In praise of checklists
We live in a world of increasing complexity, where even the best of the best can struggle to accomplish all that is expected of them. This book describes one of the most basic, yet underutilized, techniques that is available to help in such situations: the checklist.
Checklists are used as a standardized basis to guide decision-making and validate that a set of criteria have been satisfied. First introduced decades ago, after the crash of the Boeing 299 on its second flight test, checklists have had a remarkable (and largely unheralded) track record. They have been associated with dramatic improvements to operational safety in aviation, reduced fatalities in medicine, reviewing work products in development, improved performance of venture capitalists in selecting investment portfolio elements, enhanced communications in skyscraper construction, and substantiating credibility in producing and validating estimates. Heck, even Microsoft uses them!
The author, Atul Gawande, has an interesting background. He's a highly effective communicator, and a passionate crusader who doesn't shy away from big challenges. He has a very impressive educational background, with a Masters in politics, economics, and philosophy from Oxford, a medical degree from Harvard, and experience serving as a policy adviser to President Clinton. He currently is a practicing general and endocrine surgeon, and is also an associate professor in the Harvard School of Public Health. All of this experience makes him exceptionally qualified to make the journey he describes in the book, and then leverage the publicity which the book has generated to evangelize the broadest possible institutionalization of checklists within health care, while advocating it for other complex tasks.
The book brilliantly provides short and compelling anecdotes about many situations in which checklists have had profound effects. It explains why they work so well, in both individual and team situations. The book also provides potential checklist users with helpful advice on checklist design, tackling the resistance that must be overcome in introducing them to a new situation, and stressing the importance of promoting professionalism in order to gain acceptance, which are all critical to achieving the promise which checklists offer.
The most exciting parts of the book describe the potential benefits which are just now being introduced in the field of medicine. Gawande is at his best in this setting, weaving stories that are emotional, relevant, and memorable, into his own personal journey. As the book unfolds, we see him gradually moving from checklist skeptic to evangelist, as he reveals to the reader the power of the scientific method, the need to refine checklists through lab and field experience, and the importance of evidence-based techniques in demonstrating and reinforcing change. For example, he describes a study performed at the Keystone Center for Patient Safety and Quality in Lansing, MI, which initially revealed the potential of checklists to him. The studies were performed in Detroit hospitals, which were consistently underfunded and struggling to meet quality standards for patient care. Enter checklists:
After Dr. Gawande explains what checklists are, how they are used, and what you need to do in order to make effective use of them, he moves on to describe his involvement in a World Health Organization evaluation which he led. This involved an 11 month, 8 hospital pilot program around the world, in 2007 and 2008. In the recent paper which shared this experience among his professional peers, they ran a controlled experiment to evaluate the effectiveness of checklists in doing what they're supposed to do - improving team communication, promoting more consist patient care, and reducing complications and deaths associated with surgery. And when all the results were in for the 7500 patients who were involved, inpatient complications were reduced from 11.0% in the control group to just 7.0% in the group using checklists. These results are significant, inexpensive to implement, and remarkably accessible to hospitals around the world.
I attended a lecture by Dr. Gawande last week, and was very encouraged by the enthusiastic response he received from the several hundred medical practitioners who attended it from our area. Our state is the first state in the US to have committed to apply this learning across all our hospitals. Although much about health care reform is a disappointing compromise, it is reassuring to see examples like this that can quickly be put into use, receive the essential recognition and reinforcement for institutionalization, and provide dramatic cost and quality improvements which can help us achieve meaningful reform for our medical delivery systems. Similar results should be available for those in other areas with the patience and persistence to pursue them (though they should keep in mind the lesson that content and discipline applying it matter more than the checklist's presentation or sourcing).
This doesn't mean the book isn't without it's flaws. One of the chapters focuses on how checklists are developed in aviation, and describes several events which occurred during a visit which Dr. Gawande made to Boeing. Since I am familiar with the facilities, simulations and approaches which are used here for checklist authoring, validation, and rehearsals, it's apparent that some minor details which he captured in the book are not completely accurate. Despite this, Dr. Gawande gets all the important stuff right, and that's what matters.
Before reading this book, I was already a fan of the author as a result of reading one of his prior books, Better. But while that work is one of my all-time favorites about continuous improvement journeys, I found The Checklist Manifesto to be even better than Better! Dr. Gawande has an incredibly busy life, writing books, actively advocating health care reform, and authoring New Yorker articles 'part time', while still practicing medicine full-time. I'm thrilled he took the time to bring the power of this idea to as wide an audience as possible; we are all better for it!
