Atul Gawande
The Checklist Manifesto

The Checklist Manifesto

by Atul Gawande, 225 pages

Finished on 16th of March, 2023
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Complex tasks increase the likelihood of critical mistakes. Checklists are the remedy. 'The Checklist Manifesto' chronicles the journey of introducing checklists into critical fields, like medicine, to reduce errors and enhance communication.

🚀 The Book in 3 Sentences

  1. In our world in which many jobs or tasks seem to increase in complexity exponentially, making critical mistakes becomes more likely.
  2. The simple remedy is designing and testing specific checklists for important tasks which must not go wrong; examples include the construction of skyscrapers, aviation, response to natural disasters, and the starting point: medical surgery.
  3. The author’s WHO funded journey from inception of the idea to bring a simple checklist into hospitals’ operating rooms, through testing, refinement, roadblocks, and subsequent adoption all around the world is then described.

🎨 Impressions

Another book which had lived on my reading list for a very long time, because it’s been recommended everywhere, it’s a pleasantly short one, but also, the topic seemed too dry for me to pick it up immediately. So it had to wait a few years until the timing was right.

First off, I don’t regret reading it and it wasn’t as dry as a thought. It’s a solid piece of work focusing on just one key aspect of improving our lives and those of others and I respect that.

The author Atul Gawande is a well-established surgeon living and working in Boston and noticed that many of the mistakes which are bound to happen during surgeries because those are done by humans could be eliminated with a simple trick: having a checklist in place. So he made it his task to save countless lives around the world by creating a helpful checklist outline, testing it, and trying to convince the hospitals all over the world to adopt the technique. That process was one of the interesting parts of the book, because he got a budget from the WHO early on and explained the inner workings of how that looks like. For example, when he tried to get funding to test the efficacy of his checklists in highly diverse hospitals around the world, WHO would only finance the tests in those hospitals located in developing countries, even though the benefits of a successful integration would have affected people everywhere on the planet, regardless the financial situation.

Learning about the how the team work during surgery is usually set up was another interesting bit of the book. And when Gawande ventured to several other professions in order to find out about their processes and if and how they use checklists, it became a pageturner for me. It was fascinating to learn about situations such as how pilots fly and safely land their planes during technical failures (the emergency Hudson River landing by now famous pilot Sullenburger was only possible because there was a checklist for that specific case ready in the cockpit), or the building of a skyscraper able to withstand not just nature’s forces but also possible attacks without collapsing.

And since it’s a short book, it doesn’t waste one’s time with completely useless stories or any other kind of bulk.

🍀 How the Book Changed Me

  • During reading I was thinking about how to apply more checklists into my own work life but realized I’m already doing a good job with excessively using the recurring tasks feature of my task list managing software. Whenever something dumb fails, I’m now thinking about how to put this into something like a checklist or a recurring task.

📔 Highlights & Notes

1. Introduction

There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snowstorms, save people from heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre point out, we have just two reasons that we may nonetheless fail. The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. [..] The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly.

[..] the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.

2. The Checklist

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

[..] checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized.

4. The Idea

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.

I came away from [Hurricane] Katrina and the builders with a kind of theory: under conditions of complexity, not only are checklists a help, they are required for success.

5. The First Try

“Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not.”

6. The Checklist Factory

The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.

But first think about what happens in most lines of professional work when a major failure occurs. To begin with, we rarely investigate our failures. Not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any other kind of work where the mistakes do not turn up on cable news.

What experts like Dan Boorman have recognized is that the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form.

7. The Test

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.

Suppose this was just a Hawthorne effect, that is to say, a byproduct of being observed in a study rather than proof of the checklist’s power. In about 20 percent of the operations, after all, a researcher had been physically present in the operating room collecting information.

The baseline rate of surgical complications was indeed lower in the four hospitals in high-income countries, but introducing the checklist had produced a one-third decrease in major complications for the patients in those hospitals, as well—also a highly significant reduction.

But these particular improvements could not explain why unrelated complications like bleeding fell, for example. We surmised that improved communication was the key.

Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care. Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?” A full 93 percent said yes.

8. The Hero in the Age of Checklists

Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.

But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs 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. Such people are rare and extremely hard to spot.

The closest our professional codes come to articulating the goal is an occasional plea for “collegiality.” What is needed, however, isn’t just that people working together be nice to each other. It is discipline.

How do you feel after reading this?

This helps me assess the quality of my writing and improve it.

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