The Checklist Manifesto by Atul Gawande
How to Get Things Right
My favorite part of the book is the Van Halen “no brown M&Ms” contract clause discussed in chapter 4. If you don’t read anything else on the summary, I suggest reading my notes on chapter 4.
Over the years I’ve heard many people reference this book and it has been on my reading list for some time. Just reading about the book inspired me to create several checklists for my workplace. See my RFI checklist as one example.
Overall I liked the book, it is geared a lot towards the medical profession but there are other applications throughout the book. The principles of checklists are applicable to most professions.
Author’s website: atulgawande.com
My Favorite Quotes
- A checklist reminds us of the minimum necessary steps that must be taken and makes them explicit. They instill a discipline of higher performance.
- Checklists help with memory recall and clearly set out the minimum necessary steps in each process.
- Checklists establish a higher standard of baseline performance.
- Checklists provide a kind of cognitive net, they catch mental flaws of memory, attention, and thoroughness inherent in all of us.
- Checklists can provide protection against elementary errors.
- Under conditions of complexity, checklists are required for success.
- Why do we fail at what we set out to do in the world?
- What do you do when expertise is not enough?
- What do you do when even the super-specialists fail?
- Can checklists help avert failure when the problems combine everything from the simple to the complex?
- How can we be sure we have the right knowledge in hand?
- How can we be sure we are applying this knowledge correctly?
The author set out to answer this question: Why do we fail at what we set out to do in the world?
One reason is “necessary fallibility” which mean that some things are simply beyond our capacity. Many things are outside of our understanding and control.
Two reasons we fail in realms where we have control:
- Ignorance – we err because of partial understanding
- Ineptitude – the knowledge exists but we fail to apply it correctly
The problem we face today is making sure we apply the knowledge we have, consistently, and correctly.
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.
Defeat under conditions of complexity occurs far more often, despite great effort rather than from a lack of great effort.
The capability of individuals is not proving to be our primary difficulty.
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.
That is why we need a different strategy for overcoming failure. One that builds on experience and takes advantage of the knowledge people have, but somehow also makes up for our inevitable human inadequacies.
The strategy is….a checklist.
Chapter 1: The Problem of Extreme Complexity
Medicine has become the art of managing extreme complexity.
The 9th edition of the World Health Organization’s international classification of diseases lists more than 13,000 different diseases, syndromes, and types of injury.
Clinicians now have at their disposal 6,000 drugs and 4,000 medical and surgical procedures. Each with different requirements, risks, and considerations.
The author asked Harvard Vanguard for some stats on their physicians, these are the results. The average physician evaluates an average of 250 different primary diseases and conditions annually. This only includes office visits and excludes patients seen in a hospital. Each doctor prescribes an average of 300 medications, orders more than 100 type of laboratory tests, and performs an average of 40 different kinds of office procedures.
Israeli Scientists published a study that observed ICU patients in 24 hour increments. They found the average patient required 178 individual actions per day.
The fundamental puzzle of modern medical care: you first have to get the knowledge right, and you have to make sure that the 178 daily tasks are done correctly.
Super-specialists have two advantages over ordinary specialists.
- Greater knowledge of the details that matter
- A learned ability to handle the complexities of a particular job
Medicine poses a significant challenge. What do you do when expertise is not enough? What do you do when even the super-specialists fail?
The answer has come from an unexpected source that has nothing to do with medicine.
Chapter 2: The Checklist
An initial test flight of the Boeing B-17 Flying Fortress crashed because of a small pilot error. The plane was initially considered too complicated for one pilot. A checklist was developed to help the pilots remember the steps required. Instead of being cancelled, the B-17 was put into production.
Most people believe their jobs are too complicated to reduce to a checklist, in many complex cases this is not true.
What are the vital signs that every hospital records? Body temperature, pulse, blood pressure, and respiratory rate. Missing just one measure can be dangerous.
Two main difficulties of a complex enviornment:
- The fallibility of human memory and attention
- People can skip steps even when they remember them
In the case of “all or none” processes, (flying a plane, baking a cake, etc.) if you miss just one key thing, you might as well not have made the effort at all.
The purpose of a checklist is to provide protection against these two failures. They remind us of the minimum necessary steps and make them explicit. They instill a discipline of higher performance.
Checklists in Hospitals
In 2001, Peter Pronovost decided to try using a checklist in the ICU at Johns Hopkins Hospital. He designed it to tackle just one task, avoiding infections when putting in a central line.
The checklist Peter made included these steps that Doctors must take:
- Wash hands with soap
- Clean the patient’s skin with chlorhexidine antiseptic
- Put sterile drapes over the entire patient
- Wear a mask, hat, sterile gown, and gloves
- Put a sterile dressing over the insertion site once the line is in
After using this checklist for one year, then another 15 month period, the results were dramatic.
- The 10 day line infection rate dropped from 11% to zero in the first year
- Only two line infections occurred during the next 15 month period
- The checklist prevented 43 infections, 8 deaths, and saved 2 million dollars in costs
Because of the astounding results of this checklist, they began testing the use of more checklists.
Research has shown that having doctors and nurses in the ICU create their own checklists has reduced the average patient stay by half.
Checklists help with memory recall and clearly set out the minimum necessary steps in each process. Doctors found that checklists established a higher standard of baseline performance.
Hospitals in Michigan began an initiative to use checklists in their ICU, in the first three months the central line infection rate decreased by 66%. This was known as the Keystone Initiative, you can read more about it from the New England Journal of Medicine articles here and here.
It is estimated that the Keystone Initiative, in its first 18 months, hospitals saved $175 million in costs and more than 1,500 lives. All because of a checklist.
Chapter 3: The End of the Master Builder
Checklists provide a kind of cognitive net, they catch mental flaws of memory, attention, and thoroughness inherent in all of us.
It is important to identify which kinds of situations checklists can help with, and which ones they can’t.
Brenda Zimmerman and Sholom Glaberman (professors that study complexity), propose that three types of problems exist:
- Simple (baking a cake from a mix)
- Complicated (sending a rocket to the moon)
- Complex (raising a child)
Forcing Functions are straightforward solutions that force the necessary behavior. A checklist is a form of forcing function.
We are besieged by simple problems. Such as failure to wear a mask when inserting a central line (medical practice), or missing a court deadline in legal practice. Checklists can provide protection against elementary errors.
You want people to make sure to get the “stupid stuff” right. Yet you also want to leave room for craft, judgment, and the ability to respond to unexpected difficulties.
The value of checklists for simple problems seems self-evident.
Can checklists help avert failure when the problems combine everything from the simple to the complex?
The Construction Industry
- How can they be sure they have the right knowledge in hand?
- How can they be sure they are applying this knowledge correctly?
A building is like a body:
- Skeletal System
- Vascular System (Plumbing)
- Breathing System (HVAC)
- Nervous System (Wiring)
For most of modern history, the dominant way people would build a building was by going out and hiring a master builder.
The days of master builders are gone, the variety and sophistication of advancements in the construction process have overwhelmed the abilities of any individual to master them.
Each component of construction has now become further and further specialized.
A construction submittal schedule is a form of checklist.
When facing complex situations, builders must trust in the power of communication. The wisdom of the group is better than the wisdom of the individual.
According to Joe Salvia, the major advance in construction over the last few decades has been the perfection of tracking and communication (in 2009).
The biggest cause of serious error in construction is a failure of communication.
Building failure in the US is extremely rare, the annual avoidable failure rate is less than 0.00002%.
Chapter 4: The Idea
Push the power of decision making out to the periphery, give people the room to adapt based on experience and expertise (decentralized decision making).
Walmart had the best emergency response to Hurricane Katrina of all organizations. They pushed the decision-making power to the front lines.
Walmart’s CEO said “This company will respond to the level of this disaster. Make the best decision you can with the information that is available to you at the time. Above all, do the right thing.” Walmart employees began delivering supplies to first responders and residents before FEMA was.
Senior Walmart officials concentrated on setting goals, measuring progress, maintaining communication lines with employees at the front lines. They did not issue instructions, they worked on making sure people talked.
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.
People require a seemingly contradictory mix of freedom and expectation. Expectation to coordinate for example, and expectation to measure progress.
Managing complexity requires balancing many virtues such as freedom and discipline, craft and protocol, specialized ability and group collaboration.
Checklists help achieve this balance by taking two forms:
- Provide a set of checks to ensure the stupid but critical things are not overlooked
- Supply another set of checks to ensure people talk & coordinate, and accept responsibility, while being left empowered to manage nuances and unpredict abilities the best they know how
After hurricane Katrina, the author came to this conclusion: under conditions of complexity, checklists are required for success.
Van Halen’s M&M Contract Clause
Van Halen had a clause in their contract with concert promoters that a bowl of M&M’s must be provided backstage with every brown one removed. David Lee Roth explained in his memoir Crazy from the Heat, that this was included as a test. If they saw a brown M&M in the bowl, they knew to line check the entire production because you could guarantee they will have missed other critical components of the show.
David Lee Roth had a checklist!
Chef Jody Adams and Rialto
They had a checklist for every customer that specified the dishes ordered, the table number, the seat number, any preferences specified by the customer or noted in a database from previous visits, food allergies, special occasions, and more.
Prior to every dinner service the team gathers in the kitchen and goes through a communication checklist. They review reservation count, menu changes, and unanticipated changes and concerns, large parties, and more.
Everywhere the author looked, he found that checklists could help in every field or profession.
Chapter 5: The First Try
Common attributes of an outbreak investigation and how they are stopped or slowed:
- Simple interventions
- Widely transmissible benefits
Could a checklist be our “soap” for surgical care? Simple, cheap, effective, and transmissible?
How can you make a checklist that is both simple and effective for the many problems posed by surgery?
Surgery has four big killers:
- Unsafe anesthesia
- The unexpected
The first three can be almost completely eliminated. Most are the result of simple failures that can be prevented by utilizing checklists.
One of the biggest dangers in surgery is a “silent disengagement” which can be a result of specialized technicians sticking to their domains. “That’s not my problem” is possibly the worst thing people can think in the midst of a surgery or other critical task.
Giving people a chance to say something at the start of the surgery activated their sense of responsibility and their willingness to speak up. Researchers call this an “activation phenomenon.”
Chapter 6: The Checklist Factory
Daniel Boorman is a pilot who has spent two decades developing checklists for Boeing aircraft.
Boeing pilots have a binder with scores of checklists. Each one applies to a different situation.
Boeing issues over 100 new or revised checklists every year.
Bad checklists are vague, imprecise, too long, hard to use, and impractical.
Good checklists are precise, efficient, to the point, and easy to use. They provide reminders of only the most important and critical steps. Above all, good checklists are practical.
You must define a clear pause point at which the checklist is to be used.
You must decide whether you want a “do, confirm” or a “read, do” checklist.
The do, confirm checklist: team members perform jobs from memory and stop to run the checklist and confirm everything was done.
The read, do checklist: read each task and do them as you check them off. Like a recipe.
A good rule of thumb is to keep your checklist between 5-9 items.
Try to fit the checklist on one page. Make it free of clutter and unnecessary colors.
First drafts always fall apart, keep testing and refining the checklist until it works consistently.
Checklists are quick and simple tools aimed to buttress the skills of expert professionals.
We rarely investigate our failures.
The necessary knowledge has to be translated into a simple, usable, and systematic form.
Chapter 7: The Test
An inherent tension exists between brevity and effectiveness.
The final draft of the first World Health Organization safe-surgery checklist had 19 checks in all, broken down into three pause points.
You can view and download a copy of the full safe-surgery checklist from the World Health Organization in multiple languages here.
Testing the Checklist: The Study
With the WHO they tested this checklist in eight hospitals around the world.
At the time of the test, most hospitals had no idea of their complication, death, and systems failure rates.
Prior to using the checklist, the overall complication rates in surgeries ranged from 6-21%.
They tracked the performance of six specific safety steps:
- The timely delivery of antibiotics
- The use of a working pulse oximeter
- The completion of a formal risk assessment for placing an airway tube
- Verbal confirmation of the patient’s identity and procedure
- The appropriate placement of intravenous lines for patients who develop severe bleeding
- A completed counting of sponges at the end of the procedure
They found gaps everywhere. The very best missed at least one step 6% of the time. On average they missed one step in 2/3rds of patients.
Results of the Study
- The rate of major complications for surgical patients in all eight hospitals fell by 36% after introduction of the checklist
- Deaths fell 47%
- Infections fell by almost half
- The number of patients having to return to the operating room after original operations fell by 1/4th
- Using the checklist spared more than 150 people from harm and 27 from death
Chapter 8: The Hero in the Age of Checklists
Checking boxes is not the ultimate goal. The goal is embracing a culture of discipline and teamwork.
Most occupations have a definition of professionalism or a code of conduct.
- Expectation of selflessness
- Expectation of skill
- Expectation of trustworthiness
- Expectation of discipline (especially for for aviators)
Checklists require revisiting and refinement. Airlines put a publication date on their checklists. They are expected to change with time.
Chapter 9: The Save
Closing chapter, I didn’t take any notes. He tells a story of how the checklist saved the life of someone he operated on and includes other anecdotes about the use of checklists.