The Checklist Manifesto (Atul Gawande)

A wonderful example of taking an idea from one domain (flying aircraft) and applying it in another (surgery) to make a dramatic impact in terms of reliability of outcomes for complex processes - ie a greatly reduced death rate.

Contains some gory stories of what can go wrong in hospitals and how implementing simple checklists and requiring communications can help to prevent them.

The book explains how you cannot force central control in complex unpredictable situations but that checklists avoid the simple repetitive parts of a process getting forgotten.  The defined breaks for communications and the shifts in power to allow the whole team to speak up with concerns improve both teamwork, motivation and outcomes.



Locn. 486-88 Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.
Locn. 531-33 The researchers found that simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.
Locn. 597-99 Michigan’s infection rates 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.
Locn. 638-41 Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.
Locn. 703-6 So as I looked up at this whole building that had to stand up straight even in an earthquake, puzzling over how the workers could be sure they were constructing it properly, I realized the question had two components. First, how could they be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly?
Locn. 1015-20 the giant discount retailer’s chief executive officer, Lee Scott, issued a simple edict. “This company will respond to the level of this disaster,” he was remembered to have said in a 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.” As one of the officers at the meeting later recalled, “That was it.” The edict was passed down to store managers and set the tone for how people were expected to react.
Locn. 1029-32 Senior Wal-Mart officials concentrated on setting goals, measuring progress, and maintaining communication lines with employees at the front lines and with official agencies when they could. In other words, to handle this complex situation, they did not issue instructions. Conditions were too unpredictable and constantly changing. They worked on making sure people talked.
Locn. 1051-55 the real lesson is that 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, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals.
Locn. 1162-63 The volume of surgery had grown so swiftly that, without anyone’s quite realizing, it has come to exceed global totals for childbirth—only with a death rate ten to one hundred times higher.
Locn. 1165-67 Worldwide, at least seven million people a year are left disabled and at least one million dead—a level of harm that approaches that of malaria, tuberculosis, and other traditional public health concerns.
Locn. 1442-45 It felt kind of hokey to me, and I wondered how much difference this step could really make. But it turned out to have been carefully devised. There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do.
Locn. 1449-1645 The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up. These were limited studies and hardly definitive. But the initial results were enticing. Nothing had ever been shown to improve the ability of surgeons to broadly reduce harm to patients aside from experience and specialized training. Yet here, in three separate cities, teams had tried out these unusual checklists, and each had found a positive effect. At Johns Hopkins, researchers specifically measured their checklist’s effect on teamwork. Eleven surgeons had agreed to try it in their cases—seven general surgeons, two plastic surgeons, and two neurosurgeons. After three months, the number of team members in their operations reporting that they “functioned as a well-coordinated team” leapt from 68 percent to 92 percent. At the Kaiser hospitals in Southern California, researchers had tested their checklist for six months in thirty-five hundred operations. During that time, they found that their staff’s average rating of the teamwork climate improved from “good” to “outstanding.” Employee satisfaction rose 19 percent. The rate of OR nurse turnover—the proportion leaving their jobs each year—dropped from 23 percent to 7 percent. And the checklist appeared to have caught numerous near errors.

 When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory 
Locn. 1648-50 The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. Boorman didn’t think one had to be religious on this point.
Locn. 1724-27 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.
Locn. 2100-2106 In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room. Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care. Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?” A full 93 percent said yes.
Locn. 2250-58 When he first introduced the checklist, he assumed it would slow his team down, increasing the time and work required for their investment decisions. He was prepared to pay that price. The benefits of making fewer mistakes seemed obvious. And in fact, using the checklist did increase the up-front work time. But to his surprise, he found they were able to evaluate many more investments in far less time overall. Before the checklist, Cook said, it sometimes took weeks and multiple meetings to sort out how seriously they should consider a candidate investment—whether they should drop it or pursue a more in-depth investigation. The process was open-ended and haphazard, and when people put a month into researching an investment, they tended to get, well, invested. After the checklist, though, he and his team found that they could consistently sort out by the three-day check which prospects really deserved further consideration and which ones didn’t. “The process was more thorough but faster,” he said. “It was one hit, and we could move on.”
Locn. 2308-9 Smart published his findings more than a decade ago. He has since gone on to explain them in a best-selling business book on hiring called Who.
Locn. 2372-78 Here are the details of one of the sharpest checklists I’ve seen, a checklist for engine failure during flight in a single-engine Cessna airplane—the US Airways situation, only with a solo pilot. It is slimmed down to six key steps not to miss for restarting the engine, steps like making sure the fuel shutoff valve is in the OPEN position and putting the backup fuel pump switch ON. But step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE. Because pilots sometimes become so desperate trying to restart their engine, so crushed by the cognitive overload of thinking through what could have gone wrong, they forget this most basic task. FLY THE AIRPLANE. This isn’t rigidity. This is making sure everyone has their best shot at survival.
Locn. 2475-96 We’re obsessed in medicine with having great components—the best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well. Berwick notes how wrongheaded this approach is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment of trying to build the world’s greatest car by assembling the world’s greatest car parts. 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.” Nonetheless, in medicine that’s exactly what we have done. We have a thirty-billion-dollar-a-year National Institutes of Health, which has been a remarkable powerhouse of medical discoveries. But we have no National Institute of Health Systems Innovation alongside it studying how best to incorporate these discoveries into daily practice—no NTSB equivalent swooping in to study failures the way crash investigators do, no Boeing mapping out the checklists, no agency tracking the month-to-month results. The same can be said in numerous other fields. We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point. We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber—a machine so complex no one was sure human beings could fly it. They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist. And so can we. Indeed, against the complexity of the world, we must. There is no other choice. When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It’s time to try something else. Try a checklist.