or who executed which steps of the procedure, or in what order they executed them.

An auditable checklist is a checklist that serves the needs of both auditors and the users of conventional checklists. And auditors need to know the identity of the person who checked off the item on the checklist, and the date and time when they did it.

One way of making a checklist auditable is to add space for date, time, and user ID alongside the space for the checkmark for each item. Although this sounds simple enough, such a change dramatically reduces the usability of even the best-designed checklists. Users must enter much more data, and the checklist then becomes visually cluttered.

That's the problem. Extending a conventional checklist to include the information auditors need makes the checklist less usable for its primary purpose. I call this the auditability gap. Another way to think of it is that auditor's usage mode is incompatible with the usage modes of other users.

Closing the auditability gap

In some situations, technology can close the auditability gap. By converting the checklist into an active form, supported by software running in the background, we can capture all information needed for audits without troubling the people who use the checklist to run the procedure. To accomplish this, the user of the checklist must use it on an electronic device capable of running the background software. Any web browser will serve, but paper will not.

The tradeoff we must make to gain this capability is prohibitive in some situations. But if devices as simple as a commercially available tablet are available, users can get access to the auditable checklist and enter data as they would in a conventional checklist, while the checklist carries the burden of capturing the audit data.

Last words

When something has gone wrong, we need to know whether or not people followed prescribed procedures. Because the data contained in the auditable checklists provides the answers, the data captured in auditable checklists must be secured. This circumstance reveals another requirement: the data captured from auditable checklists must be lockable and tamper-proof.  Top    Next Issue

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Footnotes

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