The Checklist Manifesto

 Checklist Manifesto - How to get things right written by Atul Gawande 

The problem of extreme complexity. We see on TV and in movies, how simple it looks to save the life of a patient. But it's not that simple in reality. Scores of people carry out thousands of steps correctly. The degree of difficulty in any of the steps is substantial.

 An American on an average undergoes 7 operations in her/his lifetime. With surgeons performing more than 5 crore operations annually- the amount of harm remains substantial. We continue to have upwards of 1.5lk deaths following a surgery every year- more than 3 times the road traffic fatalities. 

The knowledge exists. However supreme specialized we may have become, steps are still missed, mistakes are still made by humans. Medicine with dazzling successes still has limitations. It therefore possesses a challenge. What do you do when even super- specialization fails? What do you do when the expertise is not enough? 

The author and his team began to see an answer and the answer has come from an unexpected source - -one that has nothing to do with medicine at all.... 

The Checklist 

In complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention. Example..A doctor getting a patient throwing up and the upset family asking him what's going on, it can be natural for him to forget to check the pulse of the patient. Faulty memory and distraction are a particular danger in what engineers call all-or none processes. Whether running to store to buy ingredients for a cake, preparing an airplane for takeoff, evacuating a sick person in a hospital, if you just miss one key element, you might as well not have made the effort at all. Checklist seems to provide protection against such failures. They remind us of the minimum steps and make them explicit. In hospitals that were surveyed, the patients not receiving the recommended care dropped from 41% to 4%, the occurrence of pneumonia fell by a quarter and 21 fewer patients died than in the previous year. 

The end of master builder 

There are three types of problems in the world : The simple, the complicated and the complex problems. Simple problems they note are like baking a cake from a mix. There is a recipe. Sometimes there are basic techniques. Once mastered, following the recipe brings a high likelihood of success. 

Complicated problems are like sending a Rocket to the moon. They can sometimes be broken down into series of simple problems. Success frequently requires multiple people, often team and specialized expertise. Unanticipated difficulties are frequent. training and co-ordination becomes serious concerns. 

Complex problems are like raising a child. Once you have send a Rocket to a moon, you can repeat the process because one Rocket is quite similar to the next one. Although raising a child needs experience it cannot guarantee success with the next child. the next child might need entirely different approach. Raising a child does not look complex just because it is a very slow process. We feel relaxed, even in a complex problem if it is slow. 

In police work, Legal works, Training works, Doctors profession there is entire range of problems, simple, complex and the complicated.. It seems mechanical but no two pneumonia patients are identical. A doctor must be prepared for unpredictable turns that checklists seems completely unsuited to address. 

Now the question was, can checklist avert failures when the problems combine everything from simple to complex? 

The author happened across an answer in an unlikely place. he found it as he was just strolling down the street one day. He saw a new building under construction. The author was wondering how did the coworkers know that they were building right? How could they be sure that it wouldn't fall down? 

The author made a sincere attempt to study the construction process. He found their system quite similar to the Doctors system of working. In construction business the Architects or the Engineers design the structure and then piece by piece each component further goes to a specialized person/team and split off. Despite the similarity people in medicine still continue to exist in a system created in the master builder era-a system in which lone master physician dominates. He was told that in the construction business the master builder model will be too risky and they always stay away from it. Since every building is a new creature, every building checklist is new too. 

"Man is fallible, but men are less so". this belief makes the construction process a bit safer. The checklist works. 

The idea: 

When we are confronted with complex, non-routine problems system does not work. For example Katrina made landfall in Plaquemines Parish in New Orleans. Government found it really tough to evacuate the rescue the citizens in trouble. Of all the organizations, it was oddly enough Wal-mart that best recognized the complex nature of the circumstances, according to the case study from the Harvard's Kennedy school of government. Lee Scott, the CEO issued a simple edict in the meeting saying, "A lot of you are going to have to make decisions above your level. make the best decision with the available information, and above all, do the right thing." That was it. Within 48 hours more than half of the 126 damaged stores were up and running again. 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 centre 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 towards the common goals. This was the understanding people in the skyscraper building industry had grasped. More remarkably, they had learned to codify that understanding into simple checklists. They had made the reliable management of complexity a routine. 

That routine requires a balancing of number of virtues: Freedom and discipline, Craft and Protocol, Specialized ability and group collaboration and for checklists to achieve that balance, they have to take two almost opposing forms. 

The first try: 

The World Health Organization wanted to develop a global program to reduce avoidable deaths and harm from surgery. The WHO wanted some help from Atul Gawande. One interesting example the author has mentioned in this book is of Karachi. There was an infectious outbreak. After a lot of investigation, it was found that the root cause of the infections was the "Soap". P & G the consumer product conglomerate, was eager to prove the value of its new antibacterial safeguard soap. Soaps were distributed free of cost to all the people. After a period of time it was found that the P & G attempt had brought no change. They failed! 

The secret was that the soap was more than a soap. P & G handed the soaps, but no safeguard instructions. P & G tried solving the economic problem, that really wasn't because Soap was quite cheap for them. The instructions, techniques, the frequency was more important. The learning is that a product or a hi-tech gadget won't always suffice. What is more important is the message that needs to be transferred as to what to do the best with that product, when and how. 

None of the studies was complete to prove that a surgical checklist could prove what WHO was ultimately looking for--a measurable, inexpensive and substantial reduction in overall complications from surgery. By the end of Geneva conference, they agreed to have a surgery checklist to be tested on a large scale. The author gave the checklist a try to himself. He pointed it out and took it to the operating room. He told all the staff members that he has learned in Geneva. Unfortunately the first check list did not work well. The reason was that the physical check by individuals and the verbal discussions on those checks differed because some points were ambiguous. The reaction was "Forget making a checklist for the world, when it is not working in one operating room." 

The checklist Factory : 

After the miserable try the author tried doing something that he should have done to begin with. He found a co-relation between the checklists of surgeons and that of the pilots, as in both the cases the time factor and the presence of mind is crucial. He met a veteran pilot from Washington, who had spend last two decades developing checklists. The learning was that Good checklists are precise, efficient, to the point and easy to use even in the most difficult situations. The pilots do not spell out everything. --a checklist can't fly a plane. Instead they provide reminders of the most critical steps. They make priorities clear. Good checklists above all are practical. Checklists do have an expiry date. They need to be modified with the changes in objectives, systems and the critical factors. 

Checklist can't be lengthy. A rule of thumb some use is to keep it to between five to nine items, which is the limit of working memory. Some professionals feel the need of more than nine check points in the professions where high risks are involved, especially in terms of human lives. 

The Test 

The final WHO safeguard checklist spelled out nineteen check points in all. Before anesthesia there are seven, after anesthesia and before incision, come seven more and finally at the end of the operation, before the team wheels the patient, come five final checks. Nonetheless, some skepticism persisted. 20% of the staff did not find it easy to use, thought it took too long and felt it had not improved the safety of care. These people were asked a question, "If you were having an operation, would you want the checklist to be used?" 93% said yes! 

Expectations 

All learned occupations have a definition of professionalism, a code of conduct. it is where they spell out their ideals and duties. the codes are sometimes stated, sometimes just understood. But they all have at least three elements common. 

(1) Expectation of selflessness : The professionals like Doctors, Lawyers, Teachers, Pilots, Soldiers, Public authorities etc. will place the concerns of those who depend on usabove our own. 

(2) Expectation of Skill: That we will aim for excellence in our knowledge. 

(3) Expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges 

The aviators have the 4th expectation, discipline. 

In our own fields we don't study routine failures. Failures in teaching, in Law, in government programs, in financial industry or elsewhere. We don't look for patterns of our recurrent mistakes or devise and refine potential solutions for them. Technology has solved many problems but it has limitations. Technology finds tough to handle uncertainties, behavioral changes that are needed. When we look closely we look the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. Its time to try something else.

Disclaimer:

 The summary made is just an attempt to preserve the good points that left an impact. In this attempt I have mixed my experiences, observations, foresights, discretion and my perceptions. There is no attempt to challenge  or change the original ideas of the author.

 

Vinay Wagh