Illustration by Phil Foster
When San Francisco Public Defender Jeff Adachi read The Checklist Manifesto
by medical writer Atul Gawande two years ago, he wondered if checklists could work in criminal defense as well as they had in medicine. He reasoned that having a list of recommended steps in a certain type of court hearing or a list of what evidence reports to watch for in the first 30 days of a homicide case - on DNA, fingerprints, or gunshot residue, for instance - could help public defenders make fewer errors. It also could help their managers track performance, Adachi says, and prove to funders what level of resources they need to properly run a public defender's office.
Gawande's theory is that in complex professions traditional training is not enough to avoid straightforward mistakes - which he distinguishes from errors made in ignorance. Gawande, a surgeon, reports in his 2009 book that when intensive-care nurses at one hospital used a five-point checklist to note each step doctors took in inserting a central IV line, the infection rate dropped from 11 percent to zero. And the checklist system gave hospital administrators a record of wherever corners may have been cut.
Adachi formed a committee to develop and test several checklists that his office now uses routinely. And in November, the office received a $395,000 grant from the U.S. Justice Department to work with the Center for Court Innovation in New York to formalize a guide for defenders nationwide.
"If you make a mistake in preparation of a case by overlooking one small step, the consequences can be a disaster," Adachi says. It used to be that, when those mistakes landed on his desk, the only tools he had for determining what went wrong - whether an experienced attorney was involved, or a rookie - were time sheets and court filings. "Here, we have a specific checklist of what needs to be done in each case. Part of what we'll be doing is monitoring whether people are following it."
Adachi's staff so far has developed about 40 checklists - typically with ten to twelve steps each, though some have dozens. The plan is to finalize them by the end of 2014. Lawyers in the Alameda County Public Defender's office across the Bay will then test them, and the Center for Court Innovation will monitor the process. Alameda County is a good lab for testing San Francisco's guide because both offices have about 100 public defenders and their caseloads are similar, says Brett Taylor, deputy director of national training and technical assistance for the Center for Court Innovation.
"Jeff and I are very fortunate to practice in counties that support what we do," says Alameda Public Defender Brendan Woods. He says checklists could help his office but might be even more significant in regions "where there is not as much money for training."
Even in Los Angeles County's much larger PD office - with more than 700 attorneys and with formal training for new hires and other support - checklists could be a boon, says Winston A. Peters, an assistant there and president of the California Public Defenders Association. From arraignment through trial and beyond, he says, checklists can give defenders "a framework and a guide to move in the right direction."
For his part, Adachi hopes to "ignite a checklist revolution in the public defense community."