In this podcast i review the book Checklist Manifesto by Atul Gawande. You can listen to the podcast below:

The book starts off by taking few case studies from medical field wherein some patients who had a very slim chance of survival were brought back to life due to different experts for various medical specialties coming together for a common cause. In today’s age, a single doctor can sometimes be asked to treat patients with varying types of diseases. And a single patient can sometimes have multiple diseases with different types of symptoms. When a patient gets admitted to a hospital he is subject to a plethora of procedures and tests that need to be carried out on different types of medical devices. Close to 178 daily tasks need to be performed on a patient when he is at the hospital. The field of medicine is now reeling under innumerable complexities. Nowadays, due to the complexities of ailments Doctors are pursuing superspecilization in niche areas. The diseases and procedures of the day demand such super specialists. The author himself has moved on from being a General Surgeon to an Oncology surgeon to finally an Endocrine Oncology Surgeon. Even after having super specialists, the world still witnesses thousands of deaths during surgeries half of them are from errors that can be completely avoided.

As systems evolve and turn into complicated systems, checklists come to the rescue of engineers and technicians. In the year 1935, US Army organized a competition among the Airplane manufacturers for a large contract. The frontrunner was a model from Boeing which surpassed all the requirements. However, during the test flight the plane crashed killing the pilot. This cost Boeing the contract. On careful analysis it was found that the crash was due to an error from the pilot. Flying this new beast involved many steps and the pilot missed one step. The Army decided to buy few planes and came up with a checklist of important procedures that the Pilots need to follow to fly the Boeing. When Pilots started to follow the checklist there was not a single crash thereafter. Hospitals generally have an unsaid checklist (called vital signs) comprising of five items namely body temperature, pulse, blood pressure, respiratory rate and pain that are monitored by the nurses. Any deviation in either of these five parameters is immediately brought to the notice of the doctors. This simple checklist has saved lives of many patients.

There are two main reasons that necessitate a checklist (a) The fallibility of Human memory and (b) Attention deficit, especially while doing routine tasks that lead to errors. Checklists seem to provide protection against these issues. Critical case specialist John Pronovost decided to make a checklist for doctors that involved simple steps like (a) Wash hands with soap (b) Clean patient’s skin with antiseptic (c) Put sterile drape over the patient (d) doctors to wear sterile gowns, masks, gloves (e) Sterile dressing over the site of insertion. When these steps were followed by doctors it was noticed that the cases of infections and the deaths due to infections came down drastically.

Checklists seem to be excel when the tasks are simple or straightforward, for example baking a cake, instructions to fly an airplane or monitoring patients. However there are complicated problems (like sending a rocket to moon) and there are complex problems (like bringing up a child) for which creating a checklist might be a challenge. One such complicated problem is building a high rise tower. Atul visited the office of Joe Salvia of Salvia McNamara\Salvia. Joe explained that in Medieval age there used tobe  one Master builder who know all the intricacies and used to design the buildings, engineer them and monitor the construction. But with passage of time, as structures started to become complex, such master builders lost their significance as no single person could handle the construction of an entire building.  In order to handle the complex construction projects, Joes team uses two checklists. The first checklist lists in excruciating details the tasks that need to be performed on a daily basis. Every single detail on the expected outcome are listed. There are color codes assigned to the tasks. When a task is completed, a tick mark is added to indicate the completion of the task. When a project is started this checklist is prepared and shared with all the experts involved in the project. On receiving their approval this checklist is diligently followed. Let us call this an execution checklist. Along with this checklist, the company also maintains a second checklist called communication checklist wherein communication tasks are listed. On a regular basis specialists and engineers from one division may need to interact with engineers from another division on a regular basis. All such interactions are listed in the communication checklist. By stickling to these two checklists the Company is able to execute the complex construction projects seamlessly.

Atul has seen the application of this two checklist logic in many other scenarios as well. In 2005 when America was hit by Hurricane Katrina, Walmart decided to support the people by providing food and medicines. Walmart employed the two checklist logs. The first checklist listed out the items that each Walmart employee had to follow while he/she was helping the flood victims. This ensured that the employees did not miss out on the essential details. Additionally the communication checklist was in force as well and the employees/volunteers were encouraged to talk to each other to handle emergencies on the go and coordinate with each other in order to share their experience.  Atul shares another experience from fine dining industry. Jody Adams who is a chef and owns the Rialto restaurants also has the two-checklist philosophy that has helped her to run a successful restaurant in Boston. Each of the dishes in her menu is mapped to a recipe back in the recipe book. Every cook is supplied with this recipe book and they have to follow the recipe to the T and cook it according to the instructions laid out in the recipe. This book is their version of the execution checklist. The book goes through routine updates as and when the cook hit on something unique and they see value in modifying the recipe. Additionally the restaurant maintains another customer specific execution checklist that keeps track of their tastes and allergies (like gluten allergy) this helps in personalizing the experience. In addition the staff maintain a communication checklist in the form of a daily meeting at five PM in the evening where they discuss any changes needed to the menu, assign replacement for absent employees, number of tables reserved for the day and how to handle the customer inflow for the day. The execution checklists (i.e. recipes and customer specific checklist) as well as communication checklist (daily evening meeting), help Jody run a successful restaurant.

Author’s initial attempt at a checklist was borne out of a chanced phone call from a lady at World Health Organization. He was invited to a meeting wherein experts from around the world were supposed to discuss on surgical practices and the different ways and means to reduce the number of (unnecessary) surgeries being carried out across the world. During the meeting it was felt that many of the deaths during these surgeries could be avoided if surgeons followed a set of guidelines (aka checklist). Surgeons from different hospitals narrated their own experiences with checklists and how they were able to contain accidents that could have resulted in deaths of patients. The author himself was reminded of a personal encounter with a healthcare practitioner, Stephen Luby, who was active in Pakistan and had seen a dramatic decrease in premature death of children in the slums of Karachi by following a simple step.  Luby and his team gave the people an unlimited supply of soap bars and a checklist of six situations when the bar should be used. The mere reminder to use the soap in these six situations led to an improvement in hygene and decrease in death rates. At the WHO meeting, the participants finally agreed to create a checklist comprising of three pause points. At every pause point the operating team needs to run through a set of checklist items to ensure that they are ready to proceed further. Armed with this checklist, the author decided to implement this in his own hospital. However when they ran through this checklist during their trial they realized that the checklist was too long and acted more like a distraction and they junked the checklist!

When his initial attempt at a checklist failed, Atul got in touch with checklist expert Dan Boorman to understand how the Aviation industry formulate their checklists. The checklist used by the pilots is not one single checklist. Instead it is a collection of checklists. They have few “normal” checklists for regular everyday aircraft operations. The interesting part is the “non-normal” checklists. Boing has develop hundreds of checklists for all conceivable emergency situations and the steps the Pilots need to follow when they hit each of these emergencies. For example, there is a checklist on what needs to be done when there is smoke in cockpit or what needs to be done when a specific warning light turns on or when a radio suddenly goes dead. There are checklists on what should be done if the co-pilot gets disabled or there is an engine failure etc. These checklists have been found to be so effective that pilots instinctively turn to the checklists when they are faced with a “non-normal” situation. Dan believes that there are good checklists and there are the bad checklists. Bad checklists are vague and imprecise. They are generally long and hard to use.  Good checklists are generally precise, efficient and to-the-point and easy to use. Good checklists do NOT spell out everything. Instead they merely provide reminders to the user on the most critical and important steps. In aviation industry, a checklist will usually have anywhere between five to nine items (this is just a guideline and not a hard rule though). These critical steps are the ones that even highly trained professionals might miss out during emergency hence they make it to the checklist. Dan goes on to explain that there are two type of checklists the DO-CONFIRM checklists and READ-DO checklists. In case of a DO-CONFIRM checklist, the user first performs all the tasks from his memory/experience and then looks at the checklist to confirm that he has completed all the tasks, whereas in case of READ-DO checklist one first looks at the checklist and follows it step by step. When a new checklist is created, one needs to decide if it is going to be a Do-Confirm checklist or a READ-DO checklist.

Armed with this knowledge on creating the checklists Atul and the rest of the WHO team met again to refine the checklist that they had created. After heated discussions and disagreements the checklist was stripped to nineteen checks spread across the same three pause points aka before anesthesia (seven checks), post anesthesia but before incision (seven more checks) and finally post the operation (five final checks). The team decided to test this checklist in eight different hospitals (four of them being in developed nations like US, Canada, UK and New Zealand and the rest four from developing and poor countries like Philippines, Jordon, India and Tanzania). Members of the team decided to personally visit few of these eight hospitals to check the implementation problems. The book narrates interesting issues and problems faced in each of these hospitals. After the trials were complete and the results of the trial were analyzed the findings were astonishing. The rate of complications from major surgeries in these hospitals reduced by 36%, deaths reduced by a staggering 47%. Based on the past experience, out of the 4000 odd operations that were done, 435 were expected to have complications but this number was just 277. The findings were published in the New England Journal of Medicine and was acknowledged world over. Many hospitals around the world adopted and adapted the checklists in their hospitals.

Atul found that checklists have made their way into the hands of Investment advisors. He met three well known investors including Mohnish Pabrai and Guy Spier. Mohnish and Guy believe that, in order to control ones Greed and to be systematic one needs to have an investment checklist. A good investment checklist will help an investor to weed out investment traps that look enticing at the beginning but turn out to be worthless when passed through predefined and well-structured checklists. Pabrai understands that a checklist is not a panacea to the inherent risks and unavoidable events, but nevertheless it helps one to stay focused in choosing quality companies. Geoff Smart, a Psychologist, did a study on the success rate of Venture Capitalists with respect to their investments. Geoff followed many VCs over a period of time and noted that those VCs who followed a checklist based investment strategy tended to retain the MDs of their VC funded companies 90 percent of the time whereas the companies funded by VCs not following a checklist, saw their MDs being asked to leave at least a 50 percent of the time. Additionally, checklist-following-VCs saw their return on investment in the range of 80 percent where are VCs not following a checklist saw their return-on-investment in the rage of thirty-five percent.  In spite of these results being published and known among investment advisors and VCs, most of them fail to adopt checklists in their jobs which is strange and equally fascinating!

Thanks to Tom Hanks, we are all now familiar with the famous Airplane crash in the Hudson river. In January of 2009, Captain Chesley B. Sullenberger III (aka Sully) and First officer Jeffrey Skiles  managed to land an aircraft in the Hudson after they lost both the engines due to multiple bird hits. They were able to save all the passsengers due their experience and their Ernest intent to follow the checklists. Both the pilot and co-pilot followed all the checklists before takeoff and after the incident. Even the flight attendants followed the protocol in spite of being under stress due to the incident.

The book lists out multiple instances in diverse fields where checklists have helped people avoid accidents and improve efficiency. This book is a light read that does not require the reader to tax his brain. One can finish the book at a brisk pace. I liked the book for its content. The book chronicles the usage of checklists in diverse fields like medicine, aviation, finance etc. If you are looking for tips on writing an efficient checklist, you may end up being disappointed though. Overall it was an interesting book to read.