The Foreign Service Journal, September 2012

S E P T E M B E R 2 0 1 2 / F O R E I G N S E R V I C E J O U R N A L 21 a significant number of deaths from secondary infections, even though well-trained, highly specialized doctors were involved. Pronovost’s idea was as simple as it was controversial. He required all doc- tors to use a five-step checklist for every insertion, which basically went like this: (1) wash hands; (2) clean the patient’s skin with antiseptic; (3) put sterile drapes over the patient; (4) wear sterile scrubs; and (5) put a sterile dressing over the catheter site. The checklist seemed so obvious that it sparked skepticism. Why force experts to “dumb down” their work by using a checklist for such an easy task? Yet the results spoke for themselves. The infection rate from catheter inser- tions in the ICUs went from 11 per- cent to zero. Why? Subsequent commentaries, includ- ing surgeon Atul Gawande’s superb ar- ticle in the Dec. 10, 2007, issue of The New Yorker , detailed the important process at work in Pronovost’s ap- proach. His checklist cut through the distractions of urgent care and forced physicians to focus on the basics. ICU care is terribly complex, and demands that physicians make a large number of critical decisions in a very short time frame. Background tasks like inserting catheters can get lost in this cognitive “noise” of higher-level decision-making. Moreover, the im- pact of this cognitive noise seems to af- fect expert physicians, too, suggesting that expertise alone is not enough to forestall careless error. The beauty of Pronovost’s checklist was that it assisted physicians of all ex- perience levels in reducing mistakes. Other applications of this approach in hospitals, like inserting ventilator tubes or washing one’s hands, have shown similar results. The trick is the same: institutionalizing best practices into ex- plicit routines so that distracted practi- tioners don’t forget important funda- mentals. Lawyers Use Checklists, Too Some in the legal world are reach- ing similar conclusions about a critical high-volume, high-risk task in lawsuits: document review. Under U.S. law, parties to civil lawsuits often must turn over documents relevant to the case to the other litigants in preparation for trial. In complex matters, this process may involve combing through millions of documents — both hard-copy and electronic. Further, once the relevant documents have been selected, lawyers must find and set aside any privileged material before disclosing the remainder to the other side. Even though managing this collec- tion and review process can be quite complex, the individual reviewer’s job is often a relatively simple but repeti- tive one, similar to that of a visa officer. And like visa work, serious conse- quences can attach to even small mis- steps. One need only look at one recent malpractice claim to under- stand the dangers: a major U.S. law firm was sued for accidentally disclos- ing attorney-client privileged informa- tion when it responded to a U.S. government subpoena. Given the risks involved, some practitioners have sought to improve quality control by understanding doc- ument review as a process and stan- dardizing it, much as Dr. Pronovost did in Michigan intensive care units. At least one law firm has had its review process certified as ISO 9001–compli- ant, which generally involves extensive checklist-based internal auditing. An- other touts adherence to the principles of Six Sigma, a quality-control system from the manufacturing world that ef- fectively reduces complex tasks to checklist-type steps. Some legal commentators now pre- dict that such checklist-based systems will proliferate as document review be- comes increasingly complex. The con- sequences of even one mistake are simply too great. Checklists at the Consular Window These examples demonstrate that even the most experienced, skillful practitioners can only handle so much information without losing track of something. On the visa line, this can take the form of failing to collect a ma- chine-readable visa fee receipt, neg- lecting to check the accuracy of a name or date of birth, writing notes in the wrong case file, or missing a hit in a clearance. (It should be noted, how- ever, that officers must manually over- ride hits on serious ineligibilities to issue a visa.) This brings us back to the question posed at the beginning of this article: How can we help officers efficiently carry out high-volume, high-risk tasks like visa adjudication? Training and ex- F S K N O W - H O W State seeks to resolve the tension between speed and accuracy in visa adjudication in several ways, starting with training.