The checklist manifesto: how to get things right. By Atul Gawande, 2009
0 introduction
a story of a stabbed man without knowing how deep the assailant’s knife went.
a story of a cancer operation when the patient’s heart suddenly stopped, due to the overdose of potassium by an anesthesiologist
As Goroviz and MacIntyre point out, we have just 2 reasons that we may nonetheless fail:
- ignorance. We only have partial understanding of the world
- ineptitude. though knowledge exists, yet we fail to apply it correctly.
1 The problem of extreme complexity
A story of a 3-year-old drowned girl, heart stop 2 hours before resuming, all organs recovered after 2 days except her brain. She went home after 2 weeks.
There is complexity upon complexity. And the answer is to go from specialization to super-specialization.
2 checklist
a story of Boeing Model 299 that is difficult to operate with too many details.
The vital signs every hospital records: body temperature, pulse, blood pressure, and respiratory rate.
In a complex environment, experts are up against 2 main difficulties:
- 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.
- people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter.
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.
3 The end of the master builder
Brenda (York Univ.) and Sholom (Univ. of Toronto) proposed 3 different kinds of problems in the world:
- simple: recipe, such as baking a cake
- complicated: like sending a rocket to the moon. Unanticipated difficulties are frequent.
- complex: like raising a child. Each child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. The next child may require an entirely different approach from the previous one. The outcomes are highly uncertain.
A story of the construction of a skyscraper.
I saw a line-by-line, day-by-day listing of every building task that needed to be accomplished, in what order, and when. The schedule spread over multiple sheets. There was special color coding, with red items highlighting critical steps that had to be done before other steps could proceed.
submittal schedule: it is also a checklist, but it didn’t specify construction task; it specify communication tasks. The project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another — on X data regarding Y process.
They don’t believe in the wisdom of the single individual, but in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem.
There’s program called ProjectCenter to deal with the tracking and communication
They trust in one set of checklists to make sure the simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems.
The biggest cause of serious error in this business is a failure of communication.
4 The idea
2005 Katrina catastrophe.
The government did a poor job because it relies on a traditional command-and-control system which rapidly became overwhelmed. There are too many decisions to be made and too little information about precisely where and what help was needed. In face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible.
Walmart best recognized the complex nature of the circumstances. CEO Lee Scott said, “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 do the right thing.”
Senior Walmart officials concentrated on setting goals, measuring progress, and maintaining communication lines. In a complex situation when conditions are too unpredictable and constantly changing, they did not issue instruction but worked on making sure people talked.
They had learned to codify that understanding into simple checklists.
Under conditions of complexity, not only are checklists a help, they are required for success.
Restaurant.
While Burger Kings and Taco Bells are driven by tightly prescribed protocol, in great restaurants the food is ever-evolving, refined, and individual.
Following the recipe is essential to making food of consistent quality over time.
In one case, a dish took too long for the eight-to-ten-minute turn-around that customers expect, so they re-engineered the dish, pre-prepared for the sauce and put into repeated test runs. the recipe was rewritten.
The chef also had developed a communication checklist to ensure people recognized and dealt with unexpected problems as a team. Half an hour before opening, everyone gathers in the kitchen for a quick check to discuss unanticipated issues and concerns, such as reservation count, menu changes, fill in for a sick staff member, and a party of 20 delayed into the dinner rush.
5 the first try
In 2006, a woman from world health organization request help to reduce avoidable deaths and harm from surgery. One of the benefits of joining up to work with WHO was gaining access to the health system reports and data from the organization’s 193 member countries. By 2004, surgeons were performing 230 million major operations annually.
In developing countries, the contaminated water is a source of many diseases. However, you have to wait decades for major infrastructure projects. So instead, they have to look for a low-tech solution.
Stephen Luby persuaded P&G to provide a grant for a proper study and to supply Safeguard soap with or without the antibacterial agent to a Pakistan neighborhood. They encourage people to use soap in 6 situations:
- wash bodies daily
- wash hands after they defecate
- wipe an infant
- before eat
- prepare food
- feed it to others
Each family received 3.3 bars of soap per week for one year. During this period, the incidence of diarrhea fell 52% no matter which soap was used. The secret is that the soap is more than soap. It is a behavior-changing delivery vehicle.
We want people to wash a lot. And people are quite poor. So we remove that as barrier.
The soap itself is also a factor. 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 cosumer experience than public health people.
antibiotic
The step of applying antibiotic before an incision is commonly missed. Solution is:
- a check box for the nurse to verbally confirm with the team
- a metal tent was designed to cover a scalpel, serving as a reminder to run the checklist before making the incision.
- It is also important to make clear that the surgeon could not start the operation until the nurse gave the okay and remove the tent. With this subtle cultural shift, even a modest checklist had the effect of distributing power.
There are 4 big killers in the surgery world: infection, bleeding, unsafe anesthesia and unexpected. A classic checklist could solve the first 3 except the last one. So they had determined that the most promising thing to do was just to have people stop and talk through the case together — to be ready as a team to identify and address each patient’s unique, potentially critical dangers.
Brian Sexton, a Johns Hopkins psychologist found that 1/4 surgeons believe that junior team members should not question the decisions of a senior practitioner. It turns out, the most common obstacle to effective teams is a kind of silent disengagement.
Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork.
Before starting an operation with a new team, there was a check to ensure everyone introduced themselves by name and role. Psychology studies show that people who don’t know one another’s names don’t work together nearly as well as those who do.
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.
6 the checklist factory
Boeing example. fuel freezing to ice makes the plane lose power and crash.
Bad checklists are vague and imprecise.
Good checklists are efficient and easy to use even in the most difficult situations. They don’t try to spell out everything — a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps.
The checklist can’t be lengthy. A rule of thumb is 5~9 items, which is the limit of working memory. It depends on how many seconds you have.
Some use the checklist as it is, but many went on to make their own adjustments. Just as schools and hospitals tend to do things slightly differently, airlines are encouraged to modify the checklists to fit into their usual procedures.
7 The test
In aviation, “pilot not flying” starts the checklist. This is to spread responsibility and the power to question.
Using the checklist involved a major cultural change — a shift in authority, responsibility, and expectations about care.
Forcing the obstinate few to adopt the checklist might cause a backlash that would sour others on participating. We asked the leaders to present the checklist as simply a tool for people to try in hopes of improving their results.
8 The hero in the age of checklist
Just ticking boxes is not the ultimate goal, embracing a culture of teamwork and discipline is.
A story of investors. They don’t buy according to some computer algorithm. They do intensive research and invest for the long run.
Cook enumerated the errors known to occur at any point in the investment process — during the research phase, decision making, execution of the decision and even after making an investment. He then designed detailed checklists to avoid the errors, with clearly identified pause points to run through the items.
The checklist doesn’t tell him what to do, but help him be as smart as possible, ensuring he’s got the critical information, he’s systematic about decision making and he’s talked everyone he should.
Psychologist Geoff Smart studied how venture capitalists made their most difficult decision in judging whether to give an entrepreneur money or not. Finding an entrepreneur who can execute a good idea is more difficult than have a good idea. 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.
There are styles of thinking:
- art critics. based on intuition and long-term experience
- sponge. soaking every information then go with whatever their guts told them.
- prosecutor. interrogate entrepreneurs aggressively, testing them with challenging questions
- airline captains. methodical, checklist-driven approach. They forced themselves to be disciplined and not to skip steps.
Smart wrote a book, who, to explain this finding. But the major investor taking the checklist-driven approach doesn’t increase significantly.
We don’t like checklists. They’re not much fun. It is an embarrassment to our deep belief that the heroes improvise and handle situations of high stakes and complexity.
Hudson River Hero Sully Sullenberger III said it was crew effort. But we insist that’s just the modesty of the quiet hero. We don’t want to talk about teamwork and procedure. We want to talk about how great Sully is.
Professionalism has 4 common elements to expect:
- selflessness
- skill
- trustworthiness
- discipline
The most difficult is discipline. We are not built for discipline. We are built for novelty and excitement, not for careful attention to details. Discipline is something we have to work at.
Airlines put a publication date on all their checklists, because they are expected to change with time.
Technology can increase our capabilities, but it can’t deal with the unpredictable or manage uncertainty.
We’re obsessed with having great components, but pay little attention to how to make them fit together well.
