The Checklist Manifesto - How to Get Things Right

Checklist Manifesto Book Cover

Written by Atul Gawande in 2009, The Checklist Manifesto is one of those books that has been recommended to me from multiple sources, so at the insistence of a new colleague, I bumped it up my list.  Atul, or Dr. Gawande as he’s known in the surgical circles, was discussing with another surgeon about non-routine haphazard in the operating room.   The first anecdote involves a man brought into the ER for a stab wound, it appears shallow and the man is drunk and seemly without pain.  Only later do they find out that he was stabbed by a bayonet and ruptured the spinal aorta.  As unlikely as it is to be stabbed by a bayonet this man nearly bled out internally because of a casual oversight.  Other gruesome medical mishaps are also mentioned, but I’ll save those for the reader.  The take-away here is that Atul realized that in spite of the massive amounts of information floating around in each of our heads, we make casual mistakes daily.  For some of us these mistakes are trivial and not life-threatening, for others, not so benign.

Chapter 1: The Problem Of Extreme Complexity

Well chapter one gets off with a blazing start and best read on an empty stomach.  As a surgeon, I’m sure Dr. Gawande doesn’t think twice about the gruesome nature of his examples.  If the imagery of a 3 y/o girl having her chest opened with a power saw doesn’t engage you, perhaps the statistics that nearly every America will visit an ICU, and that 4% of IV lines become infected after 10 days, and that 5-28% of the time that’s fatal.  Vulgarity aside, the point Dr. Gawande is attempting to illustrate is that life is complex, his examples draw a sense of morbidity, but those are his experiences.  From the line-cook at a restaurant, to the Software Engineer writing a SaaS web app, the number of tasks that must be completed correctly for our jobs to be successful are increasing.  To circumvent repeated failures, to alleviate trainee stress, we must look for ways to help ensure that every task that needs done is documented and to ensure that as tasks are completed they are documented.

Chapter 2: The Checklist

Chapter two consists of multiple stories detailing failure due to complexity and the resulting success of using a checklist.  In 1935, the B17 was unveiled for the first time.  This monumental “flying fortress” had 4 engines, twice the normal amount, and at the time was the most complex air plane ever flown.  During it’s debut flight, it crashed due to pilot error.  Instead of requiring more training, the Air Force initiated a checklist for the basics.  Afterwards, during active duty service, this plane was flown more than 1.8 million miles without incident.

Referencing the IV line infection rates previously, Dr. Gawande tells of a 2001 John Hopkins ICU test where a simple 5-step checklist was implemented to help ward off line-infections.  After 12 months of testing the infection rate dropped from 11 percent to 0 percent, extending the trial to 22 months, they had only 2 line infections.  This simple checklist prevented 43 possible infections and saved 8 lives.  It was then implemented in multiple Michigan state-run hospitals.   Over the course of 3 years it cut down the infection rate by 66% and saved an estimated 175 million dollars.

The moral of this chapter is apparently checklists are good.

Chapter 3: The End of the Master Builder

Master Builders, in the building construction sense, designed, engineered, and oversaw construction of buildings such as Notre Dame, St. Peter’s Basilica, and the US Capitol building.  Building complexity has grown so great that, to paraphrase the great Adam Smith, division of labor is the only way to productively produce.

This chapter also introduces the concept of simple problems, complicated problems, and complex problems.

  • Simple: Baking a cake; easy, repeatable steps, leads to success
  • Complicated: Rockets; lots of parts, but repeatable
  • Complex: Raising a child; every one is different, a lot of unexpected events

On that note, many things approaching the level of complex can benefit from taking a multi-disciplinary approach.  Gather together all of those people responsible and knowledgeable about the topic and come to a consensus.  This is essentially how large, complicated, complex buildings are resolved.  Sixteen different trades come together to weigh in on the different phases of building a building.  There are often conflicts during the process and having a way to mediate and resolve them keeps the project on track.

Man is fallible, but maybe men are less so.

Chapter 4: The Idea

Chapter Four contains three more checklist saving examples.  The tragic Hurricane Karina left government officials scrambling to organize relief, sensing this, Wal-Mart gave the mandate to their individual store managers to do what was needed.  The managers were instructed that they will be making decisions above them, make the best decision they could and above all else, do the right thing.  The core concept here isn’t that a private company was better equipped to handle the disaster, but that they pushed responsibility down to the front-line.  This is similar to how the Japanese principle of Kaizen operates: each employee is responsible for noticing wrong and doing the correct thing.

For Van Halen, their concert contract required a backstage bowl of M&M candies, with no brown M&Ms.  Seemingly trivial, the purpose was to ensure that the concert crew read and followed the detailed contract.  There were many levels of safety requirements in the contract and if the crew missed a simple step such as removing brown M&Ms, then it’s almost assured that they missed a more complex safety issue.

The last example is a fine dining restaurant where each station has their checklist. Essentially the crew was each following their station’s list of required actions and recipes.  All gated by either the head chef or the sous chef prior to being delivered.  The gate-keeping accounted for nearly 5% of dishes being returned.

Chapter 5: The First Try

With the volume of surgery increasing worldwide, 2004 numbers showing one major operation per twenty-five humans, the World Health Organization needed to develop a program to help reduce the number of deaths.  The largest problem being that many of these surgeries were being performed in less than ideal conditions: not clean enough, operating room members not working cohesively, missing supplies, etc.  While all of these problems were nearly insurmountable you can only guess what the author offered as a solution: a checklist.

While it’s unlikely a small group committee operating under the WHO could afford to correct all of the bad behavior in more rural operating rooms, it is possible to correct some of the behavior.  The checklist put into effect includes items such as introductions, so that each team member knows the name of the other members.  A John Hopkins research team discovered that teams that knew each other’s names were more likely to communicate better.  The checklist also includes common checks pre-anesthesia, pre-incision, and post-operation.

As a bit of an anticlimactic turn, the first pass of this checklist was unsuitable for world wide use, mainly because it was unsuitable for a single well-funded, well-educated operating room.  It was too long and too ambiguous.  That’s a ‘check’ for ‘failure to meet expectations’.

Chapter 6: The Checklist Factory

Dr. Gawande visits Boeing with the goal of uncovering how pilot checklists are created.  He engages Daniel Boorman, a veteran pilot with 20 years of experience developing checklists for Boeing planes.  Boorman explains that checklists need to be succinct and include only the big items that are easy to miss or can cause catastrophic losses.  Often checklists don’t include tasks such as ‘contact Air Traffic Control’, ‘alert crew’, etc.  This is because the pilots know and seldom do not forget such steps.  Any additional checklist items that are redundant or not helpful need to be trimmed to avoid a long, cumbersome checklist that gets ignored.

Checklists are broken down into two distinct types.

  • DO-CONFIRM - job performed from memory, checklist used to make sure no task are missed
  • READ-DO - each item is read and performed in order

A DO-CONFIRM list is similar to a weekend chore list, order isn’t always important, but the list is there to help ensure nothing is forgotten.  A READ-DO is akin to a recipe, order is important and forgetting a single step or doing anything out of order can ruin the outcome.

The length of the list is imperative to the task at hand.  A task that needs to be completed within 20 seconds needs to be super short, perhaps 2-5 items maximum.  A task that possibly has minutes to complete may have more items.  In either case, checklist items need to be short and to the point, they are to remind professionals of the details, not explain to an apprentice how the task should be accomplished.

Chapter 7: The Test

After re-writing the test using the information from Danniel Boorman and mimicking the short and to-the-point checklist that pilots use, a test was put in place.  Either hospitals around the world were selected for the pilot checklist was tested.  Four were wealthier hospitals, while four were in middle to poor countries.  Each required some amount of modification to fit with their local practices.  All in all though, the 19-step checklist was put into effect.  Three months prior to implementing the checklist, surgeries were monitored and a baseline was established.  The same kind of monitor was carried through after the checklist was implemented.  Results were good, mostly double digit improvements in patient health and care.  Both wealthy and poor hospitals benefited from the new and improved checklist.

Chapter 8: The Hero in the Age of Checklists

The greatest accomplishment of any idea is the generalization of it into new areas.  The methodological nature of a checklist for medical procedures lends itself well to other, often qualitative, areas, investing for instance.  Dr. Gawande interviews and shares his checklist ideas with two of my favorite investors, Mohnish Pabrai and Guy Spier.  Both are using checklists successfully in their investment processes.  Pabrai has a 70 item checklist generated from mistakes he’s made and witnessed in his years of researching investments.

In further support of the pilot checklist, shortly after the WHO’s safe surgery checklist was made public the famous emergency landing of the US Airways Flight 1549 into the Hudson River by Captain Chesley B. “Sully” Sullenberger III.  Despite his continued attention, he constantly attributes the successful landing to the procedures put in place by people like Daniel Boorman of Boeing (though this was an Airbus A320), and his crew.  It was the proper action of everyone aboard and a handful of lucky events that allowed the plane to land without engines and suffer no causalities.

Chapter 9: The Save

This chapter retells a previous story of the checklist saving a patients life.  A routine procedure with a very low but non-zero probability of a catastrophe, 4-units of blood were not set aside as expected and the checklist caught that.  The patient ended up needing 30 units of blood, but those 4 were readily available to keep him alive while the rest of the team scrambled.