The Checklist Manifesto : How to Get Things Right (English) Atul Gawande

Introduction

Would you believe if someone told you that checklists can save lives? Yes it can. It changed my life. Hi, guys I’m [your name] and I’m using checklists from a while now. Somedays before I just had a thought why not to make a tutorial on it if it’s helping me a lot. A checklist might seem like a simple tool, but it has helped many experts from different fields. Surgeons and pilots, for example, sometimes forget one basic step and this leads to disaster. The solution is to make checklists. I learnt about checklists from a book called “The Checklist Manifesto”. That’s why I will be taking reference from this book and teach you. This book will teach you how important checklists are and how you can apply them in your own career.

Have you ever seen an emergency operation take place on TV or in real life? Were you ever fascinated by how well-coordinated the doctors and nurses were? Did it make you wonder how people do this? In this book, you’ll learn about the power of checklists. Even if it seems very basic, you will learn how professionals like doctors and pilots use checklists as much as possible.

Who will learn from the class?

  • Aspiring doctors and pilots, medical
  • students to increase productivity
  • Employees, managers and
  • entrepreneurs
  • Young professionals

This simple technique has proven time and time again to be effective and life-saving.You’ll also learn about the difference between good checklists and bad ones. This book will teach you how to make your own checklists that can aid you in your work.No matter what career you are in or training you have, you can become overwhelmed with all the work you are responsible for. This book will teach you how a simple checklist can make things easier and simpler. With practice, you will avoid mistakes and do each task successfully and avoid forgetting important steps.

The Problem of Extreme Complexity

A medical journal described a case study which caught author Gawande’s attention. The report described a family having a leisure walk in the woods when the parents lost sight of their three-year-old daughter. It was only three-seconds, but in that short time, the child fell into an icy pond. Her parents looked for her, and after thirty minutes they found her unconscious and frozen in the water.Even though they were panicking, the parents managed to call the emergency response team.

While waiting for the team to arrive, the parents kept giving their daughter CPR. When the response team observed the girl’s condition, the outlook was grim: the three-year-old wasn’t responding at all. There was no pulse nor any sign of breathing. When they flashed a light on her eyes, she didn’t react to it. This was a sign that the brain wasn’t functioning anymore. Coldwater and debris from the pond had filled her lungs; she looked like she was gone.
 
But the response team ordered a helicopter to take the child to the nearest hospital. As she was being transported, the emergency crew continued performing CPR on her. Once they arrived, a surgical team planned to attach her to a heart-lung bypass machine. This machine would keep pumping blood into her, as her heart and lungs are not functioning anymore.The surgeon cut through the skin on the child’s groin and attached a silicone rubber tube into an artery.

This tube would take the girl’s blood out of her while another silicone tube was attached to a vein and sent the blood back into her body.Right up to the point when she was plugged into the bypass machine, the girl had been lifeless for one hour and a half. But with blood flowing into her veins, her temperature began to rise and her heart started to beat once more.The child’s lungs were damaged because of dirty pond water, and the doctors found twigs, dirt and other objects inside of her lungs. Because of this, her lungs couldn’t pump oxygen into her body. So, the medical team used an artificial lung system that could pump oxygen for her. The team opened her chest with a power saw and inserted lines from the system to her lungs and heart.
 
Through the following night and day, the team performed fiberoptic bronchoscopy on the little girl. This meant that they removed the water and other objects from her lungs. The next day, the child’s lungs slowly recovered.Meanwhile, the child’s brain was also swelling, but the team managed to get that under control, too. For more than a week, the child was comatose. But after a few more weeks, all her organs were repaired and functioning, and she recovered.The whole team behind her recovery were like superheroes, don’t you think? It was as if they brought the three-year-old girl back from the dead.

What the team did was extremely complicated. Not a single person could have done everything on their own, which made it more impressive, because many people had to work together to make sure every step of every single, complex operation would be perfect. Can you imagine the level of coordination required to accomplish this? Not to mention, this wasn’t the only case they were working on. Every person on the team had other tasks, too.
 
Despite that these professionals are experts in their fields, there is no denying that there are sometimes errors.There are more than 150,000 deaths every year concerning surgery. Studies have shown that at least 50% of these 150,000 deaths could have been avoided. For example, a member of the medical team might have forgotten to wash their hands or wear a face mask, or a tool may not have been properly sanitized and therefore led to a surgical infection.Even though they are professionals with lengthy training, they can still miss an important step. So, how do we combat this? How can we save more lives?

The Checklist

During the 1930s, the US Military Air Corps held a competition as to which airplane manufacturer would be their official supplier. The plane that Boeing brought to the competition was their best ever. It was a sight to behold: the Boeing 299 had a 103-foot wingspan and instead of two engines, it had four. It lifted smoothly off the ground and climbed to about 300 feet in the air. Boeing almost got the deal. But after a few minutes, the plane stalled and burst into flames.

Out of the five crew members in the plane, two died, including the pilot.An investigation was launched and it was discovered that there was nothing wrong with the plane itself. The report concluded that the tragedy happened because of an error made by the pilot. The aircraft had complex engines, landing gear, and other high-tech features. Because he had to attend to a lot of controls, the pilot forgot to do just one crucial step. This led to the plane’s explosion and his own death. In the end, the Air Corps went for Martin and Douglas Company, but the army still purchased a few planes from Boeing.
 
Some people were convinced that the Boeing 299 was definitely flyable. So, test pilots set out to prove this, but they started with a different, yet surprisingly smart approach. The new team created a pilot’s checklist. For people who are experienced in flying airplanes, it could just be a hassle. The checklist was unnecessary! It was like having a checklist on how to get the car out of your garage. But the Boeing 299 was a complex plane. It was too complicated to be left to the memory of just one person, even if that person was an expert.The pilot’s checklist was simple and straight to the point.

It was a step-by-step guide for pilots to follow for take-off, flight and landing.  Yes, it sounded like such an unnecessary thing to do. After all, pilots wouldn’t be pilots if they don’t know how to fly a plane, right? You’d think that the checklist would not make any difference, but it did. The pilot who used a checklist managed to fly the Boeing 299 for many miles without a single accident.
 
Most professional fields today are complex. Think of a dentist performing a root canal, or a surgeon doing a heart transplant. It can be difficult for people to do their jobs by relying only on their memory. Our memories are faulty. When we get used to a routine, we often forget or skip a step. We don’t do it on purpose, but our minds focus on the things that are new or urgently need our attention. We think that just because one step is simple, skipping it won’t matter. Until one day it does, and we or someone else suffers the consequences. Checklists help us to remember these boring, yet important steps.

Checklists emphasize why these steps are there in the first place.In 2001, Peter Pronovost, a critical care specialist at John Hopkins Hospital, tried out a checklist for doctors. He decided to focus on one of the risks that a doctor can bring to a patient, which involved infecting central lines.Central lines are catheters that are inserted in the veins of a patient when the heart, kidney, or lungs, have failed. The lines are connected to a bypass or dialysis machine so that the patient remains stable, even if the major organ is not functioning. If a doctor forgets just one step in the process of inserting central lines, then germs go directly into the patient’s bloodstream and infect his or her internal organs.
 
On a sheet of paper, Pronovost listed out the protocol for setting up central lines. Just like the pilot’s checklist, this list was simple. If you were a doctor who had been practicing for years, you’d laugh at the checklist. You could easily go through the protocol with your eyes closed.Here was the checklist: first, wash your hands with soap.Second, clean the patient’s skin with antiseptic. Third, put sterile drapes over the patient’s whole body. Fourth, wear a sterile surgery gown, hat and face mask. Fifth, place a sterile dressing on the insertion area once the central line is inside the patient’s vein.Pronovost asked the nurses to observe if the doctors followed every step in the checklist for a month.
 
The results were surprising: doctors would skip at least one basic step in every one out of three patients.The administration at the John Hopkins Hospital made it clear that if a doctor skipped a step, the nurse could stop them during the procedure and point it out. However, if the doctor didn’t listen, the nurses would have the administration as a backup. For a year, the checklist was enforced.Pronovost and his colleagues were shocked at the results.

After the checklist was implemented, the number of infections from central lines decreased from 11% of patients (having an infection every 10 days) to 0%! For another 15 months, the hospital observed patients who had the procedure. During this time, only two of them had a central line infection. Based on the team’s calculations, the checklist did wonders. It prevented 43 infections, 8 deaths, and saved the hospital about $2,000,000. 

The End of the Master Builder

Checklists serve as a safety net for people no matter how experienced they are in their field. Since humans have faulty memory and short attention spans,checklists can prevent disasters. However, checklists have their limits. You need to understand when they come in handy and when they don’t. According to professors Brenda Zimmerman and Sholom Glouberman, who have both studied the science of complexity, there are three kinds of problems in the world: simple, complicated and complex.Simple problems are like baking a chocolate cake.
 
There’s a recipe, and you eventually get the hang of it. Once you have baked one, you can easily successfully repeat the same recipe every time. Complicated problems are like sending a rocket to the moon. Problems like these can be broken off into different simple problems. However, you can’t guarantee if the outcome will be a success or not.

For complicated problems, you need to rely on other people. This is where coordination becomes a crucial factor.Complex problems have many factors – like raising a child. There’s no straightforward road to success. Each child is different, and what will work for one child may not work for another. Complex problems bring uncertainty, there is no guarantee what the results will be. Although it’s not impossible to raise a child, it can be very challenging.
 
Checklists work well for simple problems. They can prevent doctors from forgetting to wash their hands before a procedure, such as we saw in the case of central line infections. But how about complex problems when you have to consider a lot of details? An Intensive Care Unit team has a lot of crucial tasks to do for every patient. On top of that, they need to coordinate with a lot of specialists, as well.

Having a checklist for each task would be impossible.So, how do we go about addressing complex problems? Is a checklist even possible?The answer might surprise you. One day, author Atul Gawande noticed a large, new building under construction on his way to work. It was a fascinating thing to see.How did the people behind this construction know that what they were building was right? What made them sure that the building wouldn’t collapse?
 
How do engineers guarantee that the elevators would work? How do they design an effective plumbing and ventilation system for the whole building? During medieval times, there were Master Builders who did all the construction work from start to finish. They worked alone and they did everything all by themselves.However, by the 20th Century, Master Builders were already gone.

The advancement of the construction industry—and other industries—was too complex for just one Master Builder to handle.Atul Gawande became curious about the whole construction industry, so he paid a visit to Finn O’Sullivan, a construction project executive. Enter the checklists. The author was surprised to see dozens of them in the office of O’Sullivan. He was one of the people who made sure that the construction workers were doing their jobs properly. 
 
The numerous checklists were made according to specialization. One checklist was for the engineering trade, another was for the plumbing trade, and so on.Every week, the people involved in the project would go through the checklists to make sure that nothing had been skipped.However, what happens when something goes wrong? There was no Master Builder who could easily solve it.O’Sullivan showed the author a brainstorming schedule. It was a schedule for when an expert would talk to another expert. Each expert would have their own opinion on the problem.
 
Then, they would discuss it with the other experts. In the face of complex problems, they completely relied on communication. Having different people to look at the problem brings much wisdom to the table. It’s through this gathered wisdom that they were able to solve construction problems quite well.Therefore, to solve complex problems, first, you need multiple checklists for every specialization. Second, as an expert, you need to consult with other experts so that every angle of the complex problem is studied. Then, you can come up with the best and most effective solution.

The Checklist Factory

Gawande tried to replicate the checklists that O’Sullivan used for construction projects. He applied these checklists to general surgery, his field of expertise, and it was hard. The checklists took months to complete. Since he was a surgeon, every minute was crucial. So, Gawande sought help from the aviation industry and he met the seasoned pilot Daniel Boorman.Boorman was famous in his profession. He had been developing checklists for Boeing for the last two decades. He studied thousands of plane crashes over the years. He made it his goal to avoid human error as much as possible.

At their meeting, Boorman showed Gawande a handbook. It was about 200 pages long. To his surprise, Gawande discovered that it wasn’t just one checklist. It was a collection of multiple checklists. Each one was short and written with simple words. Each checklist covered different kinds of scenarios that a pilot would encounter before, during, and after their flight. The handbook also included scenarios which pilots would almost never encounter in their careers, but if ever they did, the checklists were there so they would know what to do.
 
According to Boorman, there were good and bad checklists. Bad checklists were confusing, long, and hard to use. They were good in theory, but useless when you actually needed them. Good checklists are straight to the point, easy to use, and most importantly, practical. Boorman and other people who crafted good checklists made sure that these worked in real life.To make a good checklist, you need to first answer this question: is this checklist a DO, then CONFIRM list? Or a READ and then DO checklist?? For a DO then CONFIRM checklist, you go through the steps of a job from memory.

However, you stop and consult the checklist to make sure you didn’t skip a step.For a READ then DO checklist, you carry out the steps while you check them off. It’s similar to going through a recipe.After you know what type of checklist you’re aiming for, make sure that it isn’t lengthy. The limit of our memory is between five to nine items, so try to stick with that number. When it comes to the steps you should include, Boorman refers to them as the “killer items”. These items are too dangerous to skip, yet are often overlooked. If the step you’re considering is not a “killer item”, you can remove or revise it.
 
Use simple words and use language that is familiar to your profession. Try as much as possible to fit your checklist into just one page and don’t add unnecessary details. Boorman even suggested using a huge wide font like Helvetica.No matter how much thought you put into your checklist, it won’t be a success on the first try. Theory will always be different from practice.

Things will be different when applied in the real world. You should always be open to change. These changes will help you make your checklist better. Eventually, your checklist will be able to work all the time and you can share it with others.Boorman and other pilots often undergo flight simulation exercises. They always try to create a READ then DO or DO then CONFIRM checklist. Simulation has enabled them to experience dangerous situations without putting their lives and the lives of their passengers at stake.

Conclusion

In this book, you learned that even experts are prone to mistakes. This is a reality because we are human and imperfect. The solution to forgetting things and dealing with complex problems is to make checklists.You learned how to make your own checklist. It should be short, easy to understand, and practical. Theory is different from practice, so test out your checklist in real life and make necessary revisions.

This book made you realize that something as simple as a checklist can make a huge impact. We always think that we don’t need help, but even the heroes of today, such as doctors and pilots, need the support of each other.We need to communicate openly. Experts wouldn’t have gone far if they only counted on themselves. We need to rely on one another to create amazing things and bring about change.A checklist may be just what you need in your life. Who knows, maybe you’ll be so good at it that you’ll explore other activities to make more checklists! You can share your checklists with your colleagues and make a difference for your team or organization. Or you can share your checklists at first with us for your practise. I’m always their to help you out.

We will be happy to hear your thoughts

Leave a reply

free books
Logo