The Checklist Manifesto: How to Get Things Right by Atul Gawande. 

4/5 rating. 

Book #26 of 2020. Read May 1, 2020.

This was a very powerful book about how checklists are saving the world! While this may sound like a terribly boring premise, Atul uses his career as a surgeon to explain why he has become fascinated with implementing checklists in surgeries, and elsewhere.

Atul spends the book telling about his life, and many different places where he reviewed their successful implementations of checklists. After seeing the effectiveness of checklists in other disciplines – namely airplanes and commercial (skyscraper) construction projects – Atul wonders if they could be as useful in the highly complex world of medicine. While checklists had been used before in medicine, they had not been heavily studied or adopted, so the WHO reached out to Atul to try some trials. What came next is absolutely incredible:

“The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent.”

I really think that this book could apply to almost all jobs and everyone’s lives. All doctors and nurses, especially, need to read this book because implementation at hospitals would save lives! Go read this book and see how it could help you in your life!

Quotes:

“I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It is not money or government or the threat of malpractice lawsuits or insurance company hassles—although they all play their role. It is the complexity that science has dropped upon us and the enormous strains we are encountering in making good on its promise.”

“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.”

“‘This has never been a problem before,’ people say. Until one day it is.”

“The 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.”

“The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.”

“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, above all, do the right thing.” – Lee Scott, Walmart CEO in discussions about Katrina

“The lesson of this tale has been misunderstood. Some have argued that the episode proves that the private sector is better than the public sector in handling complex situations. But it isn’t. For every Wal-Mart, you can find numerous examples of major New Orleans businesses that proved inadequately equipped to respond to the unfolding events—from the utility corporations, which struggled to get the telephone and electrical lines working, to the oil companies, which kept too little crude oil and refinery capacity on hand for major disruptions. Public officials could also claim some genuine successes. In the early days of the crisis, for example, the local police and firefighters, lacking adequate equipment, recruited an armada of Louisiana sportsmen with flat-bottom boats and orchestrated a breathtaking rescue of more than sixty-two thousand people from the water, rooftops, and attics of the deluged city.”

“No, the real lesson is that 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.”

“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. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.”

“It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives.”

“The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.”

“Take the safe surgery checklist. If someone discovered a new drug that could cut down surgical complications with anything remotely like the effectiveness of the checklist, we would have television ads with minor celebrities extolling its virtues. Detail men would offer free lunches to get doctors to make it part of their practice. Government programs would research it. Competitors would jump in to make newer and better versions.”

“If the checklist were a medical device, we would have surgeons clamoring for it, lining up at display booths at surgical conferences to give it a try, hounding their hospital administrators to get one for them—because, damn it, doesn’t providing good care matter to those pencil pushers?”

“We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, ICU medicine, and beyond—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.”

“We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber—a machine so complex no one was sure human beings could fly it. They too could have decided just to ‘try harder’ or to dismiss a crash as the failings of a ‘weak’ pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist.”

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