BOOK REVIEW: The Checklist Manifesto by Atul Gawande

The Checklist Manifesto: How to Get Things RightThe Checklist Manifesto: How to Get Things Right by Atul Gawande
My rating: 5 of 5 stars

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Checklists have a bad, bureaucratic rap. Like Taylor’s time and motion studies and forms filed in triplicate, checklists seem to exist only to compound the drudgery of the workplace. Furthermore, many of the sectors in which checklists are most necessary are also those in which they are certain to be resisted—i.e. places in which there is a strong leader who is unused to having his or her instructions challenged: e.g. operating rooms and airplane cockpits. The element that ties those two locations together (along with other places where checklists are found) is that they are domains in which extremely complex activities take place, and in which one missed detail can have tragic consequences.

While the main story being told in this book is about the author’s experience leading a task force to build a surgical checklist and research its efficacy via a global study. However, Dr. Gawande takes us on the rounds of industries that found checklists before medicine did, and which had a thing or two to teach doctors about building and using them—notably the construction and air travel industries.

The book consists of nine chapters. After an Introduction that features a surgical case exemplifying how unexpected case characteristics can easily be overlooked when seconds count, the problem of extreme complexity is described as a rationale of the need for checklists in Chapter 1. While we tend to think we humans are tailor-made for complexity, the fact of the matter is that we aren’t. Mother Nature gives no capabilities that aren’t demanded to survive in the environment in which one evolved. So while we’ve done a great deal of cultural evolution to increase our capacity to deal with complexity (checklists included), the fact of the matter is that our minds and bodies are limited instruments. We can only hold a few items in short-term memory at once. We are no good at multi-tasking—despite the fact that most people feel otherwise. And when stress throws us into “fight or flight” mode, we develop tunnel-vision, not helping our capacity to see the minutiae in the big picture.

Chapter 2 delves into the checklist as solution to the aforementioned problem of extreme complexity. This chapter begins with the story of a bomber aircraft that had awesome capabilities but was deemed too complex for a single pilot to fly. (All it needed was a checklist.) The chapter then goes into medical examples. The first is a study of one of the major cause of infections: central line insertions. This offers a prime example of a procedure in which medical staff members know exactly what to do, but often small details are overlooked leading to disastrous outcomes. Then there is the case in which a little girl was saved against apparently impossible odds, in part due to a checklist performance.

Chapter 3 is entitled “The End of the Master Builder,” and as that name suggests, it’s largely about the role of checklists in construction. Construction can be compared and contrasted with medicine. The major similarity is that both fields have such high degrees of complexity that many specialists must be involved. The major difference is that time isn’t so critical in construction. (Just stopping and mulling over a solution is frequently not an option in surgery.) The biggest takeaway of this chapter is that it’s not only the tasks to be performed that need to be on the checklist but also the communication between team members.

Chapter 4 explains how centralized decision-making can be death in complex environments. The principle case discussed was how Wal-Mart out-performed the government in the wake of Hurricane Katrina in large part because leadership supported but did not dictate to managers of the stores in the storm-damaged area. However, the most fascinating piece of information for me was the explanation of why Van Halen had its infamous contract rider about having a bowl of M&M’s with all the brown ones removed. Apparently, no one cared about the candy. It was just an easy way to see at a glance whether anyone had been through the minutiae of the document–minutiae that included critical information such as how much weight the stage had to accommodate—i.e. safety issues not so easily observed but which would be potentially devastating if missed.

Chapter 5 tells the story of the World Health Organization (WHO) contacting Dr. Gawande and his first attempt at building and implementing a surgical checklist. As to be expected, there was a lot about that initial trial that wouldn’t work.

This led the author to go to what he calls “The Checklist Factory” in Chapter 6. Said “factory” is at Boeing, and it writes and updates all the checklists for Boeing aircraft—which are then modified by the individual airlines, presumably within limits governed by regulatory agencies. While the construction people taught Gawande that communication had to be on the checklist, the aircraft people taught him the need to simplify. One can’t put every detail on the list, only those that could be easily overlooked with devastating consequences. (i.e. One doesn’t need to write “Make an incision” because that’s impossible to forget, but one does include “Ensure antibiotics were delivered.”) Boeing also taught the author that there are two different flavors of checklist: READ-DO and DO-CONFIRM.

Chapter 7 describes the pilot study of the revised surgical checklist in eight hospitals in eight different countries (four developed and four developing.)

Chapter 8, “The Hero in the Age of Checklists,” explores the problem mentioned above about there being resistance in a many sectors (including medicine) because those leaders have rock star vibe going. We admire risk-takers and those who excel under pressure, but checklists seem to run counter to those traits. Thus, even when it’s clear that checklists save lives, there can be a reluctance to adopt them. Of course, as in the airline industry, eventually the checklist becomes accepted, and its use becomes second nature.

Chapter 9 tells of one of the author’s own surgical foibles, and how it led him to work to improve the procedure in order to reduce the risk of that kind of accident. It’s also an example of how the checklist kept the tragedy from being much worse.

This book has its sources annotated, but contains no graphics or other ancillary matter.

I’d recommend this book, particularly for those who work in the domain of complexity. However, I read it because it was referenced in a book I’d read on decision-making under fear. So it may also be of interest to you if you’re into questions of optimal human performance.

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POEM: Three Tanka City

Stiff iron trusses
skeletonize a building
outlining order
wind whistles over I-beams
flexing,  moaning, and rising

Steel lugged upward
welded into false order
chaotic city
don’t pretend order reigns here
litter skitters on the wind

From: the Butterfly
To: the city residents
Sorry my flapping
caused the storm that destroyed your
lovely burgh. I didn’t know.