A Better Way to Operate: The Surgical Placemat

In early 2018, I met an expert on checklists—yes, they exist. She works closely with NASA to develop checklists that keep astronauts safe and productive. I asked her, "what is one way to use a checklist that I wouldn't have thought of?" After all, I bought into the fact that someone could be good at making checklists, but I wanted to know what else I was missing. She asked me to give her a situation or problem that might lend itself to a checklist. I said, "surgery," followed with, "we have protocols, and logs, but we don't use a checklist and it burns us a lot." Not that our animals were dying, but I've seen the antiseptic skipped over, lidocaine forgotten, and I have showed up to empty oxygen bottles because the valve wasn't closed at the end of the day.

My new checklist expert friend went on to ask, "does each step have an item, or tool associated with it?". "Yes," I followed, "just about all of them." She then said, "well here's one thing to think about doing," as if this was one of thirty tricks up her sleeve, "you could make a large placemat with a bunch of pouches, and each pouch is preloaded with your tool and the order of pouches walks you through the surgery." How simple, I thought; and brilliant. For the rest of the afternoon all I could think about was sewing custom, ordered pouches into canvas for everything I do in a day.

Atul Gwande's, The Checklist Manifesto, is a very readable exposé on the utility of checklists not only in surgery, but almost all personal and professional endeavors. Checklists assist pilots in starting a plane as well as any and all emergency situations in the air. "FLY THE PLANE" is often number one on the emergency checklist, testament to how simple and direct a good checklist should be. A checklist can help an investor stay true to a method and keep them from letting their gut get the best of them (and their clients). However, what was missing from the book is what my checklist expert honed in on: tactics to increase compliance.

A checklist is only worth its weight if it's followed; step by step, line by line. That's where a checklist—a good checklist—beats a protocol. Protocols are developed as a "Do-Confirm" style list that is better at informing an auditor to the procedure than being something an operator can efficiently utilize. The "Read-Do" style checklist is more useful, more tactful, and built for the experienced operator. Still, the Read-Do method suffers from compliance, as it is easy for anyone with experience to think they know the next three steps, skip ahead, and ink the check-check-check after skipping ahead.

That's where the physical checklist comes into play. The next step in the list is not possible or revealed until a real-world action satisfying the previous step has taken place. For me, the surgical placemat was a perfect solution. It outlines all the items and tools we need in surgery and sits directly on the operating table. It can be preloaded before the operation and thrown out at the end. Although we perform many types of operations in our lab, the setup and teardown is mostly the same.

This is just a prototype—a start—as it is a constant challenge to balance too much with too little, and succinctly separate what needs to be checked-off from what simply needs to be performed. But it seems like the right step forward.