A hospital story that changed how teams “finish”

In 2004, more than 100 intensive care units across Michigan adopted a simple, explicit checklist for central line procedures. The team behind it, led by Peter Pronovost, treated “done” as objective and observable: hand hygiene completed, sterile drape in place, chlorhexidine used, line site reviewed, and unnecessary lines removed. Within 3 months the median bloodstream infection rate fell to zero; at 16 to 18 months the mean fell from 7.7 to 1.4 infections per 1,000 catheter-days, a roughly 66 percent reduction, and the gains were sustained years later (1)  

That is the Definition of Done in the wild. When “done” is a clear, jointly owned standard, throughput rises and rework collapses. The same principle scales beyond hospital theatres and wards.

What is DoD - Definition of Done

A DoD is a single, visible, shared list of exit criteria that every increment must meet before it leaves the team’s hands. 

Model: the five rungs of “done” clarity

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  Ad hoc: “Done” lives in people’s heads, so work ships on gut feel and standards vary by whoever shouts loudest.

  
  


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  Implied: A loose list exists somewhere, yet it is inconsistent, unenforced and easy to ignore when deadlines bite.

  
  


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  Explicit: One visible, team-owned Definition of Done is written as observable checks that apply to every increment.

  
  


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  Embedded: The DoD is wired into the workflow, pull requests, tests and reviews so items cannot progress without meeting it.

  
  


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  Engineered: The DoD is measured, audited and continuously improved using telemetry and feedback to lift speed and quality.

  
  

At the top rung, DoD is engineered into your workflow, tests and audits. It is not a poster on a wall, it is the wall.

Why a strong DoD accelerates flow and quality

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   Checklists work in high-risk domains. Systematic reviews of the WHO Surgical Safety Checklist show significant reductions in complications and mortality when teams use explicit, shared “done” steps before sign-off (2). More recently, when hospitals re-implemented and audited the checklist as a system, they improved safety culture, behaviour and outcomes (3).

   
   


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   Specific standards plus feedback drive performance. Goal-setting research shows that clear, specific standards with frequent feedback outperform vague intentions. In management contexts this shows up as F.A.S.T. (4) goals that are frequently discussed and transparently measured. F.A.S.T. standing for frequent discussions; ambitious in scope; specific; and transparent. In performance settings, a 2022 systematic review and meta-analysis in sport found goal setting improves task performance and key psychological outcomes, reinforcing the value of explicit, measured standards (5) 

   
   


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   DoD operationalises high-performing delivery. A clear Definition of Done makes good delivery habits automatic: every item must meet the same basic checks, the same reviews, and the same tests before it moves on. That consistency cuts surprises, reduces defects, and shortens lead time, so small changes ship more often with less fuss.

   
   

Applying the Burger Framework to DoD

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How to implement a DoD that moves the needle

Here is a simpler, no-nonsense version.

How to implement a DoD that actually moves the needle

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  Write it together. Get the team in a room and agree one shared Definition of Done. Keep it to one page.

  
  


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  Make every check observable. Use plain tests like “all automated tests pass,” “no critical security issues,” “docs updated,” “feature toggled on.” (6)

  
  


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  Separate it from acceptance criteria. Acceptance criteria are for a single story. The DoD is the basic quality bar for everything. You need both.

  
  


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  Put it where work happens. Add the checks to your board, pull request template, CI pipeline and release checklist.

  
  


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  Pin it where people can see it. Post it near the team board and in the repo README so no one can miss it.

  
  


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  Measure the basics. Track cycle time, escaped defects and change failure rate. Review these in the retro and tighten the DoD monthly.

  
  


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  Teach it. Walk new starters through the DoD on day one. Rehearse it in refinement, stand-ups and reviews.

  
  


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  Keep it lean. Focus on outcomes, not process. If a check does not add quality or speed, remove it.

  
  


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  Use WIP limits. Do not start new work until you finish what is already in progress. Finished beats started.

  
  


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  Make improvements easy. Treat the DoD like a living document. Update it when you learn, and tell the team what changed.

  
  

If you want a quick reminder, think burger: e.g. the DoD is the bright tomato slice everyone can point to. If it is missing, the burger is not ready to serve.

Risks if you ignore this

Skip a clear Definition of Done and you invite rework, delays and endless test–fix loops as people ship to different, shifting standards; WIP swells with “done-ish” items that boomerang back, cycle times stretch, defects leak to customers, and credibility with stakeholders erodes, which means more escalations, less trust, more cost and a team stuck firefighting instead of flowing. A parallel from kitchens that never ship undercooked

Atul Gawande described how the Cheesecake Factory turns “done” into production reality: layouts, recipes, plating standards and timing make quality unambiguous. Orders appear on screens with step lists and countdown timers, and nothing leaves the pass until it meets the agreed standard. In other words, the kitchen’s DoD is explicit, embedded and engineered (7). 

Bottom line

A crisp, co-created, enforced DoD accelerates throughput and quality because it removes argument at the finish line, converts quality into observable checks and wires those checks into the work. The result is fewer defects, shorter cycle times and calmer reviews. As the hospitals learned with checklists, speed and safety are not a trade-off when “done” is designed.

By Sally Foley-Lewis

Keywords: Agile, Change Management, Leadership

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