The Checklist Manifesto: How to Get Things Right

There is no promise in this book to help you make checklists. What Gawande does is show us his process. IT IS THE SCIENTIFIC METHOD The process itself is imperative to finding the result. It is a process of POSING A QUESTION; How can we make operating rooms safer? Then RESEARCHING THE QUESTION e.g. how do others who deal with complicated processes prevent them from going awry? He checks the construction industry and then the airline industry.He DRAWS AN HYPOTHESIS: Checklists will make operating rooms safer. He takes what he learned and applied it to one area of medicine. He makes up a checklist and tests it, then revises it. TESTING HIS HYPOTHESIS AND THEN HE DRAWS A CONCLUSION: CHECKLISTS WORK. In other words he used critical thinking skills, which are sorely lacking in our culture. Checklists can't be spoon fed. You have to figure out what works for your given problem and go through the same process of refinement. The greatness of this book is that Gawande is a talented writer and engages us in his process. He has an innate curiosity which enables him to set aside his ego enough to research, question and even institute the checklist in his own hospital- The glorious Brigham and discover surprise, surprise that it improves care even in this auspicious institution.He has enough humility to admit his own mistakes and use them to teach us how not to make them and how the culture change caused by the checklist improves teamwork and saves lives. It is important to realize that this book is about far more than a checklist. It is about how an instrument like this can effect a culture change. The checklist mandates that the surgeon acknowledge the members of his team. This empowers them and motivates them to give their best effort for the patient's benefit. It causes them to focus on the task at hand. It also forces the surgeon to regard each patient as a human being with a surgical problem not a surgical problem that happens to exist in a human being. Dr. Gawande is surprised that not only are the specific items on the checklist improved, but the over all complication rate improves. This should be no surprise. Being careful carries over to all aspects of CARE. The more meticulous the care, the fewer the complications. Readers interested in this subject should also read Dr. Gawande's previous books Complications: A Surgeon's Notes on an Imperfect Science Better: A Surgeon's Notes on Performance and Peter Pronovost's Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out

The KISS principle states that simplicity should be a key goal in design, and that unnecessary complexity should be avoided. When translated, KISS stands for "keep it short and simple." There are few authors today that are willing to tell the truth and be objective, while still maintaining credibility. I would like to address Atul Gawande's most recent entry and classic, "The Checklist Manifesto: How To Get Things Right." Gawande is also the author of Better and Complications, a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, an associate professor at Harvard Medical School and the Harvard School of Public Health, and leads the World Health Organization's Safe Surgery Saves Lives program. Quite an impressive resume Mr. Gawande has there; however, his ego never gets to him. His "down-to-earth" approach to the implementation of checklists is wholly inspirational. In The Checklist Manifesto, Gawande attempts to redefine society's mentality through his ability to write cleverly and eloquently while being objective and straight to the point. He supports his in-depth research and provides a variety of careers and fields where a simple checklist can be implemented. In fact, it works. Gawande establishes his cleverness and objectiveness early in the The Checklist Manifesto. He talks about a true story of how an anesthesiologist used the wrong concentration of potassium that he'd intended. In fact, the anesthesiologist used "a concentration one hundred times higher" (Gawande 6). The team did everything they could to try to stabilize the patient: "The surgical team was so shaken they weren't sure they could finish the operation. They'd not only nearly killed the man but also failed to recognize how. They did finish the procedure though" (Gawande 7). Now, you may be sitting there thinking "Why would it matter if they made a mistake? As long as the surgical team was able to save the patient, then it shouldn't matter, right?" Let me ask you this question: "Are we to rely on luck over and over again?" This was just one patient and a simple mistake almost killed the patient. By spending a few seconds (or even minutes) looking over and using a checklist, you can substantially minimize potential mistakes. Gawande also tells the reader of an instance in aviation where a Delta Air Lines flight from Shanghai to Atlanta with 247 people aboard almost crashed on November 26, 2008. The engine failed because of icy conditions. The pilot and copilot "got out their checklist and followed the lessons it offered" (Gawande 135). Because of what they did, the engine recovered and all 247 people were saved. "If you were having an operation, would you want the checklist to be used? A full 93 percent said yes" (Gawande 157). This was a survey taken by medical professionals. Gawande is consistent in being clever throughout The Checklist Manifesto and never loses his focus on the importance of checklists. Gawande is able to capture medicine in all of its complex and chaotic glory. He inspires all of us, doctor or not, to lose our ego, implement a simple checklist, and be better. Less is more. Keep it simple. I highly recommend The Checklist Manifesto by Atul Gawande to any reader because it can apply to the lives of just about anyone. Gene

The author, Dr Atul Gawande is an American general and endocrine surgeon, and public health researcher. I have been meaning to read and review his book for many years. What a fitting introduction to ‘The Checklist Manifesto: How to Get Things Right.’ Philosophers Samuel Gorovitz and Alasdair MacIntyre tackled the issue of why we fail at what we set out to do in the world. One reason, they explain is “necessary fallibility”, a consequence of some things in the world, and our lives, being beyond our understanding and control. But there is much that is not, and yet we fail at these too. Gorovitz and MacIntyre suggest that there are two reasons for this: ignorance and ineptitude (incompetence or clumsiness.) For most of human history, people’s lives have been lived largely in ignorance. However, over the last few decades, science has filled in enough knowledge to make our ‘ineptitude’ as much of a challenge as our ‘ignorance’ was in the past. Gawande’s context is the ineptitude in medicine. While our knowledge and sophistication has grown enormously, the struggle is still how to deliver on this know-how. The knowing-doing gap is found everywhere. From the frequent mistakes authorities make when disaster strikes, to the legal mistakes our lawyers make that are the result of little more than simple administrative errors. “Every day there is more and more to manage and get right and learn,” Gawande points out. With all we are required to manage, failure happens far more often - despite great effort rather than from a lack of it. Expertise has been seen as the solution to ineptitude in most areas of work – “they need more training!” and modern medicine has been no different. But capability clearly isn’t our primary difficulty; in most fields training is longer and more intense than ever. In the early twentieth century, you could practice medicine with only a high school diploma and a one-year medical degree. Today doctors have six years of university, and three to seven years of residency to practice paediatrics, surgery, neurology, or the like. Yet our failures remain frequent, but there is a solution – checklists. Though this seems almost ridiculous in its simplicity - especially to those of us who have spent years carefully developing ever more advanced skills - it has proven not to be. In 1935 the US Army was looking for the next generation long-range bomber. Boeing’s aluminium-alloy Model 299 was able to carry five times as many bombs as the army had requested, and could fly faster and farther than previous bombers. The army planned to order at least 65 planes until it stalled on a test flight, turned on one wing, and exploded. The crash, attributed to ‘pilot error, killed 2 of the 5 crew members. This prompted Boeing to come up with an ingeniously simple approach: they created a pilot’s checklist. It is worth noting that using a checklist for takeoff was about as odd as using a checklist to back out of your garage. However, flying this new plane was too complicated to be left to the memory of any person, no matter how expert. The test pilots made checklists for takeoff, flight, landing, and taxiing, and armed with the checklist, flew a total of 1.8 million miles without one accident. The army ultimately ordered almost 13,000 planes. Like flying, many areas of our lives and work have become “too much airplane for one person to fly.” Faulty memory and distraction are a constant danger in “all-or-none processes” like going to the shop to buy ingredients for a cake, piloting a plane through a takeoff, or treating a sick person in the hospital. “If you miss just one key thing, you might as well not have made the effort at all,” says Gawande. Another human danger you may well recognize, is allowing yourself to skip steps even when you remember them. You skip steps because it has never been a problem before – until one day it is. Checklists can provide protection against such lapses, as they remind us of the minimum necessary steps. Professors Zimmerman and Glouberman distinguish between 3 different kinds of problems: the simple, the complicated, and the complex. ‘Simple problems’ are ones like baking a cake from a recipe with a few basic techniques you need to learn. Master them and you most likely will have success. ‘Complicated problems’ are like sending a rocket to the moon. There is no straightforward recipe, and success usually requires many people and great expertise. Unanticipated problems are common, and timing and coordination become serious concerns. ‘Complex problems’ are like raising a child. You can’t repeat and perfect the process as you can with rockets. Every child is unique, and while expertise is valuable, it is not sufficient. The outcome remains highly uncertain. The value of checklists for simple problems is self-evident: that is why we have a shopping list. But much of the most critical work people do, is not simple. Checklists help prevent failure especially when the problems combine everything from the simple to the complex. The real value of checklists is in conditions of true complexity, where the knowledge requirements exceed that of any individual, and unpredictability reigns. Commands and control from the centre will fail. Under these conditions, not only are checklists a help, they are essential for success. In these complex situations where individuals must exercise their own judgement, this judgement will be enhanced by checklist procedures. Bad checklists are vague and imprecise, too long and hard to use. They are written as if the people using them are stupid, and they try to spell out every single step. Good checklists, are precise and begin with the premise that a checklist cannot fly a plane. That is why, faced with catastrophe, pilots are astonishingly willing to turn to their checklists. Checklists come in two forms: DO-CONFIRM and READ-DO. Using a DO-CONFIRM checklist, people do jobs from memory and experience, then stop and check. Using a READ-DO checklist, people carry out the tasks as they check them off, like a recipe. To get value from checklists, they must make sense for the particular situation. A rule-of-thumb is to keep it to between five and nine items, simply worded, and exact. Does this work? This was rigorously tested in the World Health Organization’s ‘safe surgery’ research across a variety of hospitals of different sizes, rich and poor, in countries from Tanzania to the US. In this carefully constructed study, a 2-minute, 19 step surgery checklist, resulted in an immediate drop in infection and mortality in thousands of operations in 8 participating hospitals. Major complications dropped 36%, and deaths fell by 47%. That is how much a checklist can add to the skills of highly trained, highly skilled surgeons. It is worth a serious try in your business. You will get startling results too. Readability Light ---+- Serious Insights High +---- Low Practical High +---- Low *Ian Mann of Gateways consults internationally on leadership and strategy, and is the author of the recently released Executive

As a physician, I found it to be not only an excellent read, but also a useful information tool for my day-to-day activity. I read most of his works! Gifted writer!

This book can be very helpful in showing how a simple check list could help your life or career. Please read and enjoy.

This was an interesting book. The stories of the medical situations that caused the author to develop and use checklists are incredible. If I ever have surgery i will be asking if they use checklists. The title, "The Checklist Manifesto", fits the theme of the book as to how important checklists can be. The weak part of the book is the follow through of the subtitle, "How to get things right". One would expect more of how to use checklists, how to develop checklists, and how to implement them. None of this really appears. The stories do give a hint as to what a checklist should be- short, easy to use, and versatile, but that is the extent of advice. The book is worth the read just from the the stories, but falls short of a "how to" book. So with the right expectation, I would recommend it.

It's a little strange to say that I enjoyed a book about checklists, but it was great. The author's stories are meaningful and memorable, which made it a fast, engaging read. The case for using checklists is laid out convincingly, and it made me think about which of my workflows would benefit from having an associated checklist.

In all professions experts face a rise in complexity due to increased domain knowledge. The traditional answer has been to specialize into an ever-smaller niche to be able to keep the expert status. Besides creating the undesirable second order consequence that too few have the ability to overview larger areas, this strategy is also running out of steam when it comes to avoiding mistakes. However, there is a way to improve performance without any increase in skill – checklists. Atul Gawande, MD, MPH, is one of those persons that make you wonder if they somehow have discovered a parallel universe with more hours than your own. He is a practicing surgeon, a professor, public-health researcher and sits on various boards. Gawande has been a staff writer for The New Yorker magazine since 1998, has written three New York Times bestsellers including this book and – yes – he’s got a family. Over the last few decades progress in the medical profession has been spectacular. Yet, there is a huge amount of unnecessary suffering and casualties due to complications caused by oversights and mistakes. In this book we get to follow the author’s own journey to find a way to handle this frustrating situation and along the way he finds a tool that can be of use in areas outside his own. In some cases people fail because they don’t have the knowledge or skill. Other failures occur as the knowledge and skill is not applied or is not applied correctly. In the second case an ever-increasing complexity of the task at hand meets the fallibility of human memory and attention. Further, out of convenience we often lull our-selves into skipping steps: “this hasn’t caused any problems before”. Checklists increase performance not because they teach us something we didn’t know but because they make steps explicit, helps wandering minds and brings discipline. In the Checklist Manifesto Gawande lets us follow his learning process on how, when and where checklists work. It’s a journey where he meets with professionals in aviation, equity investing, in restaurants and high-rise construction. Pilots are obviously the classic users of checklists but constructing buildings also turns out to be the process of following a large number of checklists. Interestingly, constructors have two types of lists. One for the routine construction tasks, making sure there are no stupid mistakes. Then another set of lists used for complex situations outside the normal. These lists turn out to be for communication tasks. There might be no manual to follow and the best is to let the professionals use their judgment and experience. But to yield the best result they must communicate with each other to harness the wisdom of the crowd. Checklists turn out to come in various shapes. Some constitute the task as a recipe; you check them off as you go through the process. Others work as a circuit breaker where you now and then take a moment to control that everything has been thought of, in a process otherwise ungoverned by a checklist. Gawande ends up doing a number of tests with checklists in surgeries worldwide together with the WHO. After a shaky start the outcome is a massive success. Infections plummet, death rates do the same, millions of dollars are saved both when patients can return home quicker and due to less law suites and lowered staff turnover. Still, despite the results a large number of surgeons turn out to be opposing any reforms. They see checklists as something that challenge their status in the theater and that implies that they don’t know their job. However, when asked if they would want a checklist to be used if they themselves were having an operation, 93 percent said yes. Investing is another high stress, high complexity area that should benefit from using checklists. Still, very few do. Is the same type of misguided professional vanity the reason? This book should help to persuade the more intelligent forerunners. The others will have to try to catch up later. This is a review by investingbythebooks.com

The book takes off gruelingly, but picks up the pace and reads like an exciting quest in search of holy check list. The book has inspired me to introduce check lists in some routine tasks i perform at work.

Ottimo

Thought provoking not just in learning how risky surgery actually is, even what is considered routine in advanced Western hospitals, but also in discussing how we can learn from other disciplines. I am curious how these lessons can be applied to developing checklists in even more fields.

I’ve had the checklist manifesto in my “to-read” list for about 5 years now. It’s a book I’ve had reccomended to me many times and, in a nutshell, it’s a manifesto for the use of checklists. Atul Gawande who wrote it is a surgeon who has a history of process improvement projects. The checklist manifesto is his attempt to convince people that checklists, simple as they are, can massively improve the output quality and consistency of tasks that we repeat frequently. What is more surprising though, is that his research uncovers that even in areas where there are complex problems for which we can’t cheklist – checklists can help significantly in resolving complex and unforeseen problems. The thesis is simple. Checklists raise output quality and consistency. The reason they do this is simple – we overestimate our ability to routinely perform series of tasks dramatically. In scenarios where there is stress or complication, the rate at which we overestimate our ability rises dramatically. Gawande examines three key scenarios – flight checklists, large scale construction projects and his own home – the operating theater. IN each scenario, he tackles simple, routine problems and also complicated and complex problems. What emerges is a surprisingly strong case for checklists as a tool to ensure consistency, and to change behavior, and also as a tool to aid resolution in complex and unforeseen circumstances. The bottom line is that we are inadequate repeaters of routine tasks, people routinely skip steps for one of two reasons – either they just forget through distraction or inattention, or they don’t know about, or don’t believe in the efficacy of a step – so they skip it. In each of these cases, checklists function as a kind of spot audit – telling people that they didn’t perform a step, and ensuring that they do. In many cases, authority was granted to people responsible for overseeing the checklist to stop a process if people didn’t perform it as written. What followed in each case, was a dramatic improvement in performance – in one case, a US hospital system had 1500 fewer yearly deaths after introducing checklists to key procedures. Routine tasks aside, complex tasks were also found to benefit. IN routine simple and complicated tasks, the series of steps required to be carried out were documented in order so that they could be directly followed. In Complex tasks however, this wasn’t possible because what was required to be done was typically an emergent phenomenon like an accident or disaster and needed to be analysed and dearth with on the fly. While task based checklists were not capable of operating in this environment, what was shown to produce results was checklists describing mandating communication among team members and the best results were found in cases that included delegation of authority to act away from a central organisation. The book contains excellent tips on how to make checklists work. It boils down to keep them short, precise, and practical. They don’t over-describe – they provide reminders of only the most critical and important steps. The point of invocation of the checklist needs to be clear for it to be useful. Checklists also come in two distinct types – Do-confirm and read-do. One is about an audit of what you carried out, the other provides steps to follow – which you do in order and tick off. Checklists should also be a maximum of 5 to 9 items – which is cognitively about all we can handle. There is also some very specific advice on formatting – right down to fonts and typeset. One interesting point made repeatedly was that there were substantial improvements in the ability to cope with crises by teams that came together at the start of a surgery to work through the checklist. Checklists are the simplest way to protect you, and others, from you – and the systematic mistakes you make by believing that you’re systematic – when you’re not. They’re also the simplest way to get an advantage without being smarter or first, you can be more thorough – EVERY time

Atual Gawande is an American-raised indian Born surgeon practicing in Boston and he is also a writer for the New Yorker he has written 3 books, all three of them excellent. Complications his first is a revelation, better his middle one I enjoyed less, and this third one, the Checklist, is spellbindingly good Gawande is no mere doctor he was also a Rhodes Scholar (i.e seriously bright) earning a PPE in Oxford England in the late 90s. To me, it seems that this is the secret to his appeal, he is a seriously intelligent and gifted academic, who later turned to the practical art of surgery. So he is very well rounded. The central feature of his writing is to convey to the layperson that there are no easy choices, no bravura macho surgeons who can reliably fix everything. He is searingly honest about the shortcomings of medecine and his own shortcomings in particular, relaying again and again over all three books where he has screwed up, often very badly. These accounts read very well as fair accounts of how difficult it is to actually do any significant surgery on anyone without killing them, or making them iller. He is neither too harsh nor seeking to exculpate himself. He starts with the premise that (nearly) all doctors want to help, but that medecine can be horribly complicated and difficult, that they make mistakes and they are sometimes out of their depth, and that they are all learning on the job. What is magnificent about checklists is that, you'd think there wouldn't be much to say about them, that could hold your interest for very long. In this you'd be seriously wrong. it turns out that our prejudicial views on checklists (we don't like them and find them patronising) is in inverse proportion to how useful they are regardless of your levels of commitment to excellence, ingenuity or sheer brilliance. In the heat of an emergency many of the things that go wrong are EXACTLY the kinds of things that simple checklists can help you spot when your mind skips steps to focus on what you think is essential. in this book, Gawande focusses on the usefulness of checklists in medecine, commercial flying, architecture/engineering and finance and he does a masterful writerly job of keeping you engaged and enlgightened as he slowly builds a very compelling case for dropping the prejudice and adopting the checklist in more and more areas of life. One fascinating aside to me, is that the going through a checklist with other people (say before operating) was no mere mechanical procedure, but that it had a 'activating effect' of equalising the status and hierarchy of all concerned, suddenly you were no longer just some nurse or mere technician in awe of the surgeon. In fact, taking responsibility for your own part of the checklist made you a vital member of a team, and it was this team building spirit that made people work better together, think better and most importantly handle disasters with far greater focus as they knew each other and didn't waste time on blame or evasion. Much more commonly checklists even prevented disasters because since everyone felt part of a team, the junior members were not so intimidated into not pointing out errors which could later develop into disasters. It's a list on a piece of paper, but adhering to it in this public and collegiate way, had a profound impact on the psychology of the practitioners solidifying their sense of being part of a team and therefore being steadfast in calling things as they saw them, rather than simply deferring to authority and keeping quiet (a frequent cause of all types of disasters). Gawande is a good friend of Malcolm Gladwell, but he is no mere wannabe, Gawande has his own unique authorial voice and he comes across as a genuinely likeable, clever decent and highly sophisticated but down to earth human being. He is such a good writer that not least of his skills is how funny he sometimes is when he points out the absurdities of human foibles (especially his own) and of taking on any ambitious human endeavour. He is no pious preacher.