Book Review: The Checklist Manifesto

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.