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Baby Blog: Checklists

Baby Joshua

This is baby Joshua.  He was born this summer, and my wife and I have been scrambling to keep up with him ever since. One thing I think definitely helped us was a series of checklists we had around the house.  And this blogette is all about how those checklists helped us.  By recording our impressions, I am contributing to the huge amounts of advice out there for new parents.  Hopefully, it is a public good, and I'd love to hear your thoughts, so please don't hesitate to contact me and I'll post your responses.

The Checklist Revolution

A few months before Joshua was born, I was coincidentally at a conference at which Dr. Atul Gawande of Harvard Medical School gave a lecture on his checklist manifesto.  The idea is simple.  No matter how many times we do something, or how expert we are at it, we sometimes forget to think through all the steps we should.

A simple solution is to have a list of items to think through, ensuring that all the major points are seen to.  Dr. Gawande gives examples of where checklists are used from restaurants to airplanes to surgery.  In each case, he documents where checklists have been and can be a critical reminder as to all the important steps to think through when undertaking an activity.

In his own words,

We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber—a machine so complex no one was sure human beings could fly it. They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist. And so can we. Indeed, against the complexity of the world, we must. There is no other choice. When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It’s time to try something else. Try a checklist.

In each of the cases he describes in his book, 'The Checklist Manifesto', he shows how checklists allow us to handle difficult or complex situations by reminding us of the critical steps we should take.  His work has had a broad and celebrated impact.

As we got closer to Joshua's due date, I wondered if checklists could be useful to us in the first few weeks of his life or more. And as an additional nudge, here was what greeted me in the labour ward of the hospital in which Joshua was born, a proto-checklist;

Hospital checklist

I was sold.  In the madness of the first few months of looking after Joshua, there would be a lot for us to remember.  What better way to remind us but to have a few checklists about the house?

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Checklists and babies 

It seems like a complicated task to look after a baby.  Once you get home from the supportive environment of the hospital, it feels a bit as though you are on your own with one of the most complex tasks you've ever faced - nurturing a new life.  There are lots of things to remember about lots of disconnected tasks.  So we put together a range of checklists to remind us of the steps we should be taking in caring for our new boy.

One was to help us remember what to do when changing a nappy.  It asked whether we had sealed and closed the nappy bin, and washed our hands.  Another, for bath time, reminded us to ensure that we had a bowl of warm water ready for his face separate from fresh water (which we quickly gave up on).

The checklists had varying success.  The nappy changing one definitely got me washing my hands more frequently, and closing the nappy bin most of the time.  The bath one got quite wet and blurred over time.  My wife believes they really helped her learn good practice in even the most routine tasks.

The best checklists for me, however, ended up being nothing to do with Joshua at all.  They were in fact about looking after ourselves.  Whilst the checklists we created for him were useful for a week or two, we quickly learned how to look after him.  We were so focussed on looking after him, however, what we needed were nudges about looking after ourselves.  So for example, just by our front door, we wrote the following,

Everyday reminders

Frequently it reminded us of things we should have been doing like making something with iron in it for my wife, or having a cuddle.

A checklist also helped us relieve tensions we had felt.  Whilst focussing on Joshua, we kept forgetting to ensure quality time for ourselves, both alone and together.  We felt it had been good that we put the below checklist in our bedroom to remind us that we both needed some time out of iron grip of our new leader.  However, it was also really good to put down in writing that my wife was always going to be more constrained than me in terms of gaining this freedom.  That made sure we were both kept aware of that fact.

This is not to say that the other checklists were not useful, but I was surprised that the above were our favourites.  They definitely helped us have a healthier and less stressful time of it over the first few months.

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Learning and nudging 

As we developed the art of the checklisting for babies, we found a very similar set of principles worked for us as those laid out in 'The Checklist Manifesto'.  The best checklists for our purposes were simple, direct nudges.  When we wanted to ensure we were washing our hands before food preparation, we put the following in the kitchen;

The photo was in the middle of the kitchen cabinets, starkly on its own, so that one's eye was drawn to it.  It kept nudging me whenever I was in the kitchen to get into a habit of washing my hands regularly (as you never remembered exactly when you were covered in baby fluids).  It became increasing habit, so I was learning, but keeping it up definitely gave me the occasional reminder.  It also nudged me to do it when I was on the fence of laziness.

The discipline involved was to ensure you went back every so often and looked through the checklist.  Like the one by the front door above, we tried to put them in places we would be forced to encounter them, so all we then had to do was push ourselves to go through it.  The best was when we went through them together, so we could give each other pats on the back for the things we had done, or agree on an activity to remedy anything we hadn't.  But it was also useful for a small moment of self-reflection.

To conclude, I will let Dr. Gawande have the last word,

The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.

Other's experiences

I would welcome hearing from others who might have tried something along the lines of checklists, so please contact me.

From Luke:

Hi Dan

Thanks very much for this. A very interesting read. I certainly agree with your statement that you never forget all the steps that need to be done to look after the baby. When I'm changing Alys at night, its almost an automatic process rather than a conscious one. We're also acutely aware of everything that needs to be done. In some ways, what was most helpful was recording the past. We have (tried) to keep a feeding and poo diary, which has given our life some structure. When she was screaming all night over the weekend, we also found a 1.5 hr shift system helped us get through the nights. However, as you also allude to, any process that is way too complicated quickly becomes obsolete. We also tried a top and tail bowl at first, but quickly abandoned it after it got way too stressful. I would agree therefore that lists are useful, but not when they are too complicated as they are quickly ignored. 

Where I really agree is on the looking after each other bit. This has been really hard. We are both on auto-pilot looking after Alys, but it’s hard to find time and energy to look after each other. I can see the benefit of checklists here, and might suggest the idea to my wife.


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