The Checklist Manifesto

Metadata

• Author: Atul Gawande
• Full Title: The Checklist Manifesto
• Category: #books

Highlights

• authorities tend to centralize power and decision making. (Location 903)
• The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works. (Location 910)
• Nevertheless, the authorities refused to abandon the traditional model. (Location 936)
• They had made the reliable management of complexity a routine. (Location 992)
• So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. (Location 1009)
• checklist for every customer. (Location 1052)
• Thinking of these essential requirements—simple, measurable, transmissible—I (Location 1172)
• Even a modest checklist had the effect of distributing power. (Location 1255)
• twenty-one-item surgical checklist. They had tried to design it, he said, to catch a whole span of potential errors in surgical care. Their checklist had staff verbally confirm with one another that antibiotics had been given, that blood was available if required, that critical scans and test results needed for the operation were on hand, that any special instruments required were ready, and so on. (Location 1263)
• the skyscraper solution—a mix of task and communication checks to manage the problem of proliferating complexity—and (Location 1269)
• Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. (Location 1273)
• These misses are simple failures—perfect for a classic checklist. (Location 1276)
• But the fourth killer—the unexpected—is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. (Location 1277)
• the most promising thing to do was just to have people stop and talk through the case together—to be ready as a team to identify and address each patient’s unique, potentially critical dangers. (Location 1280)
• Sexton also found that one in four surgeons believed that junior team members should not question the decisions of a senior practitioner. (Location 1293)
• the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. (Location 1298)
• teamwork climate (Location 1376)
• Employee satisfaction rose 19 percent. The rate of OR nurse turnover—the proportion leaving their jobs each year—dropped from 23 percent to 7 percent. (Location 1376)
• It had three “pause points,” as they are called in aviation—three points at which the team must stop to run through a set of checks before proceeding. (Location 1404)
• The problem of time seemed a serious limitation. But aviation had this challenge, too, and somehow pilots’ checklists met it. (Location 1431)
• realized the handbook was comprised not of one checklist but of scores of them. Each one was remarkably brief, usually just a few lines on a page in big, easy-to-read type. (Location 1450)
• First came what pilots call their “normal” checklists—the routine lists they use for everyday aircraft operations. There were the checks they do before starting the engines, before pulling away from the gate, before taxiing to the runway, and so on. In all, these took up just three pages. The rest of the handbook consisted of the “non-normal” checklists covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled, and engine failure, to name just a few. (Location 1452)
• Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. (Location 1510)
• With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation. The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. (Location 1547)
• keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless. (Location 1555)
• It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. (Location 1619)
• we rarely investigate our failures. Not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any other kind of work where the mistakes do not turn up on cable news. (Location 1677)
• (This customization is why, when airlines merge, among the fiercest battles is the one between the pilots over whose checklists will be used.) (Location 1697)
• We adopted mainly a DO-CONFIRM rather than a READ-DO format, to give people greater flexibility in performing their tasks while nonetheless having them stop at key points to confirm that critical steps have not been overlooked. The checklist emerged vastly improved. (Location 1709)
• aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process. If a surgery checklist was to make a difference, my colleagues argued, it needed to do likewise—to spread responsibility and the power to question. (Location 1717)
• The team members make sure they’ve been introduced by name and role. (Location 1763)
• They confirm that everyone has the correct patient and procedure (including which side of the body—left versus right) in mind. (Location 1763)
• We supplied the hospitals with their failure data so the staff could see what they were trying to address. (Location 1831)
• The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death. (Location 1939)
• There was also a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications. (Location 1975)
• Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. (Location 2008)
• But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock star status of the test pilots was gone. (Location 2023)
• He hits upon hundreds of possibilities but most drop away after cursory examination. Every week or so, though, he spots one that starts his pulse racing. It seems surefire. He can’t believe no one else has caught onto it yet. He begins to think it could make him tens of millions of dollars if he plays it right, no, this time maybe hundreds of millions. “You go into greed mode,” he said. Guy Spier called it “cocaine brain.” Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does. And that, Pabrai said, is when serious investors like himself try to become systematic. They focus on dispassionate analysis, on avoiding both irrational exuberance and panic. They pore over the company’s financial reports, investigate its liabilities and risks, examine its management team’s track record, weigh its competitors, consider the future of the market it is in—trying to gauge both the magnitude of opportunity and the margin of safety. (Location 2044)
• Warren uses a ‘mental checklist’ process” when looking at potential investments. (Location 2056)
• Yet no matter how objective he tried to be about a potentially exciting investment, he said, he found his brain working against him, latching onto evidence that confirmed his initial hunch and dismissing the signs of a downside. It’s what the brain does. (Location 2067)
• Or, in the midst of a bear market, the opposite happens. You go into “fear mode,” he said. (Location 2070)
• in a period of enormous volatility the checklist gave his team at least one additional and unexpected edge over others: efficiency. (Location 2119)
• Airline Captains had a median 80 percent return on the investments studied, the others 35 percent or less. (Location 2172)
• There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating. (Location 2180)
• The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize where one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire. (Location 2302)
• Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. (Location 2318)
• We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at. (Location 2320)
• “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” (Location 2340)
• We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point. (Location 2347)

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public: true

title: The Checklist Manifesto longtitle: The Checklist Manifesto author: Atul Gawande url: , source: kindle last_highlight: 2018-08-04 type: books tags:

The Checklist Manifesto

Metadata

• Author: Atul Gawande
• Full Title: The Checklist Manifesto
• Category: #books

Highlights

• authorities tend to centralize power and decision making. (Location 903)
• The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works. (Location 910)
• Nevertheless, the authorities refused to abandon the traditional model. (Location 936)
• They had made the reliable management of complexity a routine. (Location 992)
• So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. (Location 1009)
• checklist for every customer. (Location 1052)
• Thinking of these essential requirements—simple, measurable, transmissible—I (Location 1172)
• Even a modest checklist had the effect of distributing power. (Location 1255)
• twenty-one-item surgical checklist. They had tried to design it, he said, to catch a whole span of potential errors in surgical care. Their checklist had staff verbally confirm with one another that antibiotics had been given, that blood was available if required, that critical scans and test results needed for the operation were on hand, that any special instruments required were ready, and so on. (Location 1263)
• the skyscraper solution—a mix of task and communication checks to manage the problem of proliferating complexity—and (Location 1269)
• Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. (Location 1273)
• These misses are simple failures—perfect for a classic checklist. (Location 1276)
• But the fourth killer—the unexpected—is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. (Location 1277)
• the most promising thing to do was just to have people stop and talk through the case together—to be ready as a team to identify and address each patient’s unique, potentially critical dangers. (Location 1280)
• Sexton also found that one in four surgeons believed that junior team members should not question the decisions of a senior practitioner. (Location 1293)
• the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. (Location 1298)
• teamwork climate (Location 1376)
• Employee satisfaction rose 19 percent. The rate of OR nurse turnover—the proportion leaving their jobs each year—dropped from 23 percent to 7 percent. (Location 1376)
• It had three “pause points,” as they are called in aviation—three points at which the team must stop to run through a set of checks before proceeding. (Location 1404)
• The problem of time seemed a serious limitation. But aviation had this challenge, too, and somehow pilots’ checklists met it. (Location 1431)
• realized the handbook was comprised not of one checklist but of scores of them. Each one was remarkably brief, usually just a few lines on a page in big, easy-to-read type. (Location 1450)
• First came what pilots call their “normal” checklists—the routine lists they use for everyday aircraft operations. There were the checks they do before starting the engines, before pulling away from the gate, before taxiing to the runway, and so on. In all, these took up just three pages. The rest of the handbook consisted of the “non-normal” checklists covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled, and engine failure, to name just a few. (Location 1452)
• Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. (Location 1510)
• With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation. The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. (Location 1547)
• keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless. (Location 1555)
• It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. (Location 1619)
• we rarely investigate our failures. Not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any other kind of work where the mistakes do not turn up on cable news. (Location 1677)
• (This customization is why, when airlines merge, among the fiercest battles is the one between the pilots over whose checklists will be used.) (Location 1697)
• We adopted mainly a DO-CONFIRM rather than a READ-DO format, to give people greater flexibility in performing their tasks while nonetheless having them stop at key points to confirm that critical steps have not been overlooked. The checklist emerged vastly improved. (Location 1709)
• aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process. If a surgery checklist was to make a difference, my colleagues argued, it needed to do likewise—to spread responsibility and the power to question. (Location 1717)
• The team members make sure they’ve been introduced by name and role. (Location 1763)
• They confirm that everyone has the correct patient and procedure (including which side of the body—left versus right) in mind. (Location 1763)
• We supplied the hospitals with their failure data so the staff could see what they were trying to address. (Location 1831)
• The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death. (Location 1939)
• There was also a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications. (Location 1975)
• Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. (Location 2008)
• But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock star status of the test pilots was gone. (Location 2023)
• He hits upon hundreds of possibilities but most drop away after cursory examination. Every week or so, though, he spots one that starts his pulse racing. It seems surefire. He can’t believe no one else has caught onto it yet. He begins to think it could make him tens of millions of dollars if he plays it right, no, this time maybe hundreds of millions. “You go into greed mode,” he said. Guy Spier called it “cocaine brain.” Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does. And that, Pabrai said, is when serious investors like himself try to become systematic. They focus on dispassionate analysis, on avoiding both irrational exuberance and panic. They pore over the company’s financial reports, investigate its liabilities and risks, examine its management team’s track record, weigh its competitors, consider the future of the market it is in—trying to gauge both the magnitude of opportunity and the margin of safety. (Location 2044)
• Warren uses a ‘mental checklist’ process” when looking at potential investments. (Location 2056)
• Yet no matter how objective he tried to be about a potentially exciting investment, he said, he found his brain working against him, latching onto evidence that confirmed his initial hunch and dismissing the signs of a downside. It’s what the brain does. (Location 2067)
• Or, in the midst of a bear market, the opposite happens. You go into “fear mode,” he said. (Location 2070)
• in a period of enormous volatility the checklist gave his team at least one additional and unexpected edge over others: efficiency. (Location 2119)
• Airline Captains had a median 80 percent return on the investments studied, the others 35 percent or less. (Location 2172)
• There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating. (Location 2180)
• The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize where one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire. (Location 2302)
• Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. (Location 2318)
• We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at. (Location 2320)
• “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” (Location 2340)
• We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point. (Location 2347)