“The Checklist Manifesto” by Atul Gawande


.Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that 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.

The Checklist Manifesto chronicles Dr. Gawande’s quest to better understand the sources of the greatest stresses and failures in the practice of medicine. From an essay he read in college, he gathers that there are two kinds of failure: those of ignorance and ineptitude. “Failures of ignorance we can forgive,” he says, “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.” To remind us to apply this knowledge correctly, he happens upon a simple solution—the checklist.

He emphasizes with our inherent resistance to such a simple fix. He understands that a checklist feels by its very nature robotic and ‘soulless’ but says that a well-designed one doesn’t have to squelch our heroism. Across industries, from aviation to construction, Dr. Gawande shows that a checklist can get the routine and known checked off so we can focus our full attention on the parts of our jobs that include uncertainty.

Our world is complicated, and any method of better organizing all of our knowledge and information is much needed. Mundane as they are, the checklist has been shown to save lives and money in just about any place it’s methodically used.

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I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It is not money or government or the threat of malpractice lawsuits or insurance company hassles–although they all play their role. It is the complexity that science has dropped upon us and the enormous strains we are encountering in making good on its promise.

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.

One needs practice to achieve mastery, a body of experience before one achieves real success.

The ninth edition of the World Health Organization’s international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury–more than thirteen thousand different ways, in other words, that the body can fail. And, for nearly all of them, sciences has given us things we can do to help. If we cannot cure the disease, then we can usually reduce the harm and misery it causes. But for each condition the steps are different and they are almost never simple. Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right.

The software used in most American electronic records has not managed to include all the diseases that have been discovered and distinguished from one another in recent years. I once saw a patient with a ganglioneuroblastoma (a rare type of tumor of the adrenal gland) and another with a nightmarish genetic condition called Li-Fraumeni syndrome, which causes inheritors to develop cancers in organs all over their bodies. Neither disease had yet made it into the pull-down menus. All I could record was, in so many words, “Other.” Scientists continue to report important new genetic findings, subtypes of cancer, and other diagnoses–not to mention treatments–almost weekly. The complexity is increasing so fast that even the computers cannot keep up.

In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. 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.

A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. in complex processes, after all, certain steps don’t always matter. “This has never been a problem before,” people say. Until one day it is.

Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance.

For most of modern history, he explained, going back to medieval times, the dominant way people put up buildings was by going out and hiring Master Builders who designed them, engineered them, and oversaw construction from start to finish, portico to plumbing. Master Builders built Notre Dame, St. Peter’s Basilica, and the United States Capitol building. But by the middle of the twentieth century the Master Builders were dead and gone. The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them.

No, 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.

This was the understanding people in the skyscraper-building industry had grasped. More remarkably, they had learned to codify that understanding into simple checklists. They had made the reliable management of complexity a routine.

The routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of check to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how.

The soap experiment changed that. The field-workers have specific instructions on hand-washing technique–on the need to wet both hands completely, to lather well, to rinse all the soap off, even if, out of necessity, as the published report noted, “hands were typically dried on participants’ clothing.” The instructions also got people used to washing at moments when they weren’t used to doing so. “Before preparing food or feeding a child is not a time when people think about washing,” Luby explained. The soap itself was also a factor. “It was really nice soap,” he pointed out. It smelled good and lathered better than the usual soap people bought. People liked washing with it. “Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not.” Lastly, people liked receiving the soap. The public health field-workers were bringing them a gift rather than wagging a finger. And with the gift came a few basic ideas that would improve their lives and massively reduce disease.

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. But in medicine, we see it all the time. I’ve seen it in my own operating room.

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.

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situatiuons in which they are to be deployed. They treat people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.

Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything–a checklist cannot fly a plane. Instead, 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.

The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them.


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