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Book Summary: The Checklist Manifesto

The Checklist Manifesto

The Checklist Manifesto by Atul Gawande

Rating: 8/10

There are two reasons why people fail. Ignorance meaning we only have a partial understanding of the world and how it works, and ineptitude when the knowledge exists but we fail to apply it correctly. We have accumulated stupendous know-how and have accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Checklists are a strategy for overcoming failure by building on experience and taking advantage of the knowledge people have, but also making up for our inadequacies.

The problem of extreme complexity

Three different kinds of problems exist in the world: Simple problems like baking a cake from a mix. Complicated problems such as sending a rocket to the moon, which can sometimes be broken down into a series of simple problems and where unanticipated difficulties are frequent. Finally, complex problems like raising a child for which a process that guarantees success with every child does not exist.

Medicine, like many other professions have become the art of managing extreme complexity.

The checklist

Checklists were invented after the Boeing Model 299 test flight crashed because it was too complex for one person to fly. The solution that finally addressed the challenge with Model 299 did not require pilots to undergo longer training, they created a pilot’s checklist.

The XB-17 /Model 299/ crashed during its test flight at Wright Field on Oct. 30, 1935. /U.S. Air Force photo/
The XB-17 /Model 299/ crashed during its test flight at Wright Field on Oct. 30, 1935. /U.S. Air Force photo/

It is far from obvious that something as simple as a checklist could be of substantial help in a complex situation. Professionals are tempted to believe their jobs are too complicated to reduce to a checklist. However, in a complex environment experts need to deal with two main difficulties. The fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked, and people's ability to lull themselves into skipping steps even when they remember them.

Source: Vox
Source: Vox

In one experiment to reduce central line-infections in Johns Hopkins Hospital, Dr. Peter Pronovost decided to give checklist a try. He created a checklist with 5 simple steps to take in order to avoid infections when putting in the central line, and he authorized nurses to stop doctors if they saw them skipping a step on the checklist. A year afterward they found that line-infection rate went from 11 percent to zero in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.

By providing a cognitive net to catch mental flaws of memory and attention and thoroughness, checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realize.

Learning from the construction industry

Have you ever wondered how hundreds of people are able to build a skyscraper that stands up straight even in an earthquake? How can the workers be sure they were constructing it properly? How can they be sure that they have the right knowledge and that they are applying this knowledge correctly?

In the past Master Builders designed, engineered and oversaw construction. By the middle of the twentieth century the Master Builders were dead and gone because the variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them.

Construction companies use two main tools (a.k.a. checklists) to manage complexity. The construction schedule is a line-by-line, day-by-day listing of every building task that needed to be accomplished, in what order, and when; drawn up by a group of people representing each of the many trades. It is like a succession of day-by-day checks. The submittal schedule is also a checklist that specifies communication tasks. Project managers deal with the unexpected by making sure the experts speak to one another and take one another’s concerns into account when discussing unplanned developments and agreeing on the way forward in a situation.

Man is fallible, but maybe men are less so. To resolve complex problems you have to make sure the critical people talk.

Learning from the response to Hurricane Katrina

In the face of an extraordinarily complex problem, power needs to be pushed out of the center as far as possible.

Walmart trucks delivering relief supplies after Hurricane Katrina. Credit: Walmart Annual Report, 2006
Walmart trucks delivering relief supplies after Hurricane Katrina. Credit: Walmart Annual Report, 2006

In the aftermath of Hurricane Katrina everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible. Lee Scott the CEO of Wal-Mart realized that to handle this complex situation, he was not going to be able to effectively issue instructions. Instead he worked on making sure people talked. He was remembered to have said in meeting with his upper management: “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.”

Under conditions of true complexity - where the knowledge required exceeds that of any individual and unpredictability reigns - efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals. What is required is a mix of freedom and the expectation to coordinate.

Checklist in the operating room

In Columbus Children's Hospital they found that more than one-third of its appendectomy patients failed to get the right antibiotic at the right time. Why wasn't a simple task like this done right 100% of the time? The hospital's director of surgical administration, who happened to be also a pilot decided to give the aviation approach a try.

They created a checklist, but getting teams to stop and use the checklist - to make it their habit - was tricky. He therefore designed a small metal tent stenciled with the phrase "Cleared for Takeoff" just long enough to cover a scalpel. This served as a reminder to run the checklist before making the incision. The surgeon could not start the operation until the nurse gave the okay and removed the tent. This was also a subtle cultural shift giving the nurse the power to intervene. The checklist had the effect of distributing power.

Under conditions of extreme complexity, evidence suggests, people need to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. The most common obstacle to effective teams is not the occasional fire-breathing leader. The real danger is a kind of silent disengagement: "That's not my problem". To address this issue, the checklist required surgical staff members to stop and make sure that everyone knew one another's names and to talk about the case. The insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork.

Checklist best practices


Source: Unknown

There are two type of checklists. With a DO-CONFIRM checklist team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist people carry out the tasks as they check them off like a recipe.

Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turning them on.

Good checklists are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything, but provide reminders of only the most critical and important steps. Good checklists are, above all, practical.

To ensure that checklists get used, you must define a clear pause point at which the checklist is supposed to be used. Always the “pilot not flying” starts the checklist because the “pilot flying” can be distracted by flight tasks and liable to skip a checklist.

Checklist cannot be lengthy, keep it to between five and nine items, focusing on “the killer items”. Ideally, it should fit on one page, free of clutter and unnecessary colors. Brevity is key. Good checklists should take thirty seconds to a minute to complete. They are not comprehensive how-to guides. They are quick and simple tools aimed to buttress the skills of expert professionals. Finding the balance is difficult. If you cut too much, you won’t have enough checks to improve the process. You leave too much in and the list becomes too long to use. Finally, how do you encompass the simple to the complex, with several narrowly specified checks to ensure stupid stuff isn’t missed few communication checks to ensure people work as a team?

Checklists must be tested in the real world.

Checklists can facilitate the sharing of new knowledge. As failures are investigated and as we learn better ways of doing things, getting the word out is far from assured, and incorporating the changes often takes years. The reason for the delay is usually not laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form.

Closing thoughts

Just ticking boxes is not the ultimate goal. The culture of teamwork and discipline is.

When surgeons make sure to wash their hands or to talk to everyone on the team they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.

All learned occupations have a definition of professionalism. Code of conducts have at least three common elements: expectation of selflessness, expectation of skill, expectation of trust-worthiness. Aviators, however, add a fourth expectation, discipline, following prudent procedure and in functioning with others.

We have the best drugs, the best devices, the best specialists — but pay little attention to how to make them fit together well. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,”. If we connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo, “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”.

We recognize the same balls being dropped over and over, even by those of great ability and determination It’s time to try something else. Try a checklist.

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