This
post is an overview of the book The Checklist Manifesto by
Atul Gawande
Atul
Gawande's bio: Dr. Gawande is a surgeon at the Brigham and
Women's Hospital in Boston, a staff writer at The New Yorker, and an
associate professor at Harvard Medical School. He also leads the
World Health Organization's Safe Surgery Saves Lives program.
Key
point: The world is becoming increasingly complex and we need
tools to cope with that complexity. (One of my favorite paradoxes is that, "It is hard to keep things simple.")
Let's
start off with a shocking statistic. Columbia Law Professor James S.
Liebman did some research and found that two-thirds of death penalty
cases are overturned because of errors. If that number doesn't bother
you, I encourage you to imagine if you, or someone you love, were
wrongly convicted of a heinous crime. Putting someone to death is a
very serious decision. What's more, it can't be reversed. So, it
would stand to reason that we do our level best to not make any
mistakes in capital cases. And yet it seems that lots of errors are
still being made.
Alexander
Pope famously said, “To err is human.” The fact is, we humans
make lots of mistakes. And, as the world becomes more specialized,
and more complex, the chance of making an error goes up. The author
of this book is a surgeon. And so a lot of what he talks about comes
from the world of medicine. Gawande says, these days surgery is so
specialized that they joke about right ear surgeons and left ear
surgeons.
Consider
these statistics, from the book, “On any given day in the United
States alone, ninety thousand people are admitted to intensive car …
Critical care has become an increasingly large portion of what
hospitals do. Fifty years ago, ICUs barely existed … The average
patient required 178 individual actions per day.” With all that
complexity and activity lots of mistakes are made. The knowledge
exists so that all surgeries are safe. Even still, steps are still
missed and mistakes are still made. As it turns our, upwards of
150,000 people die annually after surgery. So the question becomes,
what do you do when expertise is not enough?
“On
October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army
Corps held a flight competition for airplane manufacturers vying to
build the military's next-generation long-range bomber. It wasn't
supposed to be much of a competition. In early evaluations, the
Boeing Corporation's gleaming aluminum-alloy Model 299 had trounced
the designs of Martin and Douglas. Boeing's plane could carry five
times as many bombs as the army had requested; it could fly faster
than previous bombers and almost twice as far. A Seattle newspaperman
who had glimpsed the plane on a test flight over his city called it
the “flying fortress,” and the name stuck. The flight
“competition,” according to the military historian Phillip
Meilinger, was regarded as a mere formality. The army planned to
order at least sixty-five of the aircraft.
“A
small crowd of army brass and manufacturing executives watched as the
Model 299 test plane taxied onto the runway. It was sleek and
impressive, with a 103-foot wingspan and four engines jutting out
from the wings, rather than the usual two. The plane roared down the
tarmac, lifted off smoothly, and climbed sharply to three hundred
feet. Then it stalled, turned on one wing, and crashed in a fiery
explosion. Two of the five crew members died, including the pilot,
Major Ployer P. Hill.
“An
investigation revealed that nothing mechanical had gone wrong. The
crash had been due to “pilot error,” the report said.
Substantially more complex than previous aircraft, the new plane
required the pilot to attend to the four engines, each with its own
oil-fuel mix, the retractable landing gear, the wing flaps, electric
trim tabs that needed adjustment to maintain stability at different
airspeeds, and constant-speed propellers whose pitch had to be
regulated with hydraulic controls, among other features. While doing
all this, Hill had forgotten to release a new locking mechanism on
the elevator and rudder controls. The Boeing model was deemed, as a
newspaper put it, “too much airplane for one man to fly.” The
army air corps declared Douglas's smaller design the winner. Boeing
nearly went bankrupt.
“Still,
the army purchased a few aircraft from Boeing as test planes, and
some insiders remained convinced that the aircraft was flyable. So a
group of test pilots got together and considered what to do.
“What
they decided not to do was
almost as interesting as what they actually did. They did not require
Model 299 pilots to undergo longer training. It was hard to imagine
having more experience and expertise than Major Hill, who had been
the air corps' chief of flight testing. Instead, they came up with an
ingeniously simple approach: they created a pilot's checklist. Its
mere existence indicated how far aeronautics had advanced. In the
early years of flight, getting an aircraft into the air might have
been nerve-racking but it was hardly complex. Using a checklist for
takeoff wold 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.
“The
test pilots made their list simple, brief, and to the point–short
enough to fit on an index card, with step-by-step checks for takeoff,
flight, landing, and taxiing. It had the kind of stuff that all
pilots know to do. They check that the brakes are released, that the
instruments are set, that the door and windows are closed, that the
elevator controls are unlocked–dumb stuff. You wouldn't think it
would make that much difference. But with the checklist in hand, the
pilots went on to fly the Model 299 a total of 1.8 million miles
without one accident. They army ultimately ordered almost thirteen
thousand of the aircraft, which it dubbed the B-17. And, because
flying the behemoth was now possible, the army gained a decisive air
advantage in the Second World War, enabling its devastating bombing
campaign across Nazi Germany.
“Much
of our work today has entered its own B-17 phase. Substantial parts
of what software designers, financial managers, firefighters, police
officers, lawyers, and most certainly clinicians do are now too
complex for them to carry out reliably from memory alone. Multiple
fields, in other words, have become too much airplane for one person
to fly.”
There
are two main problems. The first one is the fallibility or human
memory and attention. And, the other one is complacency. A lot of the
work we do is routine and can get overlooked. If you're confronted
with simple and routine problems; you want what engineers call a
“forcing function: relatively straightforward solutions that force
the necessary behavior–solutions like checklists.”
Peter
Pronovost (Johns Hopkins Hospital) created a checklist to try to
reduce the rate of central line infections. The central line is the
large catheter that is inserted at the top of your chest near your
collar bone. “Within the first three months of the project, the
central line infection rate in Michigan's ICUs decreased by 66
percent. Most ICUs–including the ones at Sinai-Grace Hospital–cut
their quarterly infection rate to zero. Michigan's infection rate
fell so low that its average ICU outperformed 90 percent of ICUs
nationwide. In the Keystone Initiative's first eighteen months, the
hospitals saved an estimated $175 million in costs and more than
fifteen hundred lives. The successes have been sustained for several
years now–all because of a stupid little checklist.”
“Two
professors who study the science of complexity–Brenda
Zimmerman of York University and Sholom Glouberman of the University
of Toronto–have proposed a distinction among three different kinds
of problems in the world: the simple, the complicated, and the
complex. Simple problems, they note, are ones like baking a cake from
a mix. There is a recipe. Sometimes there are a few basic techniques
to learn. But once these are mastered, following the recipes brings a
high likelihood of success.
“Complicated
problems are the ones like sending a rocket to the moon. They can
sometimes be broken down into a series of simpler problems. But there
is no straightforward recipe. Success frequently requires multiple
people, often multiple teams, and specialized expertise.
Unanticipated difficulties are frequent. Timing and coordination
become serious concerns.
“Complex
problems are ones like raising a child. Once you learn how to send a
rocket to the moon, you can repeat the process with other rockets and
perfect it. One rocket is like another rocket. But not so with
raising a child, the professors point out. Every child is unique.
Although raising one child may provide experience, it does not
guarantee success with the next child. Expertise is valuable but most
certainly not sufficient. Indeed, the next child may require an
entirely different approach from the previous one. And this brings up
another feature of complex problems: their outcomes remain highly
uncertain. Yet we all know that it is possible to raise a child well.
It's complex, that's all.”
In
trying to understand how to be successful in an increasing complex
world, Gawande drew much inspiration from the construction of large
buildings. He remembered trying to build a bookcase when he was
eleven years old, growing up in Athens, Ohio. His creation was an
absolute mess and it gave Atul an appreciation for the difficulties
of constructing things. When it comes to building large buildings,
“All together, projects today involve some sixteen different
trades.” That's quite a complicated task and Gawande makes note
that it isn't too different from medicine.
One of
the items on the construction checklist was that people take the time
to talk to each other. As simple as that may sound. Even simpler, a
point on a surgery checklist was that everybody introduce themselves
to the members of the team. The idea, in construction, is that “Man
may be fallible, but maybe men are less so.” It is the nature of
the construction checklist to believe in the wisdom of the group.
A common
reaction to risk is to central authority and power. But, that's the
exact wrong solution. Gawande writes, “In the face of an
extraordinarily complex problem, power needed to be pushed out of the
center as far as possible.” Stated differently, command-and-control
doesn't work. You want to empower the troops. Atul calls it, “A
seemingly contradictory mix of freedom and expectation.” The author
gives the example of Hurricane Katrina. The government did a lousy
job because they decided to centralize authority and power. Walmart
ended up being tremendously helpful because they made the conscious
decision to push authority and power out to where the action was
happening.
During
his research for the book, Gawande visited many locations. Including
restaurants. What he found was that cooking recipes are, indeed,
checklists. On a busy Friday or Saturday night a restaurant can serve
lots and lots of meals. The way the business assures efficiency and
consistency is through the effective use of recipes. Gawande writes,
“There seemed no field or profession where checklists might not
help.”
One area
where the problems of complexity is most pronounced is with medicine.
According to Gawande, “Worldwide, at least seven million people a
year are left disabled and at least one million dead,” after
surgery. What's more, “Studies in the United States alone had found
that at least half of surgical complications were preventable.” As
we know, doctors are very smart people. And yet they still make their
share of mistakes. In a lot of ways medicine is like trying to fly
the B-17 all by yourself. It may well be too much plane for one man.
And so, like aviation, Gawande believed that checklists could be of
great benefit to the medical field.
There
are two types of aviation checklists; DO-CONFIRM and READ-DO. The
names suggest how they work. With do-confirm lists you do what you
have been trained to do and then you check to make sure you did all
the right things. But, with read-do checklists, you first read the
list to refresh your memory about the things you need to do. In
constructing a checklist Gawande makes the following observations, “A
rule of thumb some use is to keep it to between five and nine items,
which is the limit of working memory … An inherent tension exists
between brevity and effectiveness … It should fit on one page. It
should be free of clutter and unnecessary colors … A checklist has
to be tested in the real world … First drafts always fall apart.”
“It is
common to misconceive how checklists function in complex lines of
work. They are not comprehensive how-to guides, whether for building
a skyscraper or getting a plane out of trouble. They are quick and
simple tools aimed to buttress the skills of expert professionals.
And by remaining swift and usable and resolutely modest, they are
saving thousands upon thousands of lives.”
“If
someone discovered a new drug that could cut down surgical
complications with anything remotely like the effectiveness of the
checklist, we would have television ads with minor celebrities
extolling its virtues.” But, professionals resist using them. Atul
continues,“It somehow feels beneath us to use a checklist, an
embarrassment.” But, “Good checklists could become as important
for doctors and nurses as good stethoscopes (which, unlike
checklists, have not been proved to make a difference in patient
care).”
Gawande
talks about the guys at Pabrai Investment Funds in Irvine,
California. Mohnish Pabrai, and his crew, have decided to use
checklists when making their decisions on where to invest. The folks
at PIF are value investors in the mold of Warren Buffett. Atul says,
“Neuroscientists have that found that the prospect of making money
stimulates the same primitive reward circuits in the brain that
cocaine does.” The big problem is that the cocaine brain can lead
to very bad decisions. So, what did Pabrai do? He created a checklist
to counteract the potential problems that arise from the cocaine
brain. “Forty-nine times out of fifty, he said, there's nothing to
be found.”
Dr.
Gawande also talks about the book Who by Geoff Smart. Smart's
book is basically a long checklist on the method his company teaches
for finding good people for your business. When investors are looking
for the right place to put their money, they're much more concerned
with who they invest in rather than what. Gawandes explains, “Finding
a good idea is apparently not all that hard. Finding an entrepreneur
who can execute a good idea is a different matter entirely.” Most
new businesses fail and a checklist is a great way to increase your
odds of successes.
Speaking
of success, remember the story of airplane pilot Chelsey “Sully”
Sullenberger? Well, you shouldn't read this book if you like to think
of him as some superhuman hero. Turns out that Sully was able to land
an passenger airplane on the Hudson River because of the system and
checklists the plane had on board. As Sullenberger himself said, the
crew's successful landing was do to teamwork and a checklist. It's
wasn't the work of ordinary genius and Sully doesn't view himself as
a hero.
I will
leave you with a few more notes from the book. “The routine can be
pointless most of the time … The fear people have about the idea of
adherence to protocol is rigidity … What you find, when a checklist
is well made, is exactly the opposite. The checklist gets the dumb
stuff out of the way, the routines your brain shouldn't have to
occupy itself with … We are by nature flawed and inconstant
creatures … We are not built for discipline. We are built for
novelty and excitement, not careful attention to detail. Discipline
is something we have to work at.”
Have you
ever heard the advice to fight fire with fire? Of course you have.
And, sometimes, it's really good advice. But, sometimes, it's not.
Sometimes it's much better to fight fire with water. This book is
about fighting fire with water. To combat the ills, and dangers, of
complexity Gawande is recommending one of the most simple of
solutions–the checklist. Try it, it works.