The Checklist Manifesto: How to Get Things Right by Atul Gawande


I just finished reading and thoroughly enjoyed The Checklist Manifesto: How to Get Things Right by Dr. Atul Gawande. I recommend it.

Mark Graban at the Lean Blog has written passionately and at length about the value of checklists in improving outcomes and patient safety in the context of lean healthcare. To learn more about how something as simple as a checklist can make double digit improvements, read Mark articles including the use of surgical checklists, a helpful demonstration of how Mark uses a checklist to create his podcasts, and a rebuttal of a rather poor Wall Street Journal review of The Checklist. Mark also points us to a The Checklist author Dr. Atul Gawando featured on National Public Radio and on the Daily Show.

The book is short, easy to read, filled with stories that open our eyes to the realities of how medicine is practiced in surgical theaters around the world. The book is also a personal journey from skepticism to belief, one that many of us leading or having gone through a lean transformation can relate closely to. The trip Dr. Gawande made to Boeing to learn from aviation checklist experts and how he subsequently applied this learning is also fascinating. The book gave me a new appreciation for how hard it can be to write a good checklist, as well as the importance of checklists as opportunities to communicate, rather than simply police and catch errors. Aside from being sold once again on the value of checklists and the urgency of spreading the practical message of lean to healthcare and other critical fields as soon as possible, the book left me with three gems which caused me to think.

The Four Big Killers

The first was the line, “surgery has, essentially, four big killers” being infection, bleeding, unsafe anesthesia, and the unexpected. Dr. Atul Gawande writes that the first three are perfect for checklists while the fourth relies on expertise, know-how, experience or hero behavior. The first three are completely preventable in other words, with a simple check. Even the last, the “unexpected” is made vastly more manageable by building checklists around experiences in ways that allow the surgical team to work together in ways that either prevent further mistakes from being made. Although business transformation is not exactly surgery, the analogy of “infection, bleeding, unsafe anesthesia” is a good one.

Many good companies go under because they were infected by bad ideas, policies or attitudes, they leaked profit and / or cash until they bled to death, or became anesthetized and could not respond to the bad things happening to them. I have no doubt that well-designed checklists could be applied to the management and turnaround of a business when faced with these “killers”.

It’s Not About Soap!

The second gem was a test by the World Health Organization to promote the use of soap in a village in Pakistan as a means of reducing illness in children. This story diverged slightly from checklists but addressed wider issues surrounding getting people to adopt something new. The promotion of hand washing resulted in a decrease in illnesses. The power of the story for me was the message “it’s not the soap!” The soap was not necessarily the best brand anti bacterial soap. People in the test did not always use the soap exactly as the testers planned. They already had access to soap. Yet the result of people caring, observing, providing a partial solution and following up was a behavior change in the villagers. The analogy that struck me was that in kaizen, 5S or any sustained lean effort, the it’s less important to do 5S perfectly, or get big kaizen ideas, or to march step by step through a TPM program along a rigid time line committed to management.

These things might even be counterproductive. The routine of washing hands (doing kaizen) is the important thing, and the soap (5S, TPM etc) may not even be all that important.

My name is Jon Miller and I’m here to remove ignorance

The third gem was something called “activation phenomenon”. It is as simple as the practice of having the surgical team each say their name and role at the start of the surgery. This mentally activates everyone and demonstrably elevates engagement and performance. What? They don’t normally introduce themselves before surgery? you may ask. After reading this book, I don’t want to know what other things are not common practice in an operating room. However I am powerfully encouraged that this book is bringing to light some powerful common sense approaches to making healthcare delivery more reliable.

An Eight Step Change Management Checklist for Implementing Checklists

Most of us would probably agree that a major business transformation requires major cultural changes, a shift in authority, responsibility and expectations about how we serve customers. Implementing a simple checklist into a surgical environment is surely a much easier endeavor. Dr. Atul Gawande writes:

“…using the checklist involved a major cultural change, as well – a shift in authority, responsibility and expectations about care”

It’s funny how changing even the smallest thing like saying who we are, what we do and checking that we are ready to start requires changing some of the biggest things like how we think of who we are, what we do and what we will do before getting started. Maybe we need a change management checklist… oh wait, no.