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The rationalist's checklist

32 Post author: Technoguyrob 16 December 2011 04:21PM

Doctor Peter Pronovost has managed to single-handedly reduce the infection rates in ICU facilities nationwide from numbers like fourteen percent or twenty percent to zero. His solution is idiotically simple: a checklist. In a process as complex as ICU treatment, doctors perform chained simple steps very many times, and it can be easy to forget a step. These things add up. Read the article before continuing.

In their phenomenal book, The Power of Full EngagementJim Loehr and Tony Schwartz discuss a pattern they have discovered among all top performers, ranging from sports to music and business. Beyond a certain level, all top performers had established positive rituals for relaxation and deliberate practice. These positive rituals were daily ingrained habits and allowed them to surpass the merely excellent performers.

It is difficult to make use of most Less Wrong posts in terms of changing one's behavior. Even if you integrate a lesson fully, you will still miss steps on occasion. I propose we suggest checklists for various recurring activities that will offload these responsibilities from conscious thought to its much more reliable brother, ingrained habit. Fortunately, we should not need many checklists.

An example of a checklist is a morning routine:

  • Short exercise (40 pushups, 50 situps)
  • Shower
  • Daily cosmetics (brush teeth, shave, skin moisturizer, hair forming cream, male scented lotion, deodorant)
  • Make breakfast, which can be depending on what day it is mod 3: Black mango tea as well as
  •    Omelette with cheese and tomatoes
  •    Cereal with a side of oatmeal
  •    A piece of fruit and yoghurt
  • Brief non-work and non-study related reading, for example, a novel

Another example of a checklist is during a conversation with a non-rationalist on the 5-second level: If you feel strong affect (anger or annoyance) at someone's point in a debate,

  • Say "Let me think about this for a second."
  • Are you two on the same  inferential level? If not, backtrack by trying to bridge it first.
  • Have either of you committed a  cognitive bias? (This may not be so helpful, given this is a potential fifty-item checklist!) If so, inform them about them about it in a friendly manner. ("Ah, I see! You have to be careful here because..." or "Oh, oops, I had forgotten here about...")

Think of this as a re-run of the 5-second level post, with an outreach towards more than just specific rationality skills. The checklists that are not required to be performed extemporaneously (i.e., not in conversation) should be like a physical checklist, that one can write down and should go through every time.

Comments (7)

Comment author: JenniferRM 23 December 2011 03:03:46AM 8 points [-]

I'm not sure if the checklist themselves were the valuable thing in the article, so much as the change to organizational processes that gave nurses the right to overrule doctors any time the doctor deviated from best practices, despite the nurses having fewer years of education and a lower salary. What if the real trick was allowing low status people to other-optimize high status people for deviating from formalized but relatively trivial adequacy standards? I don't mean to be too Hansonian here, but it seemed just kind of glaring to me.

Maybe the lesson to learn really is the checklists... but it kind seems like those might have been a safe way to implement the social hack rather than the essential thing to latch onto. If the checklists are a red herring for a status manipulation then maybe a more effective performance improvement path for someone who can think clearly and accept emotionally complicated truths might be "make it safe for low status people to other optimize you on obvious stuff".

I pulled quotes from the document and the status issues and role adjustments seemed significant. Think of this like the methods section of a scientific paper... what else might be going on here?

Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period.


Pronovost truly believed in was that checklists could save enormous numbers of lives. He took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s I.C.U.s. But this time he found few takers.

There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?


I accompanied a team on 7 A.M. rounds through one of the surgical I.C.U.s. It had eleven patients... The doctors and nurses on rounds tried to proceed methodically from one room to the next but were constantly interrupted: a patient they thought they’d stabilized began hemorrhaging again; another who had been taken off the ventilator developed trouble breathing and had to be put back on the machine. It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.

Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morning, a senior nurse walked through the unit, clipboard in hand, making sure that every patient on a ventilator had the bed propped at the right angle, and had been given the right medicines and the right tests. Whenever doctors put in a central line, a nurse made sure that the central-line checklist had been filled out and placed in the patient’s chart.


Pronovost also insisted that each participating hospital assign to each unit a senior hospital executive, who would visit the unit at least once a month, hear people’s complaints, and help them solve problems.

The executives were reluctant. They normally lived in meetings worrying about strategy and budgets. They weren’t used to venturing into patient territory and didn’t feel that they belonged there. In some places, they encountered hostility. But their involvement proved crucial. In the first month, according to Christine Goeschel, at the time the Keystone Initiative’s director, the executives discovered that the chlorhexidine soap, shown to reduce line infections, was available in fewer than a third of the I.C.U.s. This was a problem only an executive could solve. Within weeks, every I.C.U. in Michigan had a supply of the soap. Teams also complained to the hospital officials that the checklist required that patients be fully covered with a sterile drape when lines were being put in, but full-size barrier drapes were often unavailable. So the officials made sure that the drapes were stocked.


Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focused on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.


We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.

I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and coördinating a database to track the results.

Comment author: RomeoStevens 17 December 2011 01:11:23AM *  8 points [-]

I recommend a dry erase board with items you check off daily with the final item being to erase all the checkmarks for the day. This makes things like stretching, 10 min meditation, flossing, snacking on nutrient rich foods easier to ingrain as habits.

I found a dry erase board to work much better than anything printed or digital.

Also: Don't forget to take into account the range of possible gain/loss in utility from a decision when deciding how much time to spend analyzing your decision. Many decisions that seem hard are only difficult because the outcomes are so close in utility (e.g. peanut butter A instead of peanut butter B).

I'd also like to say that in general I find checklists, catchphrases, and rules of thumb et al to be MUCH more useful in behavior modification than anything more rigorous. A leaky abstraction that you actually use (and moves you even somewhat closer to optimality) is better than the perfect heuristic you don't use.

Comment author: Bobertron 16 December 2011 05:49:14PM *  8 points [-]

After short googleing, I found this checklist. Apparently it's based an an article by Kahneman (and others).

The first Item on my morning routine checklist would be: "Get checklist". I just know that I couldn't work with checklists. I couldn't make myself to print them out and waste all the paper. Or even if I did, I'd run out of them and forget to get new ones. Or I'd loose the checklists, or there would be another of a million possible complications. There should be something like "checklist paper" where you write down the items of the checklist once and only a small strip of paper is used to make the check-marks and teared off. I suppose that's what rich people have smartphones for...

Comment author: hvass 16 December 2011 06:15:53PM *  9 points [-]

Here's the HBR article by Kahneman et al.

I highly recommend The Checklist Manifesto and I have thought about implementing it in my daily life similar to your outline for daily activities that, as it is shown, sometimes just because some activities are so obvious they sometimes tend to be neglected and forgotten. I also like to have a particular checklist for the day as it is very easy for me to drift into doing irrelevant tasks and looking at an empty/partial checklist you get a disturbing feeling similar to the way of beating procrastination just by starting something and having that feeling of incompleteness.

I'm planning to use a checklist when I go back to the gym as I tend to always leave a bit earlier and skip some of the exercises I want to get done.

Comment author: Bobertron 16 December 2011 06:25:19PM 0 points [-]

Here's the HBR article by Kahneman et al.

Thank you, I have been looking for that!

Comment author: Pablo_Stafforini 24 July 2013 07:46:07PM 1 point [-]

In their phenomenal book, The Power of Full Engagement, Jim Loehr and Tony Schwartz discuss a pattern they have discovered among all top performers, ranging from sports to music and business.

Here's a good summary of The Power of Full Engagement. Here's the book itself.

Comment author: Metus 16 December 2011 11:42:59PM 1 point [-]

Thank you, practical advice is immensely useful as supplement to all the theory.