Top Quotes: “The Checklist Manifesto” — Atul Gawande

Why Are Checklists Necessary?

“In the 70s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed is ‘necessary fallibility’ — some things we want to do are simply beyond our capacity. We aren’t omniscient or all-powerful. Even enhanced by tech, our physical and mental powers are limited. Much of the world and universe is — and will remain — outside of our understanding and control.

There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snowstorms, save people from heart attacks and stab wounds. In such realms, they pointed out, we have just two reasons that we may nonetheless fail.

The first is ignorance — we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude — because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that’s built wrong and collapses, the snowstorm whose signs the meteorologist plain missed, the stab wound from a weapon the doctors forgot to ask about.

The balance of ignorance and ineptitude has greatly shifted. For nearly all of history, people’s lives have been governed primarily by ignorance. This was nowhere more clear than with the illnesses that befell us. We knew little about what caused them or what could be done to remedy them. But sometime over the last several decades — and it’s only over the last several decades — science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.

Consider heart attacks. As recently as the 1950s, we had little idea of how to prevent or treat them. We didn’t know, for example, about the danger of high blood pressure, and had we been aware of it we wouldn’t have known what to do about it. The first safe medication to treat hypertension was not developed and conclusively demonstrated to prevent disease until the 1960s. We didn’t know about the role of cholesterol, either, or genetics or smoking or diabetes.

Furthermore, if someone had a heart attack, we had little idea of how to treat it. We’d give some morphine for the pain, perhaps some oxygen, and put the patient on strict bed rest for weeks — patients weren’t even permitted to get up and go to the bathroom for fear of stressing their damaged hearts. Then everyone would pray and cross their fingers and hope the patient would make it out of the hospital to spend the rest of their life at home as a cardiac cripple.

Today, by contrast, we have at least a dozen effective ways to reduce your likelihood of having a heart attack — for instance, controlling your blood pressure, prescribing a statin to lower cholesterol and inflammation, limiting blood sugar levels, encouraging exercise regularly, helping with smoking cessation, and, if there are early signs of heart disease, getting you to a cardiologist for still further recommendation. If you should have a heart attack, we have a whole panel of effective therapies that can not only save your life but also limit the damage to your heart: we have clot-busting drugs that can reopen your blocked coronary arteries; we have cardiac catheters that can balloon them open; we have open heart surgery techniques that let us bypass the obstructed vessels; and we’ve learned that in some instances all we really have to do is send you to bed with some oxygen, an aspirin, a statin, and blood pressure meds — in a couple days you’ll generally be ready to go home and gradually back to your usual life.

But now the problem we face is ineptitude, or maybe it’s ‘eptitude’ — making sure we apply the knowledge we have consistently and correctly. Just making the right treatment choice among the many options for a heart attack patient can be difficult, even for expert clinicians. Furthermore, whatever the chosen treatment, each involves abundant complexities and pitfalls. Careful studies have shown, for example, that heart attack patients undergoing cardiac balloon therapy should have it done within 90 minutes of arrival at a hospital. After that, survival falls off sharply. In practical terms this means that, within 90 minutes, med teams must complete all their testing for every patient who turns up in an ER with chest pain, make a correct diagnosis and plan, discuss the decision with the patient, obtain their agreement to proceed, confirm there’s no allergies or medical problems that have to be accounted for, ready a cath lab and team, transport the patient, and get started.

What’s the likelihood that all this will actually occur within 90 minutes in an average hospital? In 2006, it was less than 50%.

This isn’t an unusual example. These kinds of failures are routine in medicine. Studies have found that at least 30% of patients with stroke receive incomplete or inappropriate care from their doctors, as do 45% of patients with asthma and 60% of patients with pneumonia. Getting the steps right is proving brutally hard, even if you know them.

I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It’s not money or government or the threat of malpractice lawsuits or insurance company hassles — although they all play a role. It’s the complexity that science has dropped upon us and the enormous strains we’re encountering in making good on its promise. The problem is not uniquely American; I’ve seen it everywhere — in rich countries and poor. Moreover, I have found to my surprise that the challenge is not limited to medicine.

Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and a result so has our struggle to deliver on them. You see it in the frequent mistakes authorities make when hurricanes or other natural disasters hit. You see it in the 36% increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes — the most common being simple administrative errors, like missed calendar dates and clerical screwups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks — in fact, almost any endeavor requiring mastery of complexity and of large amounts of knowledge.”

“Here, then, is our situation at the start of the 21st century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields — from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

This 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.

It is a checklist.”

“Given how much surgery is now done — Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually — the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year — more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.

Medicine, with its dazzling successes but also frequent failures, therefore poses a significant challenge: What do you do when expertise is not enough? What do you do when even the superspecialists fail?”

“In 2001, a critical care specialist at Johns Hopkins 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: 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. 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 Johns Hopkins administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were able 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 to more forceful methods. But many nurses aren’t sure whether this is their place or whether a given measure is worth a confrontation. 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% to zero. So they followed patients for 15 more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented 43 infections and eight deaths and saved two million dollars in costs.”

“Pronovost had been canny when he started. In his first conversations with hospital administrators, he hadn’t ordered the to use the central line checklist. Instead, he asked them simply to gather data on their own line infection rates. In early 2004, they found, the infection rates for ICU patients in Michigan hospitals were higher than the national average, and in some hospitals dramatically so. Sinai-Grace experienced more central line infections than 75% of American hospitals. Meanwhile, Blue Cross Blue Shield of Michigan agreed to give hospitals small bonus payments for participating in Pronovost’s program. A checklist suddenly seemed an easy and logical thing to try.”

“In 200, the Keystone Initiative published its findings in a landmark New England Journal of Medicine article. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66%. Most ICUs — including the ones at Sinai-Grace Hospital — cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90% of ICUs nationwide. In the Keystone Initiative’s first 18 months, the hospitals saved an estimated $175 million in costs and more than 15,000 lives. The successes have been sustained for several years now — all because of a stupid little checklist.”

“He had been working in Klagenfurt for six years when the girl came in. She hadn’t been the first person whom he and his colleagues had tried to revive from cardiac arrest after hypothermia and suffocation. His hospital received 3–5 such patients/year, mostly avalanche victims, some of them drowning victims, and a few of them people attempting suicide by taking a drug overdose and then wandering out into the snowy Alpine forests to fall unconscious. For a long time, he said, no matter how hard the hospital staff tried, they had no survivors. Most of the victims had been without a pulse and oxygen for too long when they were found. But some, he was convinced, still had a flicker of viability in them, yet he and his colleagues had always failed to sustain it.

He took a close look at the case records. Preparation, he determined, was the chief difficulty. Success required having an array of people and equipment at the ready — trauma surgeons, a cardiac anesthesiologist, a cardiothoracic surgeon, bioengineering support staff, a cardiac perfusionist, operating and critical care nurses, intensivists. Almost routinely, someone or something was missing.

He tried the usual surgical approach to remedy this — yelling at everyone to get their act together. But still they had no saves. So he and a couple colleagues decided to try a checklist.

They gave this checklist to the people with the least power in the whole process — the rescue squads and the hospital telephone operator — and walked them through the details. In cases like these, the checklist said, rescue teams were to tell the hospital to prepare for possible cardiac bypass and rewarming. They were to call, when possible, even before they arrived on the scene, as the prep time could be significant. The telephone operator would then work down a list of people to notify them to have everything set up and standing by.

With the checklist in place, the team had its first success — the rescue of the three-year-old girl. In another rescue, a mother and her 16-year-old daughter were in an accident that sent them through a guardrail, over a cliff, and into a river. The mother died on impact; the daughter was trapped as the car rapidly filled with icy water. She had been in cardiac and respiratory arrest for a prolonged period of time when the rescue team arrived.

From that point onward, though, everything moved like clockwork. By the time the rescue team got to her and began CPR, the hospital had been notified. The transport team delivered her in minutes. The surgical team took her straight to the operating room and crashed her onto heart-lung bypass. One step followed right after another. And because of the speed with which they did, she had a chance.”

“A building is like a body. 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. All together, construction projects today involve some 16 different trades. Each trade contributes its own separate section to construction plans. There are sections for conveying systems (elevators and escalators), mechanical systems (heating, ventilation, plumbing, AC, fire protection), masonry, concrete structures, metal structures, electrical systems, doors and windows, thermal and moisture systems (including waterproofing and insulation), rough and finish carpentry, site work (including excavation, waste and storm water collection, and walkways) — everything right down to the carpeting, painting, landscaping, and rodent control.”

Power & Hurricane Katrina

“At 6am on August 29, 2005, Hurricane Katrina made landfall in Plaquemines Parish in New Orleans. The initial reports were falsely reassuring. With telephone lines, cell towers, and electrical power down, the usual sources of info were unavailable. By afternoon, the levees protecting the city had been breached. Much of New Orleans was under water. The evidence was on TV, but the director of FEMA discounted it and told a press conference that the situation was largely under control.

FEMA was relying on info from multiple sources, but only one lone agent was actually present in New Orleans. That agent had managed to get a Coast Guard helicopter ride over the city that first afternoon, and he filed an urgent report the only way he could with most communication lines cut — by email. Flooding was widespread, the email said; he himself had seen bodies floating in the water and hundreds of people stranded on rooftops. Help was needed. But the government’s top officials didn’t use email. And as a Senate hearing uncovered, they were not apprised of the contents of the message until the next day.

By then, 80% of the city was flooded. 20,000 refugees were stranded at the New Orleans Superdome. Another 20,000 were at the Morial Convention Center. Over 5,000 people were at an overpass on I-10, some of them left by rescue crews and most carrying little more than the clothes on their backs. Hospitals were without power and suffering horrendous conditions. As people became desperate for food and water, looting began. Civil breakdown became a serious concern.

Numerous local officials and impromptu organizers made efforts to contact authorities and let them know what was needed, but they too were unable to reach anyone. When they finally got a live person on the phone, they were told to wait — their requests would have to be sent up the line. The traditional command-and-control system rapidly became overwhelmed. There were too many decisions to be made and too little info about precisely where and what help was needed.

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.

The result was a combination of anarchy and Orwellian bureaucracy with horrifying consequences. Trucks with water and food were halted or diverted or refused entry by authorities — the supplies were not part of their plan. But requisitions were held up for days; the official request did not even reach the U.S. Department of Transportation until two days after tens of thousands had become trapped and in need of evacuation. Meanwhile, 200 local transit buses were sitting idle on higher ground nearby.

The trouble wasn’t a lack of sympathy among top officials. It was a lack of understanding that, 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 wasn’t going to be possible.

Asked afterward to explain the disastrous failure, the secretary of Homeland Security said that it had been an ‘ultra-catastrophe,’ a ‘perfect storm’ that ‘exceeded the foresight of the planners, and maybe anybody’s foresight.’ But that’s not an explanation. It’s simply the definition of a complex situation. And such a situation requires a different kind of solution from the command-and-control paradigm officials relied on.

Of all orgs, it was oddly enough Wal-Mart that best recognized the complex nature of the circumstances, according to a Harvard case study. Briefed on what was developing, their CEO issued as simple edict. ‘This company will respond to the level of this disaster,’ he was remembered to have said in a meeting with his upper management. ‘A lot of you are going to have to make decisions above your level. Make the best decision that you can with the info that’s available to you at the time, and, above all, do the right thing.’

As one of the officers at the meeting later recalled, ‘That was it.’ The edict was passed down to store managers and set the tone for how people were expected to react. On the most immediate level, Wal-Mart had 126 stores closed due to damage and power outages. 20,000 employees and their family members were displaced. The initial focus was on helping them. And within 48 hours, more than half of the damaged stores were up and running again. But according to one executive on the scene, as word of the disaster’s impact on the city’s population began filtering in from Wal-Mart employees on the ground, the priority shifted from reopening stores to ‘Oh, my God, what can we do to help these people?’

Acting on their own authority, Wal-Mart’s store managers began distributing diapers, water, baby formula, and ice to residents. Where FEMA still hadn’t figured out how to requisition supplies, the managers fashioned crude paper-slip credit systems for first responders, providing them with food, sleeping bags, toiletries, and also, where available, rescue equipment like hatchets, ropes, and boots. The assistant manager of a Wal-Mart store engulfed by a 30-foot storm surge ran a bulldozer through the store, loaded it with any items she could salvage, and gave them all away in the parking lot. When a local hospital told her it was running short on drugs, she went back in and broke into the store’s pharmacy — and was lauded by upper management for it.

Senior Wal-Mart officials concentrated on setting goals, measuring progress, and maintaining communication lines with employees at the front lines and with official agencies when they could. In other words, to handle this complex situation, they did not issue instructions. Conditions were too unpredictable and constantly changing. They worked on making sure people talked. Wal-Mart’s emergency operations team even included a member of the Red Cross. (The federal government declined Wal-Mart’s invitation to participate.) The team also opened a 24-hour call center for employees, which started with eight operators but rapidly expanded to 80 to cope with the load.

Along the way, the team discovered that, given common goals to do what they could to help and to coordinate with one another, Wal-Mart’s employees were able to fashion some extraordinary solutions. They set up three temporary mobile pharmacies in the city and adopted a plan to provide meds for free at all of their stores for evacuees with emergency needs — even without a prescription. They set up free check cashing for payroll and other checks in disaster-area stores. They opened temporary clinics to provide emergency personnel with inoculations against flood-borne illnesses. And most prominently, within just two days of Katrina’s landfall, the company’s logistics teams managed to contrive ways to get tractor trailers with food, water, and emergency equipment past roadblocks and into the dying city. They were able to supply water and food to refugees and even to the National Guard a day before the government appeared on the scene. By the end Wal-Mart had sent in a total of 2,498 trailer loads of emergency supplies and donated $3.5 million in merch to area shelters and command centers.

‘If the American government had responded like Wal-Mart has responded, we wouldn’t be in this crisis,’ Jefferson Parish’s top official said in a TV interview at the time.

The lesson of this tale has been misunderstood. Some have argued that the episode proves that the private sector is better than the public sector in handling complex situations. But it isn’t. For every Wal-Mart, you can find numerous examples of major New Orleans businesses that proved inadequately equipped to respond to the unfolding events — from the utility corporations, which struggled to get the telephone and electrical lines working, to the oil companies, which kept too little crude oil and refinery capacity on hand for major disruptions. Public officials could also claim some genuine successes. In the early days of the crisis, for example, the local police and firefighters, lacking adequate equipment, recruited an armada of Louisiana sportsmen with flat-bottom boats and orchestrated a breathtaking rescue of more than 62,000 people from the water, rooftops, and attics of the deluged city.

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.

This was the understanding people in the skyscraper-building industry had grasped. More remarkably, they had learned to codify that understanding into simple checklists. They had made the reliable management of complexity a routine.

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how.”

How To Create a Checklist

“When you’re making a checklist, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off — it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.

The checklist cannot be lengthy. A rule of thumb some use is to keep it betwen 5–9 items, which is the limit of the working memory. But it all depends on the context — in some situations, you have only 20 seconds. In others, you may have several minutes.

But after about 60–90 seconds at a given pause point, the checklist often becomes a distraction from other things. People start shortcutting. Steps get missed. So you want to keep the list short by focusing on ‘the killer steps’ — the steps that are most dangerous to skip and sometimes overlooked nonetheless.

The wording should be simple and exact, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading, ideally a sans serif type like Helvetica.

No matter how much thought you put into a checklist, it has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart, and one needs to study how, make changes, and keep testing until the checklist works consistently.”

“Boeing sent a checklist 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. Just as schools or hospitals tend to do things slightly differently, so do airlines, and they are encouraged to modify the checklists to fit into their usual procedures. (When airlines merge, among the fiercest battles is the one between the pilots over whose checklists will be used.) Within a month of the recommendations becoming available, pilots had the new checklist in their hands. And they used it.”