Checklist Manifesto

Gawande, Atul. (2009). The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books.

Dr. Gawande states that, even with the best intentions, mistakes can and will happen. He explains “the how” behind the safety record of the airline industry resulting in so few airplane crashes, and how this same know-how was applied to hospital surgery resulting in a great reduction in medical errors. The connection to Marshall Goldsmith’s book Triggers is clear in the use of the Checklist to help ensure successful behavioral change by executives and leaders.

The book begins by identifying two reasons why we fail in our attempts to get better at leadership, coaching, and organizational development. First, is simple ignorance. If you don’t know what leads to errors chances are more errors occur. Acquiring knowledge and skills can help reduce this cause of an error.

The second reason for failure in our attempts to get better is not applying what we know. We might be more forgiving of ignorance but not using the knowledge we have is grounds for malpractice. In the airlines and medical field, the consequences can be disastrous. Failure to overcome these errors in any organization wastes time, money, and energy.

It was the success of the airline industry to almost eliminate errors through the use of checklists was the inspiration for Dr. Gawande to adopt this practice in the medical profession and write this book. In complex environments, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are both important and easily overlooked under the strain of more pressing events. A second problem is our human nature to make assumptions that are not true. Sometimes we get bored and we skip some seemingly less important steps to save time. When activities become routine, we assume everything will go as planned. This is often a mistake.

One antidote for such breakdowns is the use of checklists. The checklist can be invaluable for assuring that procedures are followed which are critical to successful outcomes. When it comes to passengers arriving safely to their destination, or a patient successfully coming out of surgery with a positive outcome, you would think the use of a simple tool like a checklist would be religiously followed. In one hospital, the infection rates plummeted from 11% to 0% within 10 days of adopting a checklist. It is hard to imagine a customer or patient who would not want a checklist used when flying or have surgery.

Gawande points out that a key for developing the checklist is asking those closest to the work to create it. In hospitals, nurses are on the frontline. In his book, Gawande recounts multiple stories about checking with physicians about washing their hands is a small change that saves lives. The startling statistics on reducing deaths and complications from surgery from such small corrections based on the use of checklists is compelling. For a nurse to ask such a question of a physician only happened because they had the backing from administration to confront physicians. Otherwise, the ego of many physicians involved in these studies would have squashed such questions.

The implementation of checklists in every organization requires a degree of nuance as well as executives committed to making the discipline of using checklists work. Complex problems are like raising a child. One rocket is like another rocket. But not so with raising a child…every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable but most certainly not sufficient.

Gawande emphasizes the importance of communication within the team. A man is fallible, but maybe men are a little less so. Having more people involved increases the chance of finding a problem sooner. One interview expressed the following. “The biggest cause of serious error in this business is a failure of communication,” Airlines have made a policy clear that a co-pilot must speak up if there is a concern. Surgical teams a Harvard Medical Center, where Gawande practices have set up pre-operation meetings to make sure the team is working in concert and post-operation the team meets to review the procedure. In the Army, they have adopted a practice called the After Action Review (AAR) to learn from operations immediately after completion.

A major element of the communication within the team is inclusion. Bringing in all voices who have a stake in the process. 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.

A negative example given was FEMA during hurricane Katrina in New Orleans. They were relying on information from many sources. However, the top administrators were not using email that delayed information flow. Rather than relying on those at the site to make necessary decisions (inclusion), they waited for approval or clearance from the top. In this same emergency, the group that performed the best was Wal-Mart. Wal-Mart was able to send 2498 truckloads of emergency supplies in quickly. When complexity happens, freedom to respond is important.

Dr. Gawande makes the point that: Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up. Organizations will continually need all the brains and skills we can muster to solve complex problems.

Back to checklists, here are some practical tips on their use:
• Good checklists 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.
• With a READ-DO people carry out the tasks as they check them off – it’s more like a recipe. You want to keep the list short by focusing on what is called “the killer items” – the steps that are most dangerous to skip and sometimes overlooked nonetheless.
• No matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected.
• 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.

In the surgical area, the hospital developed seven checks before anesthesia, nineteen during surgery and another five before leaving the operating room for the recovery room. In the eight hospitals that were used in the study of the potential benefits of using checklists, complications fell by 36% and deaths fell by 47%.

In our coaching using the Stakeholder Centered Coaching methodology with leaders, it is not an immediate life or death situation like surgery or flying a plane. However, the implications to organizations could be on a slower path to life or death. Organizations are clearly affected by the decisions and actions of leaders higher up in the organization. The lessons from The Checklist Manifesto have enormous benefit for our clients as the use of checklists:
1. Clearly defines specific behaviors that have been agreed upon between the leader and the coach
2. Help make the behaviors in the checklist visible through the act of writing them down
3. Serves as a reminder, or memory aid, to the leader who has many, many things competing for his, or her, attention
4. As in his book Triggers Marshall Goldsmith says: “They are active behaviors rather than passive ones.”
5. Provide reinforcement to a leader that she, or he, is succeeding in improving as a leader