The Checklist Manifesto


UPDATE Jul 11, 2019: It's terribly funny to see another book about "checklists", that almost seems to complement Gawande's with an equally Non-Succinct Title Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety. Captain "Sully" Sullenberger appears in both books.******************Original Review:

”These are…ridiculously primitive insights. ...But, really, does it take all that to figure out what house movers, wedding planners, and tax accountants figured out

UPDATE Jul 11, 2019: It's terribly funny to see another book about "checklists", that almost seems to complement Gawande's with an equally Non-Succinct Title Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety. Captain "Sully" Sullenberger appears in both books.******************Original Review:

”These are…ridiculously primitive insights. ...But, really, does it take all that to figure out what house movers, wedding planners, and tax accountants figured out ages ago?”

- Dr. Atul Gawande (Annals of Medicine, essay in New Yorker, 2007).

In 2009’s Checklist Manifesto: How To Get Things Right, Gawande explains further.

(Not a spoiler. Just... more.) (view spoiler)[ In every industry of complexity, voluminous knowledge abounds and overwhelms any individual’s capacity to perform with optimal outcome. No one person can do it all. Not even a team can do it all, all the time. Multiply any one surgical scenario hundreds of thousands of times across different settings, resources and personalities - boom, failure imminent. Certainly not always, but in any events where patient safety is at stake, the odds for success from training, specialization and advanced technology ought to be correlated exponentially higher than what it currently is.

Gawande cites some numbers. According to the 9th edition of the World Health Organization’s (WHO) international classification of diseases, there are 13,000 different diseases, syndromes, and injury types. Clinicians have access to 6,000 drugs, 4,000 medical and surgical procedures with each a different requirement, risk and consideration. The average ICU patient required 178 individual actions per day, from administering a drug to suctioning the lungs, with every single action exposed to risk. How do 178 tasks get done consistently for every patient with a rotating medical staff without missing a beat? As Gawande puts it, “it is a lot to get right”.

Here’s more. Based on 2004 WHO data, one person out of 25 undergoes surgery every year with 10 to 100 times more risk than childbirth. Globally, surgeons perform over 230 million major operations annually but over 7 million people are left disabled and 1 million dead - a staggering amount of harm rivaled by malaria, tuberculosis and other known public health concerns. 5 million Americans are admitted to the ICU annually, with an average stay of 4 days and survival rate of 86%. Research consistently showed that 50% of deaths and major complications from surgery is avoidable.

“That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy - though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.”

Enters the checklist. As a trivial exercise, check the following physiological data points at your next hospital appointment:__ Body temperature (reading: __)__ Pulse (reading: __)__ Blood pressure (reading: __)__ Respiratory rate (reading: __)(Hint: Zero would be… immediately very problematic). At every visit, these basic vital signs are recorded. One skipped is extremely sloppy, two skipped is well, don’t. Three normal readings and one highly abnormal one could cost someone their life. As first line of defense, all it takes to raise initial red flags for the safeguarding of our health, is this rudimentary routine check. And at every subsequent step of the treatment plan, whether we realize it or not, there are medical checklists upon medical checklists, and checklists of checklists… or whatever terminology variation we prefer to coat it as. The word “checklist” sometimes meets mental resistance across the medical field for being too “dumbed down”, too “reductionist”, too… too insulting that a specialist, sub-specialist, ultra-specialist! Should ever need to check little boxes for what they already know like the back of their gloved surgical hands. Yet, knowing is not always doing.

At its most fundamental level, the checklist does two things: (a) Protects against faulty memory and distraction. Raise our hands, everyone who’s had an off day at work? Or, raise our hand, everyone who’s brought our A-game but everybody else is having an off day? On those days, the eveready checklist catches human fallibility. (b) Enforces mundane, but necessary minimum steps. In 2001, a critical care specialist at Johns Hopkins, Peter Provonost, implemented a doctor checklist of five no-brainer steps to target central line infections:

(1) wash hands with soap(2) clean patient’s skin with chlorhexidine antiseptic(3) put sterile drapes over entire patient(4) wear mask, hat, sterile gown, gloves (5) place sterile dressing over insertion site The resulting observation? At least one step was missed for over a third of all patients needing a central venous catheter threaded directly into their vena cava, where an infection would be life-threatening. In the ensuring year, this “ridiculously simple” checklist produced a dramatic reduction of central line infections from 11% to ZERO%, and then only 2 cases over the next 15 months after. In more concrete numerical terms - 43 infections avoided, 8 people did not die, $2 million in costs saved (also nil emotional toll and $0 malpractice lawsuits). When Michigan state implemented Provonost’s checklist in ICUs statewide, an astounding 1500 lives and $170+ million were saved. THE CHECKLIST, its Status Elevated, is Certified Bonafide.

More checklists were tested in the JH ICU. @Checking for pain/4 hours - check. Result: patients in untreated pain? 41% to 3%. @Checking mechanical ventilators - check. Result: patients not receiving recommended care? 70% to 4%. @Checking on pneumonia - check. Result: patients who lived? 21, or 25% of total. @Importance of baseline performance checklists and check, check, check-ing them off - check. Result: Gain in checklist devotees? MANY%.

Are you checked out yet with checklist fatigue? Gawande has only just begun. Sexy, the checklist isn’t. But neither is being sick, or dead, or in public healthcare verbiage, a missed opportunity. In early 2007, WHO invited Gawande, along with numerous international medical personnel, to convene for the monumental task of addressing surgical safety in developed nations - with economic wealth, specialties and advanced technology - to third world countries - in many instances, entire hospitals are staffed by only a few very overworked medical staff with limited resources and expertise. Lots of ideas were brainstormed to address a vast variety of problems. Lots of ideas were tried but failed to gain traction. But a thought had begun to emerge - has anyone tried the humble checklist? One that could be deployed easily, cheaply, effectively, consistently and just as importantly, measured and duplicated easily, cheaply, effectively, consistently (Gawande repeatedly calls it ”transmissible” as if it’s a disease as only a doctor would!). He had noticed that all the problems have a common “leverage” attribute - a simple intervention leads to dramatically successful results. Skepticism abound but enthusiasm grew as participants after participants shared stories of their own successful use of checklists, which may include anything from medical action (e.g. crucial antibiotics within narrow 60 min window) to pow-wows for communicating pitfalls and contingencies right before commencing surgery (e.g. confirming left kidney, not right. Speech impaired, attention to non-articulated distress) to very simply, introduction of each surgical team member by name (e.g. to foster trust).

After many revisions later, the WHO surgical checklist was born. Rolled out in 8 impoverished and affluent cities internationally, the checklist produced staggeringly positive results in its pilot year - major surgical complications fell 36%, deaths 47%. Fast forward to present time, implementation of it is now mandatory in 7 countries and over two dozen U.S. states, with an estimated 1,200 hospitals opting in as users. Gawande danced a mental jig on his desk, and thought, “this thing is real” (try to imagine a reserved Gawande in his standard attire of Brooks Brothers jacket and brown Oxford loafers letting loose his inner kid…). In absolute data, the surgical checklist is the real deal.

But the real star of Checklist Manifesto: How To Get Things Right isn’t the checklist, but Gawande the writer. After all, a checklist is a checklist and a best-selling book changes nothing of its quotidian nature. Very few non-fiction authors I have read get giddy about banal topics the way Gawande does in his slightly astonished, intellectually nerdy way. As if he has discovered the wonder of sliced bread and after interrogating its shape, its thickness, its texture, pronounced it perfect for sandwiches. Then he layers on these small, interesting, colorful personal anecdotes and soon, have us chomping away at tidbits peripheral to the bread. This is my 3rd book of his, and counting *.

If we say, great storytelling, Gawande, but show me the data. Worry not, he’s done the research neatly referenced by chapters at the back of book. It isn’t just surgery and public health that he writes earnestly, insightfully and meticulously about, it’s also the many non-medical industries - construction, supply chain management, investments, aviation - highlighted for utilizing their versions of the sacred yet ubiquitous checklist. Even if we are not frequent users of the checklist, any checklists, we can bet that many checklists have been applied to our lives directly or indirectly. If the idea of personally using a checklist seems hackneyed and restrictive to creative freedom, you’re probably right. Don’t use it. Gawande isn’t asking us to, he’s merely telling why he and other professional communities, use it to get their things right.

(hide spoiler)]

"Checklist Manifesto for the Checklist Aficionado" is my takeaway impression of Checklist Manifesto: How To Get Things Right. Using the checklist already has my buy-in since… oh, forever; an incurable habit from teenage days. Somewhat mis-titled, this book isn’t really a “How-To” but a "How I”. There is no sample. There is no stories of failures. There is no setback without a comeback. There is no guide on crafting a checklist, but a few pointers. There is no promise that the checklist is the be-all and end-all, only that it is a very effective tool. One that house movers, wedding planners, tax accountants, many others and eventually even Gawande, have figured out.

[* 4 stars: Being Mortal: Medicine and What Matters in the End , 4 stars:


Complications: A Surgeon's Notes on an Imperfect Science . And Gawande's Bio]
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