The Checklist Manifesto
Atul Gawande
Metropolitan Books, 209 pages, $29.50
Surgeons are smart people. They are also important people. And busy. Every medical operation has unique aspects. So it seems silly to waste their time with going through a checklist of procedures before they begin cutting. However, implementing checklists for operating rooms is increasingly becoming the standard, because research shows it saves lives.
Government executives are smart people. They are also important people. And busy. They tackle a flurry of unique activities during the day. So it seems silly to consider that they might be able to benefit from checklists. But before you reject the notion of checklists, check out what Atul Gawande has to say.
Gawande is an unusually eclectic fellow, an associate professor at Harvard Medical School and a surgeon at Brigham and Women’s Hospital in Boston, as well as a staff writer for the New Yorker magazine. Smart, important and busy, actually. And an advocate of checklists, who played a pivotal role in getting them adopted internationally by the World Health Organization for operating rooms.
During his surgical training, he read an essay by the philosophers Samuel Gorovitz and Alasdair MacIntyre on the nature of human fallibility that has stayed with him for four decades. Some things, they declared, are simply beyond our capacity. But in others, control is within our reach, but we fail because of ignorance or ineptitude.
In the past, ignorance would have been the prime cause. But we live in a knowledge society, and so he feels the balance is shifting toward ineptitude as the cause of failure. “Or maybe it’s ‘eptitude’ – making sure we apply the knowledge we have consistently and correctly,” he writes in The Checklist Manifesto.
He notes that studies show that at least 30 percent of patients with strokes receive incomplete or inappropriate care from their doctors, as do 45 percent of patients with asthma and 60 percent with pneumonia. Between 2004 and 2007, the number of law suits against attorneys for legal mistakes increased by 36 percent, the most common being simple administrative errors like missed calendar dates and clerical goofs, as well as errors in applying the law. Authorities make mistakes when hurricanes and earthquakes occur, software is often designed poorly, and the banks… well, you know about that.
“Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated,” he writes.
“What do you mean half of heart attack patients don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors? It is not for nothing that the philosophers gave those failures so unmerciful a name – ineptitude. Those on the receiving end use other words, like negligence or even heartlessness.”
We are in an era of tremendous know-how, he reflects, in which we can accomplish wonderful things, through highly-skilled, highly-trained, highly-motivated, hard-working people. But the know-how is often unmanageable. “Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us,” he warns.
He believes the solution is something ridiculous in its simplicity yet vital and effective: the humble checklist.
Time for a story. After all, Gawande is a journalistic storyteller as well as scientist and clinician. And he shares an illuminating story from the mid-1930s, about an airplane, that furthers his case about the checklist.
On October 30, 1935, Boeing Corporation unveiled its new aluminum-alloy Model 299 bomber, which was the odds-on favourite to win a competition for the right to build the next-generation U.S. long-range bomber. It could carry five times as many bombs as the army had requested. It could fly faster than any previous bomber and twice as far.
But the plane was complicated. Indeed, a newspaper declared it “too much airplane for one man to fly” when the test flight crashed due to pilot error. Douglas Aircraft won the competition instead.
But a few of Boeing’s models were purchased as test planes, leading a group of pilots to meet to figure out how to make the plane safer. They decided the solution was not, as might be expected, more training. Instead, they opted for a simple checklist that pilots would follow before takeoff to eliminate error.
“Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of a garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert,” Gawande declares.
It worked well beyond what might be expected given the plane’s previous record. The pilots went on to fly the Model 299 a total of 1.8 million miles without an accident. The army eventually ordered 13,000 of the bombers, which became known as the B-17, and it provided a crucial air advantage in World War II.
The checklist is now, of course, common for air flight. But Gawande had to push hard, with others, to insert it into operating rooms. And there are plenty of other places where it might be of help, such as software design, financial management, firefighting, police work, construction, and lawyers preparing for a case. In each case, they face a series of steps that are required for success and if one step is forgotten they could crash and burn. The same may apply in your workplace.
The problem is that most of us feel our jobs are too complicated – or too important – to be reduced to a checklist. And checklists are painstaking, not much fun. They take away from the creativity and professionalism we want to feel at work. Although research shows that a checklist in a medical environment can save lives and for venture capitalists or investors boost the bottom line, he notes that we avoid them: “There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow seems beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – those we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.”
You couldn’t, however, be more daring or heroic than Chesley B. “Sully” Sullenberg III. He’s the pilot who landed US Airways Flight 1549 on the Hudson River after the plane struck a flock of Canadian geese and lost both engines. The initial stories fed into our traditional notion of heroism, with the landing supposedly resulting from Captain Sullenberg’s prowess as a glider pilot and his improvisational talent when the engines failed him. But Gawande went through the logs and found the pilot and co-pilot, who had never flown together, worked as a tight team after the crisis began, the co-pilot reading off the various points on the checklists established to handle such unusual occurrences. So chalk that heroism up to protocols and checklists.
Good checklists are precise, but easy to use even in difficult situations. They don’t try to spell everything out. “They provide reminders of only the most critical and important steps – the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical,” he explains. Good checklists, he stresses, also encourage cooperation. They nudge people to work together, be it when landing a plane on the Hudson, in surgical operating theatres where simply having people introduce themselves to each other improves results, and on construction sites.
The book meanders, in essay fashion, returning time and again to the medical field, but with stops in many other areas. It doesn’t offer a bullet point checklist for creating a checklist, much as you might hope. But it does make a case for checklists as an antidote to today’s complicated world. And it may have application in your field.
