Atul Gawande - The Checklist Manifesto Finished reading 11/9/2010 Gawande, a surgeon by trade, espouses the values of checklists to harness today's vast and complex society. p13 The volume and complexity of what we know has exceeded our individual abilty to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. We need a different strategy for overcoming failure=... it is a checklist. p44 Gawande cites the value of a checklist to be $175 million and 1500 lives when a checklist was implemented within hospitals outlining how to prevent central line IV infections. In some cases, instances of central lines infection decreased from more than 10% to 0%. "The successes have been sustained for several years now - all because of a stupid little checklist. p48 Checklists have limits as well. 3 types of problems: simple (recipe), complicated (procedural, but long), and complex (too many variables) "Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us - flaws of memory and attention and thoroughness. And because they do they raise wide, unexpected possibilities." p68 in regards to building skyscrapers Checklists have been used in construction for a while, but they are often know and "Project Plans", outlining the tasks and schedules of resources in great detail. "...the major advance in the science of construction over the last few decades has been the perfection of tracking and communication." ProjectCenter software ClashDetective p71 "Joe Saliva 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." improved quality and reduced costs for better products p72 "There is a particularly tantalizing aspect to the building industry's strategy for getting things right in complex situations: it's that it gives people power." "In response to risk, most authorities tend to centralize power and decision making." "When you're confronted with a complex, nonroutine problems -- such "The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. That is what works." p76 Gawande references Wal-Mart's response to Hurricane Katrina in 2006. Lee Scott, Wal-Mart's CEO issued the statement: "A lot of you are going to have to make decisions above your level. Make the best decision that yo ucan with the information that's available to you at the time, and above all, do the right thing." Wal-Mart gave out free supplies and even medicine (without prescription). p79 "nder conditions of true complexity -- where the knowledge required exceeds that of any individual and unpredictatbility reigns -- efforts to dictate every step from the center will fail." "They had made reliable management of complexity a routine." "Under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided -- and even enhanced -- by procedure." p83 Even Jody Adams' (of Rialto restaurant) uses recipes in her kitchen to main high quality and standard consistency across chefs. p93 Seek simple interventions. You can't change everything. Look for "leverage points". What processes would modify culture? p98 Even basic items like properly applying antibiotics are skipped or done incorrectly. When there are many things going on, even simple items are overlooked, and may pose a problem of greater or equal risk going forward. In other words, don't think checklists are unnecssary. Precisely because they are common, is one of the reasons they are valuable. p99 Introducing the checklist. "getting teams to stop and user the checklist -- to make it their habit -- was clearly tricky. A couple of check boxes weren't going to do much all by themselves." The surgeon put a reminder on the cover of the scalpel to ensure a reminder before every operation. This is like the David Allen technique of "putting it in front of the door." Even including "teamwork" on a checklist is okay. People work more effectively when they know each other's names. p108 "Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up." - "activation phenomenon" p120 The checklist for good checklists bad checklists are vague and imprecise, too long, hard to use, impractical. 5-9 steps (limit of psychic capacity) versioned/dated helvetica, large font, uncluttered page "They treat the people using the tools as dumb and try to spell out every single step. They turn people's brains off rather than turn them on." "The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. they can make priorities clearer and prompt people to fucntion better as a team. by themselves, however, checklists cannot make anyone follow them." Pilots learn in flight school that their memory and judgment are unreliable p122 define a clear pause point, a point at which the checklist is supposed to be used: READ-DO (read it then do it) DO-CONFIRM (do it, then confirm it) WHO List to 8 hospitals - YouTube video How to Use the Safe Surgery Checklist & How Not To Significant results were found and checklists have been on the uptake in the US, as well as in Europe, Asia, Africa, Australia, New Zealand, and South America. p161 Checklists sometimes have the ability to unspecialize an area. Basically by disseminating otherwise locked information. "Clincians will not be able to dispense with expert audacity. yet we should also be ready to accept the virtues of regimentation". Checklists good at combatting "cocaine brain" - greed/overexcitement can be tempered through rational, formal analyis - checklisting. p184 "We have most readily turned to the computer as our aid. Computers hold out the prospect of automation as our bulwark against failure. Indeed, they can take huge numbers of tasks off our hands, and thankfully already have -- tasks of calculation, processing, storage, transmission. Without question, technology can increase our capabilities. But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building, perform a livesaving operation. In many ways, technology has complicated these matters. It has added yet another element of complexity to the systems we depend on and given us entirely new kinds of failure to contend with". Donald Berwick, President, Institue for Healthcare Improvement in Boston - Systems Thinking in Medicine p184 "We're obsessed in medicine with having great components - the best drugs, the best devices, the best specialists - but pay little attention to how to make them fit together well." "We don't study routine failures in teaching, in law, in government programs, the financial industry, or elsewhere." "We are all plagued by failures - by misled subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done byond working harder and harder to catch the problems and clean up after them." "When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It's time to try something else. Try a checklist."