These highlights are from the Kindle version of Checklist Manifesto: How to Get Things Done Right by Atul Gawande.
There are a thousand ways that things can go wrong when you’ve got a patient with a stab wound. But everyone involved got almost every step right—the head-to-toe examination, the careful tracking of the patient’s blood pressure and pulse and rate of breathing, the monitoring of his consciousness, the fluids run in by IV, the call to the blood bank to have blood ready, the placement of a urinary catheter to make sure his urine was running clear, everything. Except no one remembered to ask the patient or the emergency medical technicians what the weapon was. “Your mind doesn’t think of a bayonet in San Francisco,” John could only say.
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.
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. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.
The model of medicine in the modern age seems less and less like penicillin and more and more like what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.
On any given day in the United States alone, some ninety thousand people are admitted to intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: care for premature infants; for victims of trauma, strokes, and heart attacks; for patients who have had surgery on their brains, hearts, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, ICUs barely existed. Now, to take a recent random day in my hospital, 155 of our almost 700 patients are in intensive care. The average stay of an ICU patient is four days, and the survival rate is 86 percent. Going into an ICU, being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.
There is complexity upon complexity. And even specialization has begun to seem inadequate. So what do you do? The medical profession’s answer has been to go from specialization to superspecialization.
Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one-year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice—pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology, or critical care. A young doctor is not so young nowadays; you typically don’t start in independent practice until your midthirties. We live in the era of the superspecialist.
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.
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. The 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.
“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.
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. These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process.
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 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.
Three different kinds of problems in the world: the simple, the complicated, and the complex.
You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way.
“A building is like a body,” he said. It has a skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring. All together, he explained, projects today involve some sixteen different trades.
The major advance in the science of construction over the last few decades has been the perfection of tracking and communication.
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.
“When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error.… Guaranteed you’d run into a problem.” These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor. “David Lee Roth had a checklist!” I yelled at the radio.
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected.
“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.
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.
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.
We adopted mainly a DO-CONFIRM rather than a READ-DO format, to give people greater flexibility in performing their tasks while nonetheless having them stop at key points to confirm that critical steps have not been overlooked.
In aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process.
An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.
Surgery is risky and dangerous wherever it is done.
We have an opportunity before us, not just in medicine but in virtually any endeavor. Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.
Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.
“You go into greed mode,” he said. Guy Spier called it “cocaine brain.” Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does. And that, Pabrai said, is when serious investors like himself try to become systematic. They focus on dispassionate analysis, on avoiding both irrational exuberance and panic. They pore over the company’s financial reports, investigate its liabilities and risks, examine its management team’s track record, weigh its competitors, consider the future of the market it is in—trying to gauge both the magnitude of opportunity and the margin of safety.
“Warren,” Pabrai said—and after a $650,000 lunch, I guess first names are in order—“Warren uses a ‘mental checklist’ process” when looking at potential investments.
Pabrai made a list of mistakes he’d seen—ones Buffett and other investors had made as well as his own. It soon contained dozens of different mistakes, he said. Then, to help him guard against them, he devised a matching list of checks—about seventy in all.
“When surgeons make sure to wash their hands or to talk to everyone on the team”—he’d seen the surgery checklist—“they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.”
Smart specifically studied how such people made their most difficult decision in judging whether to give an entrepreneur money or not. You would think that this would be whether the entrepreneur’s idea is actually a good one. But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.
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.
We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.
The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But 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 (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).