Notes on The Checklist Manifesto by Atul Gawande

I finally got a chance to read The Checklist Manifesto by Atul Gawande and have been talking about it incessantly ever since (along with Daemon). I found it to be a very well written and interesting account of how checklists can save lives and improve quality across a number of fields. It's something so simple it feels stupid, but people are growing so "expert," overworked, and specialized that checklists are more important than ever to assure quality when it matters.

Below are my main notes and takeaways. I highly recommend this book to anyone interested in efficiency, productivity, and public health. I'm particularly interested in ways to apply the book's concepts to many fields (including starting a business) using technology.

Introduction

• Surgeon author's stories
  
• No one remembered one step of a surgery and caused death
  
• Great failures and saves throughout his life
  
• Human fallibility
  
• Err from ignorance or ineptitude
  
• Balance recently shifted to ineptitude
  
• Legal clerical errors
  
• Training isn't the problem
  
• Unmanageable amount of know-how

Ch. 1: Problem of extreme complexity

• More than 13000 diseases/wounds
  
• 6000 drugs and 4000 medical procedures 
  
• Med = art of managing extreme complexity
  
• Hundreds of diagnoses managed each year on average
  
• 178 patient actions per day in hospital, errors in 1%
  
• Have technology to monitor and control all body functions
  
• Line infections very common
  
• Super specialization in med

Ch. 2: The checklist

• Pilot checklist
  
• Too much airplane or medicine for one person to fly
  
• All or none process: missing one step fatal
  
• 4 vital signs
  
• Nursing has adopted checklists but not doctors
  
• Fixed central line infections at Johns Hopkins
  
• Dr. Pronovost Initiative
  
• Keystone Initiative

Ch. 3: The end of the master builder

• 3 types of problems
  
• Simple: like baking cake
  
• Complicated: like sending rocket to moon
  
• Complex: like raising child (uniqueness)
  
• Complex have uncertain outcomes not solved by expertise
  
• We are besieged by simple problems; checklists help
  
• Also by complicated problems
  
• When to follow judgment vs. protocol
  
• Construction work: complicated
  
• Evolved like medicine
  
• But medicine still following "master builder" model which construction evolved beyond
  
• In medicine, care much less coordinated
  
• In construction, no margin for error
  
• Huge checklists and schedules of tasks hanging on walls in modern construction site, coordination across 16 trades
  
• Daily checks and communications across hundreds of people
  
• Can't rely on autonomy to deal with complications or unforeseen problems across 16 trades
  
• Rely on submittal schedule, another checklist
  
• Communications schedule for who to talk to who about what on which date
  
• Makes ppl talk on specific dates
  
• Wisdom of group not individuals
  
• Man fallible but maybe not men
  
• Merge all trades' floor plans to find conflicts in software called ClashDetective
  
• Flags issue for submittal schedule and emails relevant parties to talk
  
• ProjectCenter software allows anyone on site who spots problem to submit it with digital photo, emails parties, and adds check to schedule for it to be resolved
  
• Ppl given 3 days to confirm/approve and all tracked
  
• 5 million commercial buildings, 100 million low rise homes, 8 million high rise residences , in US
  
• Add 70K commercial and 1M new homes per year
  
• Very few errors or full collapses
  
• 20 serious building failures per yr (tiny percent)

Ch. 4: The idea

• Forcing function
  
• Hurricane Katrina
  
• Communication breakdown and authority power struggle
  
• Push power out of the center to the periphery
  
• Needs different system than command and control
  
• Walmart stepped up and authorized managers to do what was right
  
• Efforts to dictate all steps from center fail
  
• Judgment enhanced by discipline and procedure
  
• Fine restaurant operations
  
• Recipes followed exactly and frequently updated
  
• Daily check meeting in kitchen
  
• Every plate quality checked

Ch. 5: The first try

• Global surgery volume growing
• 230 mil per year
• Higher death rate
• 2500 different procedures
• 30% don't get properly timed antibiotic
• Pre-incision preflight checklist idea
• Checklist distributes power
• Anyone can stop procedure if not followed
• To deal with unexpected, force ppl to communicate at predetermined time
• Teamwork poor in surgery, unpredictable
• 1 in 8 don't know why doing procedure or where
• Checklist requires ppl to give each other their names
• Reduces nurse turnover and error rate
• Require 3 pause points in surgery

Ch. 6: Checklist factory

• Aviation checklists inspiration
  
• Normal checklist 3 pages plus 200 pages of checklists for non-normal situations
• Do-confirm checklist or read-do checklist like recipe
• Best if 5-9 items like working memory
• Pilot checklist at 3 points of takeoff including communication
• Checklist guided by cockpit computer
• Not meant to be comprehensive just swift help for experts
• In most fields we don't investigate failures because affects one person
• In aviation, failures make news and heavily investigated
• Use flight simulator to test checklist
• Findings incorporated immediately in new checklists and quickly save lives
• In medicine, findings take 17 yrs to be incorporated, huge deluge of medical research

Ch. 7: The test

• For surgery used do confirm format to give flexibility
• Must disperse authority
  
• 3 pause points: before anesthesia, before incision, after surgery
• Don't need to mark with check marks
• Had to eliminate a lot of checks to streamline
• Created safe surgery checklist
• 19 checks: 7 before anesthesia, 7 before incision, 5 after
• Did test in 8 international hospitals, very poor and wealthy
  
• Measured error rates before and after
  
• Checklist involved culture change
  
• Start by testing in one OR with senior staff, ppt, YouTube vids
  
• 3 month pilot study dropped infections and deaths by half
  
• Mix of ops unchanged
  
• Hawthorne effect of being observed? No because had been there before started checklist
  
• Improved teamwork
  

Ch. 8: The hero in age of checklist

• Investors incorporating formal checklists
  
• Portfolio managers, value investors
  
• Read broadly, look widely
  
• When get greedy over good opportunity, need discipline
  
• Buffett uses mental checklist
  
• Brain works against you to seduce and make you ignore downside
  
• Same signals in brain when found profit opportunity as when on cocaine
  
• Checklist delivers better financial performance
  
• Avoids risks
  
• Large resistance against checklists
  
• VC investment decisions studied
  
• Checklist driven VCs had better performance
  
• Feels beneath ppl to use checklist
  
• Doesn't match idea of heroism
  
• Hudson miracle due to following procedure
  

Ch. 9: The save

• Saved his patients many times 
  
• Starting a business like construction and medicine
  
• How can checklists be used