Book Review: The Checklist Manifesto

I recently read the book The Checklist Manifesto by Atul Gawande – a respected surgeon, noted author, MacArthur fellow, New Yorker staff writer, and a professor at Harvard Medical School.

The premise of the entire book is the author’s dive into the concept of a checklist and how they have dramatically improved the efficiency and reliability of professionals in the medical profession, the aeronautical industry, the architecture industry and even the venture capital industry.

So what is a checklist? It is the minimum set of critical steps for any task to be achieved.

Why are they useful? Because checklists protect against many kinds of dangers. For example:

1. “Faulty memory and distraction are a particular danger in what engineers call all-or-none processes – if you miss just one key thing, you might as well not have made the effort at all (whether it is buying ingredients for a cake or preparing an airplane for takeoff).”
2. “People can lull themselves into skipping steps even when they remember them. Especially in busy and stressed workplaces (such as hospitals). In complex processes, certain steps don’t always matter, may be it affects only 1 out of 50 times. But when it does, it can be catastrophic.”

One of my favorite passages in the book is as follows (it’s a longer excerpt than I would have liked, but all the parts were really important, so please read the whole passage to understand what’s going on):

Checklists 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. Which is precisely what happened with vital signs – thought it was not doctors who deserved the credit.

The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, especially creating a checklist for themselves.

With all the things nurses had to do for their patients over the course of a day or night – dispense their medications, dress their wounds, troubleshoot problems – the “vitals chart” provided a way of ensuring that every six hours, or more often when nurses judged necessary, they didn’t forget to check their patient’s pulse, blood pressure, temperature and respiration and assess exactly how the patient was doing.

In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten. And nurses have developed yet further such bedside innovations – for example, medication timing charts and brief written care plans for every patient. No one calls these checklists but, really, that’s what they are. They have been welcomed by nursing but haven’t quite carried over into doctoring.

Charts and checlists, that’s nursing stuff — boring stuff. They are nothing that we doctors, withour extra years of training and specialization, would ever need or use.

In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn’t attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: central line infections.

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in. Check, check, check, check, check. 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.

The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place or whether a given measure is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?”) The new rule made it clear: if doctors didn’t follow every step, the nurses would have backup from the administration to intervene.

For a year afterward, Pronovost and his colleagues monitored what happened. 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. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.

If that, my friends, does not explain the power of a simple checklist, I don’t know what can.

And yet, despite these results, people were reluctant to adopt checklists. In fact, I know you are dismissing the idea right now. Try writing down 5 reasons why checklists are stupid and won’t work for you. Now write 5 reasons why it will work. Think over it. I bet most people find the 5 reasons against checklists, easier to write, but will be convinced about it after writing the 5 reasons for it.

Personally, I have been drilled into the idea of checklists thanks to the GTD Weekly Review. Since I use a checklist once a week, I started making checklists for the routine yet essential parts of my life, from organizing things around the house once a day to a preparation checklist for trekking.

I am trying to think of ways that checklists can apply to IT and software development. I guess we already have it in many ways – whether (1) in the form of Agile / Scrum / XP methodologies, or (2) in the form of code reviews (verification is outsourced to another human who has to run through the checklist manually), or (3) in the form of automated test suites (verification is automated).

But we seem to resist these checklists (as detailed in the book in other contexts including the venture capital industry), we think “Oh, I’m too professional for such a methodology” or “Pfft, it’s a waste of time, I just want to code.” I have been guilty of it many times as well.

And at the same time, I had not imagined that checklists can be used for ensuring communication to all the concerned parties.

Let me take an excerpt from Atul Gawande’s exploration of the architecture field in the book:

It is unnerving to think that we allow buildings this difficult to design and construct to go up in the midst of our major cities, with thousands of people inside and tens of thousands more living and working nearby. Doing so seems risky and unwise. But we allow it based on trust in the ability of experts to manage the complexities. They in turn know better than to rely on their individual abilities to get everything right. They trust instead in one set of checklists to make sure that simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems.

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

In the Citicorp building, for example, the calculations behind the designs for stabilizing the building assumed the joints in those giant braces at the base of the building would be welded. Joint welding, however, is labor intensive and therefore expensive. Bethlehem Steel, who took the contract to erect the tower, proposed switching to bilted joints, which are not as strong. They calculated that the bolts would do the job. But, as a New Yorker story later uncovered, their calculations were somehow not reviewed with LeMessurier. That checkpoint was bypassed.

It is not certain that a review would have led him to recognize a problem at the time. But in 1978, a year after the building opened, LeMessurier, prompted by a question from a Princeton engineering student, discovered the change. And he found it had produced a fatal flaw: the building would not be able to withstand seventy-mile-an-hour winds – which, according to weather tables, would occur at least once every fifty-five years in New York City. In that circumstance, the joints would fail and the building would collapse, starting on the thirtieth floor. By now, the tower was fully occupied. LeMessurier broke the news to the owners and to city officials. And that summer, as Hurricane Ella made its way toward the city, an emergency crew worked at night under veil of secrecy to weld two-inch-thick steel plates around the two hundred critical bolts, and the building was secured. The Citicorp tower has stood solidly ever since.

The construction industry’s checklist process has clearly not been foolproof at catching problems. Nonetheless, its record of success has been astonishing. In the United States, we have nearly five million commercial buildings, almost one hundred million low-rise homes, and eight million or so high-rise residences. We add somewhere around seventy thousand new commercial buildings and one million new homes each year. But “building failure” – defined as partial or full collapse of a functioning structure – is exceedingly rare, especially for skyscrapers. According to a 2003 Ohio State University study, the United States experiences an average of just twenty serious “building failures” per year. That’s an annual avoidable failure rate of less than 0.00002 percent. And, as Joe Salvia explained to me, although buildings are now more complex and sophisticated than ever in history, with higher standards expected for everything from earthquake proofing to energy efficiency, they take a third less time to build than they did when he started his career.

The checklists work.

The lesson learned for me is that the book repeatedly showcases how simple checklists ensure that we get the basics right, which ultimately means we develop more trust in the ecosystem that things will happen (whether humans trust other humans more, or whether humans trust more in a system or process, or whether we trust ourselves more), and when that trust and stability is established, we go on to greater heights.

Let me give you an example to illustrate what I am thinking about – the trust factor also applies to any “productivity system” that you create for yourself, no matter how simplistic or naive. Until you develop trust in that system that it works and there are no major holes in the system, you will never trust the system enough to make it succeed, and ultimately you will sabotage yourself and your productivity system breaks down. This is one of the reasons why the Weekly Review is the secret sauce of the GTD methodology – if you review once a week, you can quickly build trust in your system that you are taking care of all that is important to you.

And, don’t forget that the Weekly Review is a checklist. And this is exactly why you probably need more checklists in your life.

So what are the checklists that you think you should have in your work life and personal life? I’m curious to hear, so looking forward to your comments.

P.S. I have taken the liberty of such long excerpts from the book in this blog post, because these two excerpts are from only the first 80 pages of the book, there are many more gems in the book (like the story of Hurricane Katrina and Walmart and the lesson of decentralizing decision making using checklists), if you’re interested, you should definitely go buy the book.