The Checklist Manifesto

A brief digression from TED to describe a great book I just finished called The Checklist Manifesto. Written by Boston doctor Atul Gawande, it describes the huge impact checklists can have in medicine. Checklists are common in other industries, such as aviation. Pilots adopted checklists when airplanes became so complicated that it was beyond the capacity of one human to remember every step required for flying. However, it is only recently that medicine, the profession with arguably the most complex tasks, have started to adopt checklists.

Johns Hopkins did some pioneering work on developing a check list to reduce the infection rate in central lines. This check list consisted of merely five steps - all no-brainers:

1. wash your hands with soap
2. clean the patient's skin with chlorhexdine antiseptic
3. put sterile drapes over the entire patient
4. wear a mask, hat, sterile gown and gloves
5. put sterile dressing over the insertion site once the line is in.
   

Simple and obvious, right? And yet steps were being skipped time and again. Who'd have thought that, a century and a half after Lister, surgeons and nurses would still need reminding to wash their hands?!? In early tests, this checklist astoundingly reduced central line infections from 11% to 0. This central line checklist has now spread to many hospitals with similar results, reducing infections in both the best and the worst hospitals.

Meanwhile, research was going on at University of Toronto and and Toronto General and at Kaiser in California on checklists for surgery. These experiments delivered equally stunning results. Gawande started to experiment with checklists. He used them in his own operating rooms, feeling out what worked and didn't work.

Then Gawande was approached by WHO to improve the safety of surgery around the world. After all, at least one million a year die in operations, just slightly more than from malaria. Gawande decided that the greatest contribution could be made by designing a surgery checklist. For a pilot, he chose hospitals as disparate as hospitals in high income countries in Toronto, Seattle, Aukland and London, and intensely busy hospitals in low and middle income countries, in Manila, Amman, New Delhi, and a rural hospital in Tanzania. These hospitals started introducing a two-minute, 19-step checklist. Comparisons of outcomes in the three months before and after introducing the checklist were astonishing. Major complications had dropped 36% and deaths 47%. Many highly sophisticated innovations in the OR have cost lots of money (an example might be robotic surgery) without a good return on that investment in terms of improved outcomes for large numbers of patients. Yet this simple, virtually free innovation seemed to make a huge difference.

Several lessons from this book will stick with me.

• The first step on the checklist is to require the surgical team to introduce themselves at the beginning of an operation. Typically, the group in an OR will not usually know each other very well, or at all. Gawande says the simple introduction goes a long way toward turning that collection of people into a team. Who'd have thought you could be undergoing an operation, something dangerous and unexpected could happen, and the team operating on you would have to communicate in this emergency without even knowing each other's names? This is part of a sea change in medicine from the accent on the individual hero doctor to the team.
• Put the checklist it in the hands of the circulating nurse and giving her or him the authority to stop the process if a step is skipped. Another aspect of making it a team sport.
• Keep the checklist as short as possible. If it's too long, practitioners will view it as a distraction from taking care of the patient, and will ignore it. As is so often the case with strategy, deciding what not to do or include is your most important decision.
• After these results, it seems almost criminal for a hospital not to adopt checklists. However, the constraint on adoption of innovation is the reluctance of people to change behaviour. Doctors are no different. As a public champion of checklist adoption, Gawande even admits to his own resistance initially to using the checklist he'd helped develop.
  
• If you want to succeed at innovation, start with a single, focused innovation. Once you have proof of concept you can expand beyond that initial niche. In the OR, for instance, there is scope for specialized checklists for all sorts of specialized operations, rather than just the general one to cover all surgery, Then, just like in aviation, you could develop a series of checklists which spring into action to guide actions in emergencies.
  
• It's a real innovation to look beyond your own industry for ideas that are transferable and transformative. Gawande talked to many people outside healthcare - in industries as diverse as construction and investing. His most important insights came from aviation, the pioneers in the use of checklists. Boeing spends huge amount of resources building checklists for the pilots who will fly their planes. He argues that Captain Sully, the 'Hero of the Hudson', was not being modest when he said it was the team that ensured the plane landed safely on the river. He was being dead right. And in the cockpit, the checklist for what to do upon losing engines after a bird hit was a key contributor to the pilot's ability to land the plane.

This book is a very quick and interesting read, sprinkled with delightful and relevant anecdotes that bring the material to life. It should be a must-read for anyone in healthcare, but it's hard to think of an industry that could not apply checklists.