Let's see. English muffins: check. Potatoes: check. Rotisserie chicken: check. All the stuff we need for the weekend: check.
Simple tasks and checklists go together like English muffins and marmalade. But it's Atul Gawande's contention that the basic checklist has become indispensable well outside such mundane areas -- and in the world of increasingly complex work. "Know-how and sophistication have increased remarkably across all our realms of endeavor," he writes. Yet in a great many fields, avoidable failures are common and persistent because "the volume and complexity of what we know has exceeded our ability to deliver its benefits correctly, safely, or reliably."%%DynaPub-Enhancement class="enhancement contentType-HTML Content fragmentId-1 payloadId-61603 alignment-right size-small"%% In The Checklist Manifesto: How to Get Things Right (Metropolitan Books, $24.50), Gawande makes an engaging, and often engrossing, case that frustrating and even catastrophic errors can largely be eliminated via Santa's simple stratagem: making a list and checking it twice.
A writer for The New Yorker, Gawande is also a professor at Harvard Medical School and a much-respected surgeon at Boston's Brigham and Women's Hospital. So it's hardly unexpected that many of his examples are drawn from the world of medicine. But the author also offers stories and significant lessons from numerous other fields, including construction, restaurant cooking, money management, venture capital, and, fascinatingly, the airlines.
Checking Across Disciplines
At about this point, you're probably having the same reaction as many of Gawande's colleagues: I don't need some #$%!!#!&* checklist to tell me how to do the job I've trained for and worked at for years. Gawande may persuade you otherwise, as he shows one industry after another reinventing the checklist wheel. Part of his purpose, one suspects, is to gather a lot of this diverse experience in one place to help iron out the uneven development across professions.
It's possible to read this book simply for its gripping, and downright scary, tales from the operating room. Early on, "an ocean of blood" from a patient's midsection engulfs a surgical team that thought it was treating a routine stab wound sustained at a Halloween party. Near the book's end comes a terrifying episode when a surgeon removing a patient's tumor accidentally slices into the main vessel that returns blood to the heart. Checklists feature in the solutions to both near-catastrophes.
Such stories keep the pages turning, as does Gawande's account of how, in 1935, Boeing Corp.'s huge, state-of-the art "flying fortress" crashed during a test run, killing two of the five crew members, including the pilot who was the air corps' chief of flight testing. Debacle loomed for the manufacturer of the seemingly defective plane and for the government. Then test pilots hit on a solution that in time led the army to order 13,000 of the aircraft: a brief checklist, with step-by-step checks for such "dumb stuff" as making sure that brakes are released, that elevator controls are unlocked, and so on. The test pilots went on to fly the plane 1.8 million miles without an accident.
The construction industry provides a further bit of refinement in checklist science. As in flight, one mistake in skyscraper construction could endanger thousands. Also as in flight, which once depended on highly skilled wing jockeys, construction once relied on the talents of "master builders." But the division of labor into dozens of complex skills has led the building industry, too, to employ checklists: "construction schedules" with line-by-line listings of every task and when it needs to be completed, and "submittal schedules" that require conversations between the various experts. This second checklist represents a key innovation to Gawande: "The way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another-on X date regarding Y process." Indeed, repeatedly Gawande invokes the wisdom of such cooperation-invoking devices.
Checklists in the Age of Heroes
A practical checklist cannot grow too long or too vague, as to make them a distraction from the task at hand. That's a lesson the author learned as he joined a World Health Organization effort to create a surgery checklist that would be applicable across the globe. But as Gawande and others labored to pare down the list, there was one simple item that he refused to cut: the requirement that before starting an operation, all present, from attending surgeon to nurse to anesthesiologist, introduce themselves by name. Giving everyone a chance to say something at the start proved to activate their sense of participation and a willingness to speak up if they saw something wrong.
The WHO checklist, implemented in eight pilot cities during 2008 after two years of experimentation, proved a whopping success: Deaths on the operating table fell by 47%, and major complications were down by 36%. (You can check out a short video demonstration of the WHO safe surgery checklist on YouTube.)
But if such a simpleminded tool as a checklist can make such a difference, whither the masterful hero who marches to his own drummer -- whether Gary Cooper, battling fascists in For Whom the Bell Tolls, or Chesley "Captain Sully" Sullenberger, saving 155 passengers by smoothly landing his disabled US Airways plane in the Hudson River?
Gawande has a response to that question, too. The "miracle on the Hudson," he demonstrates, was as much a victory for teamwork and checklists as for Captain Sully. In our complex world, Gawande suggests, we must begin recognizing a different type of role model: a collectivity that's not reluctant to seek a balance between "freedom and discipline, craft and protocol, specialized ability and group collaboration."
Oh, well. This may be the age of Captain Sully, but it's also the age of Tiger Woods. Perhaps it's best not to count too much on individual heroes.
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