Book Depository: The Checklist Manifesto by Atul Gawande

Aircraft manufacturers regularly circulate checklists. Every plane contains a book of them, and each airline customises them to their own practices. They enable pilots, skilled as they are, to ensure that the many routine tasks of flying an aircraft are accomplished rigorously. Aside from those that are used for every flight, separate checklists exist to solve problems. They instruct pilots what to do if, for example, an engine cuts out in mid-flight, or a door alarm comes on. Boeing’s checklists condense thousands of hours of experience, analysis of many accidents, and testing in simulated flights, into a succinct list of check-points.

Flight checklists have saved thousands of lives. In abstracting and decentralising routine operations, they catch careless mechanical oversights that could otherwise cause or worsen accidents. Their simplicity conceals a wealth of research and experience that pilots could not otherwise access. Checklists free the flight crew to use their skill and professional judgement elsewhere. Other industries might improve their effectiveness by using checklists, ensuring that emergencies occur less often, and that people are better prepared when they do. But very few industries do.

This book describes Atul Gawande, a surgeon, leading a World Health Organisation initiative to drive the creation and adoption of three checklists for use in operating theatres around the world: one before anaesthetic, another before the first incision, and another after operation. The team encounters considerable design and social challenges. They must determine whether to adopt a read-do or do-confirm approach, work out what to put in and what to leave out, make the standardised list relevant to different types of hospital around the world, decide who should be responsible for imposing it during surgery, persuade people to use it, and test its effectiveness. His team’s final checklists, with a total of just nineteen points, were put into practice in a three-month trial involving eight hospitals. The results are significant: the checklists prevent between a quarter and a half of complications and patient deaths during surgery. But even in the light of the success of such a simple intervention, it is difficult to encourage many hospitals to adopt them.

This is a cultural problem. In general, checklists are not popular wherever heroism and the skills of the individual are celebrated and rewarded. Surgery is such a field, but Atul Gawande also considers the world of investment finance, where a handful of successful investors made their own private checklists. Surgeons are accustomed to rebutting interference and protecting their own interests, and can find the imposition of a checklist demeaning. Atul Gawande argues that this attitude can be overcome, and must be. His surgical checklist includes a stage where people introduce themselves and their roles before the operation. For psychological reasons, this is one of the most important checks: simply taking time to learn colleagues’ names can dramatically improve the effectiveness of an operating team.

Even in unpredictable situations, and even when qualified, experienced people are in control, it is usually simple oversights that cause trouble. A good checklist will prevent many problems altogether. In forcing preparation of contingency plans, it will also improve the chance of success whenever an emergency occurs, options dwindle, and focus starts to narrow. Forcing people to cross-check their work with colleagues empowers subordinates to speak up, share knowledge, and co-operate, which catches more mistakes.

At their best, checklists actively create a strong team discipline. The aviation industry, where every accident is analysed forensically, was the first to come to this conclusion. It had to transform the way it saw the world, and other organisations should do the same.