Making a list…checking it twice…

Checklist Manifesto coverThe Checklist Manifesto

Atul Gawande

Picador.  2011.  240 pgs.

I’ve read two other wonderful books by Gawande:  Better, about a surgeon’s search for improved performance and Complications (reviewed on this blog) about what can go wrong in medicine.  His newest book, The Checklist Manifesto, is his best yet, because its lessons are applicable to all fields of work.

In it, Gawande describes his quest for a solution to the common failures of surgery:  infection, bleeding, unsafe anesthesia and a fourth amorphous but deadly factor he simply calls “the unexpected.”  This investigation will take Gawande to such disparate settings as operating theaters, jumbo jet cockpits, building worksites, investment firms and restaurant kitchens:  anywhere where it is no longer appropriate for mere humans to rely on focus, daring, wits and the ability to improvise.  Gawande demonstrates that many work settings where we attempt to function are too complex and risky for professionals to rely on those afore-mentioned traits, despite our zeal, hours of work and training.

What is the answer?  Gawande proposes the humble checklist — a short, succinct list of questions that can be run through before and during any high-stakes endeavor — whether slicing open someone’s chest or taking 200-300 human souls up to 30,000 feet.  This isn’t Gawande’s original idea: he traces the history of successful checklist-based work from the early days of aviation to the present, and describes how the ” miracle on the Hudson” — Capt. “Sully” Sullenberger’s successful landing of U.S. Airways flight 1549 — was actually due to calm and professional work from a checklist for engine failure and water-based landings.  Gawande describes how the use of complex checklists, with the addition of required communications and cross checks between teams, are what enable the construction of skyscrapers.  He interviews successful financial investors who shared their use of pre-investment checklists, ensuring that every financial report is plumbed for the signs of risk — particularly in the areas of debt leverage —  in order to avoid what one financier described as a “cocaine brain” rush to invest in the next sure thing.

Of course, Gawande writes primarily about his own field, surgery, and he describes his work with the World Health Organization to come up with the Safe Surgery Checklist — a two-minute check of vital pre- and post-surgical factors directly linked to the common failures of surgery.  One of the most interesting aspects of the checklist was the incorporation of communication:  having the entire surgical team introduce themselves to each other and formally, but quickly, share any concerns about the patient.  Gawande describes how the introductions and rapid but effective team bonding empower all team members to speak out, particularly nursing staff who may observe risks before surgeons do.  In fact, nursing staff can read off the checklist and in some cases, will prevent a surgeon from picking up a scalpel if a key checklist component has been missed.  The Safe Surgery Checklist was tested in eight hospitals around the world, and was featured in an early release article in the January 2009 issue of the New England Journal of Medicine.  It has been linked to significant, statistical improvements in care — and Gawande bravely and humbly describes how the checklist prevented a death in his own operating room.

One of the signs of a great book is that it changes you for the better.  One of my personal quests is to become a better manager.  The Checklist Manifesto made me ask the question:  what are the common failures of management?  I thought of two:  failure to communicate a vision and lack of connections between staff and manager.  Would a checklist help me try to avoid these pitfalls more consistently despite the complexity, shifting priorities and general madness of each day?  I hold weekly status meetings with each staffperson and I started to wonder, since I already prep before meeting with staff, would a checklist help?  Here is my proposed pre-meeting checklist for my regular meetings:

Do we need to meet?  Did we meet informally earlier in the week and could our time be better spent without the meeting?

Review notes and assignments from last meeting.  What needs to be followed up on?

Review emails from and to the employee over the past week.  What has happened?  Did something unexpected come up?  Is there a new priority on the horizon?

Are there outstanding questions I need to address?

What role is the employee playing with any long-term organizational goal?  Where are they on that?

What are my concerns about this employee?  Should I bring them up?  What might theirs be — I’ll be sure to ask.

The Checklist Manifesto teaches us that it is not a weakness to lean on a humble tool when stakes are high and risks are many.  As usual, Gawande presents a clear and compelling vision and this time his lesson is that we need all the help we can get to be fully human and fully successful in the increasing complexity we live in.

Atul Gawande

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