Checklist Manifesto

The CheckList Manifesto by Atul Gawande - ISBN:0312430000

2010-03-05-UdellGawandeChecklists

Preventing Medical Errors.

Lots of credit given to Peter Pronovost, as appropriate. http://en.wikipedia.org/wiki/Peter_Pronovost

Once you set some standards, you quickly find out how they're not being followed, even if you assumed they were. In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs.

Three kinds of problems

• simple: solve by following recipe
• complicated: impossible to anticipate all difficulties, but there is definitely learning to apply from one case to the next
• complex: repeating process won't even get same results (Raising Kids) (Complex System)
• (how about Wicked?)
• Lots of Medical Error-s are from not following Simple-problem recipes. But other cases are not so simple.

Building Construction case

• many CheckList-s
• every building gets new set of CheckList-s created - One Methodology Per Project
• add communication tasks to CheckList: this especially helps bring distributed expertise to bear on non-Simple surprises.

Shared Mission also helps distributed experts adapt and Collabor Ate when standardization would fail, esp in Complex cases. Compare actions in Hurrican Katrina: FEMA vs WalMart.

Van Halen "brown M&M" story. Van Halen was the first band to tkae huge productions in tertiary, third-level markets... And there were many, many technical errors... "When I would walk backstage, if I saw a brown M&M in that bowl, we'd line-check the entire production. Guaranteed your'e going to arrive at a technical error."... In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.

Restaurant Kitchen-s use CheckList-s.

Air Plane crew uses CheckList-s

• a few pages of "normal" checklist items
• an entire handbook of specialized checklists for non-normal cases
  • some of these are built into avionics systems
• Boeing creates/edits 100+ checklists every year (that might include maintenance/etc not just flight-crew)
• Do Confirm vs Read Do structure (latter is more like an active recipe, former is more of having periods of indepedent work brought together by checkpoint)
• Flight Simulator-s (Simulation) allow for testing checklists and training to follow them
• checklists can't be too long or people start to ignore them, so leave out things that have near-perfect compliance already, or have low cost-of-failure, or extremely low odds of happening. (Often process of negotiation to trade off these factors to narrow down the list.)
• new ice-accumulation-prevention checklist issued Sept'2008: Pilots across the world were somehow supposed to learn about these findings and smoothly incorporate them into their flight practice within 30 days. They did! Conversely, in medicine, study of 9 different major treatment discoveries found it took doctors 17 years to adopt the new treatments for at least half of American patients.

His main story of moving this forward: WHO global CheckList for surgeries

• past of successful global Public Health programs
  • not too many of them
  • examples were simple, measurable (trackable actions, trackable outcomes), and transmissible (Scal Able/Leverage)
• communication tasks are key: instant team-building, improves Collaboration under surprise, also gives players with less Power (e.g. nurses vs doctors) more comfort at enforcing CheckList. (Note a factor in greater airplane crashes in some cultures is related to co-pilot not being willing/able to challenge the pilot.)
• developed checklist of 19 items, including communication tasks, covering 3 periods.
  • (Does it make sense to have a single checklist for all cases? It's easier to communicate, but seems to conflict with the One Methodology Per Project attitude.)
• studied at 8 hospitals for 3 months
  • in 3mo before intervention, there were 4000 surgeries, with 400+ having major complications
  • intervention led to 36% reduction in complications, 47% reduction in deaths.
• one criticism from field: study had not established how the checklist was producing such dramatic results... We surmised that improved communication was the key.
• published in NEJM Jan'2009
• by end-2009, 10% of American hospitals had either adopted the checklist or taken steps to implement it. Still kinda sad.
• we could be creating lots of specialized checklists for specific surgeries, and non-surgical interventions. But too much resistance still!

Another example: some professional investors use checklists

• stops you from letting your excitement talk you into something
• Mohnish Pabrai made investing checklist of 70+ items - hmm is that too long?
• another (anonymous) investor found that checklist made him more efficient - he could narrow down candidates in 3 days of analysis instead of weeks of meetings.
• Geoff Smart studied 51 Venture Capitalist-s. Found that evaluation of the Entrepreneur seemed more important than evaluation of the idea. Identified 6 styles of evaluation used by VC-s. One he called "Airline Captain" which was checklist-driven. That group was more successful than the others. But it wasn't the most-popular style.

Is US Culture of Individualism a barrier to adopting checklists? Airline example of "Sully" crash. He kept telling everyone is was a crew effort but media wouldn't tell that story (Narrative).

• counter: Professional culture?
  • 3 common (theoretical) elements: selflessness, skill, trustworthiness
  • pilots add discipline
• another counter: Systems Thinking - optimizing parts is not a good route to system excellence