Sunday, March 31, 2013

The Checklist Manifesto - Atul Gawande

Now this book written by an oncologist and a bestselling writer ('Complications' and 'Better' being his other two bestsellers) certainly makes one reach for a paper and a pen to make out a checklist right away. Yes, checklists are a must and one must do what one's grandma's did so well for so many years. One tends to forget, miss or ignore important steps in every process and one cannot afford to do that if one wants greater efficiency and / or is in a position of responsibility. I fully agree with Dr. Atul Gawande and I shall make my check lists in all that I consider important starting today.

'The Checklist Manifesto - How to Get Things Right' is a New York Times bestseller. Dr. Atul Gawande's is a MacArthur Fellow, a general surgeon at Brigham and Women's Hospital in Boston, a staff writer for the New Yorker and an assistant professor at Harvard Medical School and the Harvard School of Medical Health. He has spent much time in understanding how to increase efficiency and bring in systems that reduce errors. His take in this book is that in a world of increasing complexity it is not possible to rely on any one person's internalised knowledge and experience completely. Instead we should work as team's, share every one's knowledge and tick off the dumb stuff so the basics are covered. It's safe, secure and process oriented. For me who is very interested in processes this book makes immense sense. In India we must bring in these processes in all public offices to make things simpler and increase efficiency.

Dr. Atul Gawande starts with stories across the globe of surgeons sharing their stories - the successes and the failures. The case of a young girl who drowned in icy waters and suffered a cardiac arrest, the man who got stabbed by a bayonet, the patient who was given an almost lethal dose of potassium on the operating table, line infections that almost killed another patient and so on. In each case certain small procedures were followed or rectified which could have been avoided in the first place if there was a checklist kind of a system. But how does one tell surgeons of great reputations that they should follow a dumb checklist? Would it not insult their intelligence?

But it's not so much about stored intelligence in the mind anymore. Now more than ever things are so complex that one person may make a mistake. It's all about team work now and about ticking off all the basics more so since all procedures are laid down and information is easier to harness. As a case in point Dr. Gawande goes back to the humble checklist that was introduced by the US Air Force decades ago to help pilots fly aircraft. He cites the example of a flight competition held in 1935 for airplane manufacturers for the next generation long range bomber. Boeing's Mode 299 which was nicknamed the 'Flying Fortress' was being piloted by one of the most experienced pilots but crashed during the demo - the pilot had forgotten a simple procedure to unlock a system after take off. Considered the plane that was too much for one man to fly, Boeing's engineers got together and came up with checklists to avoid pilot error. Airplanes have step-by-step checks for take off, flight, landing and taxiing - all the dumb stuff which made the same planes fly 1.8 million miles without an accident. We could use it in our day-to-day stuff too and see results.

Dr. Gawande cites the Keystone initiative by Dr. Peter Pronovost who compiled a doctor checklist to check whether central line infections could be reduced by following a checklist. The results of the initiative were astounding - by following a simple checklist of do's and dont's, infections decreased by 66%, quarter infection rates came down to 0, saved 175 million in costs and an estimated 1500 lives. When Dr. Gawande was invited on board a WHO program to reduce avoidable deaths and harm from surgery he knew where he was headed. With extensive research in diverse industries - construction of skyscrapers, investment banking, business and even high profile chefs - that combine similar level of complexities but with far greater levels of safety, Dr. Gawande arrived at the conclusion that the simple checklist can improve efficiency drastically.

Dr. Gawande looks at the four major killers in surgery - infection, bleeding, unsafe anesthesia and the unexpected. He looks at communication checklist and the process checklists. When finally he conducted his experiment with checklists in surgery in 8 hospitals across the globe, four in advanced countries and four in backward countries, the results gave him (and us) a big thumbs up. After three months of use,the 2 minute, 19 step surgery checklist brought down major complications by 36%, deaths by 45%, infection rates by 50%, patients returning back for complication by 25%. A clear case for following checklists in all our processes. It is interesting to see what Dr. Gawande says at the end when he finds about 73% in favour of checklists and 20% not in favour. But when asked if they would like surgery teams to follow checklists of the surgery was being preformed on them, 93% responded affirmatively.

Dr. Gawande speaks of how checklists must be short enough to be effective. Much thought must be put in to make them effective and cover critical areas (without going into stuff that experts normally would not ignore or forget). One must look at checking off things that might skip the expert's mind, procedural matters where communication checklists or information sharing checklist can rule out errors. Having said that I was hoping to see one checklist - of the aircraft pilots or of the surgery one.

I liked what Dr. Gawande says about the four aspects of professionalism - selflessness, high amount of skill and a search for excellence, trustworthiness and responsible behavior and an innate discipline to follow procedures. If you are a professional who prides his or her work go make the checklists right now. Even if you are not and still want to have greater efficiency in the work you put out make the checklists. It adds a lot to all effort. And thank you Dr. Atul Gawande. And Vinod Ekbote for lending me this fine book!

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