Book Reviews

The Checklist Manifesto by Atul Gawande -Book Notes, Summary, and Review

16. The Checklist Manifesto - Atul Gawande

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Rating: 7/10

Date of reading: 17th – 23rd of April, 2018

Description: If information is all it would take to solve our problems in life, everyone with an internet connection would be problem-free. We know a lot, but when it comes to the right implementation of actions and in the right order, we completely suck. Solution? A checklist. But how to create one which provides direction, but isn’t too stifling and a nuisance? The Checklist Manifesto answers that question.

 

My notes:

 

Introduction

 

“We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hard working people in our society.” ( :25)

“Knowledge has both saved us and burdened us.” ( :25)

 

2. THE CHECKLIST

 

“The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The army air corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.” ( :45)

“simple approach: they created a pilot’s checklist.” ( :46)

“Thetestpilotsmadetheirlistsimple,brief,andtothepoint— short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing.” ( :46)

“fly the Model 299 a total of 1.8 million miles without one accident.” ( :46)

“When you’ve got a patient throwing up and an upset family member asking you what’s going on, it can be easy to forget that you have not checked her pulse.)” ( :48)

“In complex processes, after all, certain steps don’t always matter. Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients.”This has never been a problem before,”people say. Until one day it is.” ( :48)

“These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more than a third of patients, they skipped at least one.” ( :50)

“The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period.” ( :50)

“average length of patient stay in intensive care dropped by half.” ( :51)

“They helped with memory recall and clearly set out the minimum necessary steps in a process. He was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions.” ( :51)

“He spoke in an average of seven cities a month. But few adopted the idea. There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the ICUs have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the idea was being properly implemented. How about in the real world—where ICU nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the notion of filling out yet another piece of paper?” ( :52)

“for a population with the lowest median income of any city in the country.” ( :53)

“Tom Piskorowski, one of the ICU physicians, told me his reaction: “Forget the paperwork. Take care of the patient.”” ( :53)

“Instead, he asked them simply to gather data on their own line infection rates.” ( :55)

“The successes have been sustained for several years now—all because of a stupid little checklist.” ( :56)

“So he and a couple of colleagues decided to try something new. They made a checklist.” ( :58)

 

3. THE END OF THE MASTER BUILDER

 

“Much of the most critical work people do, however, is not so simple. Putting in a central line is just one of the 178 tasks an ICU team must coordinate and execute in a day—ICU work is complicated—and are we really going to be able to create and follow checklists for every possible one of them? Is this even remotely practical?Thereisnostraightforwardrecipeforthecare of ICU patients. It requires multiple practitioners orchestrating different combinations of tasks for different conditions—matters that cannot be controlled by simple forcing function.” ( :62)

“”If engineers were in charge, every building would be a rectangular box,”Salvia said.” ( :69)

“”A building is like a body,” he said. It has a skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring.” ( :69)

“He tried to explain how he and his colleagues made sure that all those people were doing their work correctly,that the building would come to get her properly, despite the enormous number of considerations—and despite the fact that he could not possibly understand the particulars of most of the tasks involved. But I didn’t really get his explanation until he brought me to the main conference room.” ( :73)

“big white oval table, hung sheets of butcher-block-size printouts of what were, to my surprise, checklists.” ( :73)

“As I peered in close, I saw a line-byline, day-by-day listing of every building task that needed to be accomplished, in what order, and when—the fifteenth-floor concrete pour on the thirteenth of the month,a steel delivery on the fourteenth, and so on. The schedule spread over multiple sheets.” ( :73)

“Hepostedanewprintoutshowingthenextphase of work each week, sometimes more frequently if things were moving along. The construction schedule was essentially one long checklist.” ( :74)

“I was curious to know how they handled this question, for there was inevitable uncertainty. How could they know that the problem was just ordinary settling, that loading the steel frame would in fact level out the floor? Rouillard acknowledged, “variances can occur.” This was a situation of true complexity.” ( :76)

“In the absence of a true MasterBuilder—a supreme, all-knowing expert with command of all existing knowledge— autonomy is a disaster.” ( :77)

 It produces only a cacophony of incompatible decisions and overlooked errors. You get a building that doesn’t stand up straight. This sounded to me like medicine at its worst.” ( :77)

“They didn’t believe in the wisdom of the single individual, or even an experienced engineer. They believed in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem and then letting the watchers decide what to do.” ( :79)

“Joe Salvia had earlier told me that the major advance in the science of construction over the last few decades has been the perfection of tracking and communication. But only now did I understand what he meant.” ( :80)

“”The biggest cause of serious error in this business is a failure of communication,” O’Sullivan told me.” ( :82)

 

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.” ( :85)

“The traditional command-and-control system rapidly became overwhelmed. There were too many decisions to be made and too little information about precisely where and what help was needed.” ( :87)

“Nevertheless, the authorities refused to abandon the traditional model.For days,while conditions deteriorated hourly, arguments roared over who had the power to provide the resources and make decisions. The federal government wouldn’t yield the power to the state government. The state government wouldn’t give it to the local government. And no one would give it to people in the private sector.” ( :87)

“in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.” ( :87)

“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.”” ( :88)

“When a local hospital told her it was running short of drugs, she went back in and broke into the store’s pharmacy—and was lauded by upper management for it.” ( :89)

“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.” ( :91)

“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.” ( :91)

“I understood perfectly well how the Burger Kings and Taco Bells of the world operate. They are driven by tightly prescribed protocol.” ( :93)

“People celebrate the technique and creativity of cooking.Chefs are personalities today, and their daring culinary exploits are what make the television cooking shows so popular. But as I saw at Rialto, it’s discipline—uncelebrated and untelevised—that keeps the kitchen licking. And sure enough,checklists were at the center of that discipline.” ( :94)

“Even for her, she said, “following the recipe is essential to making food of consistent quality over time.”” ( :94)

“You make the creamed corn a few hundred times and you believe you have it down. But that’s when things begin to slip, Adams said.” ( :95)

“I counted the dishes as they went by. At least 5 percent were sent back. “This calamari has to be fried more,”the sous chef told the fry cook. “We want more of a golden brown.”” ( :97)

 

5. THE FIRST TRY

 

“So instead, he said, he looked for low-tech solutions. In this case, the solution he came up with was so humble it seemed laughable to his colleagues. It was soap.” ( :107)

“The secret, he pointed out to me, was that the soap was more than soap. It was a behavior-change delivery vehicle. The researchers hadn’t just handed out Safeguard, after all. They also gave out instructions—on leaflets and in person—explaining the six situations in which people should use it.” ( :108)

“At the start of the study, the average number of bars of soap households used was not zero. It was two bars per week. In other words, they already had soap.” ( :108)

“There wasn’t much more to it. But getting teams to stop and use the checklist—to make it their habit—was clearly tricky.” ( :111)

“ThenRichardReznick,the chairman of surgery at the University of Toronto,spoke up.” ( :112)

“through the case together—to be ready as a team to identify and address each patient’s unique, potentially critical dangers.” ( :114)

“”That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. But in medicine,we see it all the time. I’ve seen it in my own operating room.” ( :115)

“Yet somehow, from the moment we six were all dropped together into this particular case, things clicked. It had been almost criminally enjoyable.” ( :119)

“The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.” ( :120)

“There was a pause right before the patient is given anesthesia, one after the patient is anesthetized but before the incision is made, and one at the end of the operation, before the patient is wheeled out of the operating room.” ( :123)

“Fifteen minutes later, we were about to put the patient to sleep under general anesthesia, and I had to say, Wait, what about the checklist? “I already did it,” Dee said. She showed me the sheet. All the boxes were checked off. No, no, no, I said. It’s supposed to be a verbal checklist, a team checklist. “Where does it say that?” she asked. I looked again. She was right. It didn’t say that anywhere. Just try it verbally anyway, I said.” ( :124)

“By the end of the day, we had stopped using the checklist. Forget making this work around the world. It wasn’t even working in one operating room.” ( :125)

 

6. THE CHECKLIST FACTORY

 

“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.” ( :132)

“They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss.” ( :132)

“Pilots nonetheless turn to their checklists for two reasons. First, they are trained to do so. They learn from the beginning of flight school that their memory and judgment are unreliable and that lives depend on their recognizing that fact. Second,the checklists have proved their worth—they work.” ( :133)

“You must define a clear pause point at” ( :134)

“which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails).” ( :135)

“DO-CONFIRM checklist or a READ-DO checklist.” ( :135)

“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.” ( :135)

“First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.” ( :136)

“Although these are critical steps, experience had shown that professional pilots virtually never fail to perform them when necessary. So they didn’t need to be on the checklist—and in fact, he argued, shouldn’t be there.” ( :140)

“Only by sheer luck was no one killed, either on board or on the ground. The plane narrowly missed crashing through the roofs of nearby homes. Passengers in cars on the perimeter road around Heathrow saw the plane coming down and thought they were about to be killed. Through a coincidence of international significance, one of those cars was carrying British prime minister Gordon Brown to his plane for his first official visit to China. “It was just yards above our heads, almost skimming a lamppost as the plane came in very fast and very, very low,” an aide traveling with the prime minister told London’s Daily Mirror.” ( :141)

“The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form.” ( :145)

“It took about two weeks for the Boeing team to complete the testing and refinement, and then they had their checklist. They sent it to every owner of a Boeing 777 in the world. Some airlines used the checklist as it was, but many, if not most, went on to make their own adjustments.” ( :146)

 

7. THE TEST

 

“Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process.” ( :149)

“An inherent tension exists between brevity and effectiveness.” ( :150)

“An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.” ( :150)

“We had a team in London try the draft checklist and give us suggestions, then a team in Hong Kong. With each successive round, the checklist got better. After a certain point, it seemed we had done all we could. We had a checklist we were ready to circulate.” ( :152)

“Nonetheless, we went ahead with our eight institutions. The goal, after all, was not to compare one hospital with another but to determine where, if anywhere, the checklist could improve care.” ( :156)

“For all the differences among the eight hospitals, I was nonetheless surprised by how readily one could feel at home in an operating room, wherever it might be.” ( :162)

“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.” ( :166)

Deaths fell 47 percent.” ( :166)

 

8. THE HERO IN THE AGE OF CHECKLISTS

 

“Now, if surgeons end up using the checklist anyway, what is the big deal if we do so without joy in our souls? We’re doing it. That’s what matters, right? Not necessarily.Just ticking boxes is not the ultimate goal here.”  Embracing a culture of teamwork and discipline is.” ( :172)

“The three consider themselves “value investors”—investors who buy shares in underrecognized, undervalued companies. They don’t time the market. They don’t buy according to some computer algorithm. They do intensive research, look for good deals, and invest for the long run. They aim to buy Coca-Cola before everyone realizes it’s going to be Coca-Cola.” ( :174)

“”Munger and Buffett saw the dot-com bubble a mile away,” Pabrai said.” These guys were completely clear.” But they missed how dependent Cort was on it. Munger later called his purchase “a macroeconomic mistake.”” ( :178)

“The checklist doesn’t tell him what to do, he explained. It is not a formula. But the checklist helps him be as smart as possible every step of the way, ensuring that he’s got the critical information he needs when he needs it, that he’s systematic about decision making, that he’s talked to every one he should” ( :179)

“Pabrai had been working with a checklist for about a year. His fund was up more than 100 percent since then. This could not possibly be attributed to just the checklist.” ( :181)

“A year later, his investments were up more than 160 percent on average. He’d made no mistakes at all.” ( :181)

“People have been intensely interested in what he’s been buying and how, but the minute the word checklist comes out of his mouth, they disappear. Even in his own firm, he’s found it a hard sell. “I got pushback from everyone. It took my guys months to finally see the value,” he said. To this day, his partners still don’t all go along with his approach and don’t use the checklist in their decisions when he’s not involved. “I find it amazing other investors have not even bothered to try,” he said. “Some have asked. None have done it.”” ( :182)

“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.” ( :183)

“Smart next tracked the venture capitalists’ success over time. There was no question which style was most effective—and by now you should be able to guess which one. It was the Airline Captain, hands down.” ( :184)

“Smart published his findings more than a decade ago. He has since gone on to explain them in a best-selling business book on hiring called Who.” ( :184)

“It somehow feels beneath us to use a checklist, an embarrassment.” ( :185)

“It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.” ( :185)

“He was greeted with a hometown parade and a $3 million book deal.” ( :186)

“I want to correct the record right now. This was a crew effort.” The outcome, he said, was the result of teamwork and adherence to procedure as much as of any individual skill he may have had.” ( :186)

“The crew had more than 150 total years of flight experience—150 years of running their checklists over and over and over, practicing them in simulators, studying the annual updates. The routine can seem pointless most of the time. The routine can seem pointless most of the time. Not once had any of them been in an airplane accident.” ( :188)

“The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time?Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).” ( :189)

“They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire. Thiswaswhatwasunusual.Thisiswhatitmeanstobeahero in the modern era. These are the rare qualities that we must understand are needed in the larger world.” ( :194)

“”Anyone who understands” ( :196)

“systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment of trying to build the world’s greatest car by assembling the world’s greatest car parts.We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”” ( :197)

 

9. THE SAVE

 

“To my chagrin, however, I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed. Take last week, as I write this, for instance. We had three catches in five cases.” ( :199)


Check out more book notes at How I Read 90 Books In The Past 2 Years By Reading 20 Pages A Day

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