Checklist Manifesto
7. 1970s. Samuel Gorovitz and Alasdair MacIntyre. The nature of human fallibility.
8. At least two reasons for failure: "The first is ignorance--we may err because science has gien us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snow storms we cannot predict, heart attacks we still haven't learned how to stop. The second type of failure the philosophers call ineptitude--because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about."
8. "...sometime over the last several decades--and it is only over the last several decades--science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.
Consider heart attacks. Even as recently as the 1950s, we had little idea of how to prevent or treat them. We didn't know, for example, about the danger of high blood pressure, and had we been aware of it we wouldn't have known what to do about it. The first safe medication to treat hypertension was not developed and conclusively demonstrated to prevent disease until the 1960s. We didn't know about the role of cholesterol, either, or genetics or smoking or diabetes."
9. Preventing heart attack. "We have at least a dozen effective ways to reduce your likelihood of having a heart attack--for instance, controlling your blood pressure, prescribing a statin to lower cholesterol and inflammation, limiting blood sugar levels, encouraging exercise regularly, helping with smoking cessation, and, if there are early signs of heart disease, getting you to a cardiologist for still further recommendations. If you should have a heart attack, we have a whole panel of effective therapies that can not only save your life but also limit the damage to your heart: we have clot-busting drugs that can reopen your blocked coronary arteries; we have cardiac catheters that can balloon them open; we have open heart surgery techniques that let us bypass the obsructed vessels; and we've learned that in some instances all we really have to do is send you to bed with some oxygen, an aspirin, a statin, and blood pressure medications--in a couple days you'll generally be ready to go home and gradually back to your usual life."
10. Eptitude. "--making sure we apply the knowledge we have consistently and correctly. Just making the righ treatment choice among the many options for a heart attack patient can e difficult, even for expert clinicians. Furthermore, whatever the chosen treatment, each involves abundant complexities and pitfalls. Careful studies have shown, for example, that heart attack patients undergoing cardiac balloon therapy should have it done within ninety minutes of arrival at a hospital. After that, survival falls off sharply. In practical terms this means that, within ninety minutes, medical teams must complete all their testing for every patient who turns up in an emergency room with chest pain, make a correct diagnosis and plan, discuss the decision with the patient, obtain his or her agreement to proceed, confirm there are no allergies or medical problems that hae to be accounted for, ready a cath lab and team, transport the patient, and get started.
What is the likelihood that all this will actually occur within ninety minutes in an average hospital? In 2006, it was less than 50 percent."
"Studies have found that at least 30 percent of patients with stroke receive incomplete or inappropriate care from their doctors, as do 45 percent of patients with asthma and 60 percent of patients with pneumonia."
19. "The ninth edition of the World Health Organization's international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury--more than thirteen thousand different ways, in other words, that the body can fail."
"Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right."
44. "In December 2006, the Keystone Initiative published its findings in a landmark article in the 'New England Journal of Medicine'. Within the first three months of the project, the central line infection rate in Michigan's ICUs decreased by 66 percent. Most ICUs--including the ones at Sinai-Grace Hospital--cut their quarterly infection rate to zero. Michigan's infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative's first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for seeral years now--all because of a stupid little checklist."
52. Medical building construction. 2007. "Still, this one was no small undertaking, as the hospital's real estate manager later told me. The building, he said, would be 350,000 square feet in size, with three stories underground in addition to the eleven stories above. It would cost $360 million, fully delivered, and require 3,885 tons of steel, thirteen thousand yards of concrete, nineteen air handling units, sixteen elevators, one cooling tower, and one backup emergency generator. The construction workers would have to dig out 100,000 cubic yards of dirt and install 64,000 feet of copper pipping, forty-seven miles of conduit, and ninety-five miles of electrical wire--enough to reach Maine."
57. Joe Salvia of McNamara/Salvia structural engineering firm. "A building is like a body" he said. It has a skin. It has a skeleton. It has a vascular system--the pumbing. It has a beathing system--ventalation. It has a nervous system--the wiring. All together, he explained, projects today involve some sixteen different trades. He pulled out the construction plans for a four-hundred-foot-tall skyscraper he was currently building and flipped to the table of contents to show me. Each trade had contributed its own seperate section. There were sections for conveying systems (elevators and escalators), mechanical systems (heating, ventilation, plumbing, air conditioning, fire protection), masonry, concrete structures, metal structures, electrical systems, doors and windows, thermal and moisture systems (including waterproofing and insulation), rough and finish carpentry, site work (including excavation, waste and storm water collection, and walkways)--everything right down to the carpeting, painting, landscaping, and rodent control.
All separate contributions had to be included. Yet they also had to fit together somehow so as to make sense as a whole. And then they had to be executed precisely and in coordination. On the face of it, the complexities seemed overwhelming. To manage them, Salvia said, the entire industry was forced to evolve.
For most of modern history, he explained, going back to medieval times, the dominant way people put buildings was by going out and hiring Master Builders who designed them, engineered them, and oversaw construction from start to finish, portico to plumbing. Master Builders built Notre Dame, St. Peter's Basilica, and the United States Capitol building. But by the middle of the twentieth century the Master Builders were dead and gone. The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them.
In the first division of labor, architectural and engineering design split off from construction. Then, piece by piece, each component became further specialized and split off, until there were architects on one side, often with their own areas of subspecialty, and engineers on another, with their various kinds of expertise; the builders, too, fragmented into their own multiple divisions, ranging from tower crane contractors to finish carpenters. The field looked, in other words, a lot like medicine, with all its specialists and superspecialists.
Yet we in medicine continue to exist in a system created in the Master Builder era--a system in which a lone Master Physician with a prescription pad, an operating room, and a few people to follow his lead plans and executes the entirety of care for a patient, from diagnosis through treatment. We've been slow to adapt to the reality that, for example, a third of patients have at least ten specialist physicians actively involved in their care by their last year of life, and probably a score more personnel, ranging from nurse practitioners and physician assistants to pharmacists and home medical aides. And the evidence of how slow we've been to adapt is the extraordinarily high rate at which care for patients is duplicated or flawed or completely uncoordinated."
61. Finn O'Sullivan, project executive. The construction schedule. "As I peered in close, I saw a line-by-line, day-by-day listing of every building task that needed to be accomplished, in what order, and when--the fifteenth-floor concrete pour on the thirteenth of the month, a steel delivery on the fourteenth, and so on. The schedule spread over multiple sheets. There was special color coding, with red items highlighting critical steps that had to be done before other steps could proceed. As each task was accomplished, a job supervisor reported to O'Sullivan, who then put a check mark in his computer scheduling program. He posted a new printout showing the next phase of work each week, sometimes more frequently if things were moving along. The construction schedule was essentially one long checklist."
62. Within the Russia Wharf under construction. "We went down a couple more floors and he showed me that the "skin" of the building had now been hung at those levels. The tall, shiny glass and steel exterior had been bolted into the concrete floors every few feet. The farther down we went, the more the layers had advanced. One team of subcontractors had put up walls inside the skin. The pipefitters had then put in water and drainage pipes. The tin knockers followed and installed the ventilation ducts. By the time we got down to the lowest floors, the masonry, electrical wiring, plumbing, and even some fixtures like staircase railings were all in place. The whole intricate process was stounding to behold."
64. Atul noticed the floor tilted inward to collect water near the structure's core. "Yeah, the owners saw that and they weren't too happy," he said. He explained what he thinks had happened. The immense weight of the concrete core combined with the particular makeup of the soil underneath had probably caused the core to settle sooner than anticipated. Meanwhile, the outer steel fram had not yet been loaded with weight--there were still eighteen stories to be built upon it--and that's why he believes the floor had begun to tip inward. Once the steel frame was loaded, he fully expected the floor to level out.
The fascinating thing to me wasn't his explanation. I had no idea what to make of his answer. But here was a situation that hadn't been anticipated on the construction checklist: the tilting of the upper floors. At a minimum, a water cleanup would be needed and the schedule adjusted for it. That alone could throw the builders' tidy plans off track. Furthermore, the people involved had to somehow determine whether the tilting indicated a serious construction defect. I was curious to know how they handled this question, for there was inevitable uncertainty. How could they know that the problem was just ordinary settling, that loading the steel frame would in fact level out the floor? As Rouilard acknowledged, "variances can occur.""
65. The Submittal Schedule. "Like a patient, a building involves multiple specialists--the sixteen trades. In the absence of a true Master Builder--a supreme, all-knowing expert with command of all existing knowledge--autonomy is a disaster. It produces only a cacophony of incompatible decisions and overlooked errors. You get a building that doesn't stand up straight. This sounded to me like medicine at its worst.
So what do you do? I asked.
That was when O'Sullivan showed me a different piece of paper hanging in his conference room. Pinned to the left-hand wall opposite the construction schedule was another butcher-block-size sheet almost indentical in form, except this one, O'Sullivan said, was called a "submittal schedule." It was also a checklist, but it didn't specify construction tasks; it specified 'communication' tasks. For 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. The experts could make their indiidual judgments, but they had to do so as part of a team that took one another's concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could see where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction--who had to share (or submit) particular kinds of information before the next steps could proceed.
The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anythin could get missed. What? Who knows? That's the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.
So the submittal schedule made them talk. The contractors had to talk with the installers and elevator engineers by the thirty-first. They had to talk about fire protection with the fireproofers by the twenty-fifth. And two weeks earlieer, they had been required to talk about the condition of the core wall and flooring on the upper floors, where the water had pooled, with the structural engineers, a consultant, and the owners.
I saw that the box had been checked. The task was done. I asked Rouillard how the discussion had gone.
Very well, he said. Everyone met and reviewed the possibilities. The owners and the contractors were persuaded that it was reasonable to expect the floor to level out. Cleanup was arranged, the schedule was adjusted, and everyone signed off."
67. Digital Modeling. Ryan Walsh. "His job, he explained, was to take all the construction plans submitted by each of the major trades--the structural specs, the elevator specs, the plumbing specs, and so on. He used his mouse to walk us through the building as if we were taking a stroll down the corridors. You could see the walls, the doors, the safety valves, everything. More to the point, you could see problems--a place where there wasn't enough overhead clearance for an average-size person for example. He showed me an application called Clash Detective that ferreted out every instance in which the different specs conflicted with one another or with building regulations.
"If a structural beam is going where a lighting fixture is supposed to hang, the Clash Detective turns that beam a different color on-screen," he said. "You can turn up hundreds of clashes. I once found two thousand." But it's not enough to show the clash on the screen, he explained. You have to resolve it, and to do that you have to make sure the critical people talk. So the computer also flags the issue for the submittal schedule printout and sends an e-mail to each of the parties who have to resolve it."
68. Project Management Software. Project Center. "...allows anyone who has found a problem--even a frontline worker--to e-mail all the relevant parties, track progress, and make sure a check is added to the schedule to confirm that everyone has talked and resolved the matter. When we were back at the McNamara/Salvia offices, Bernie Rouillard showed me one such e-mail he'd gotten that week. A worker had attached a digital photo of a twelve-foot steel I beam he was bolting in. It hadn't lined up properly and only two of the four bolts could fit. Was that all right, the worker wanted to know? No, Rouillard wrote back. They worked out a solution together: to weld the beam into place. The e-mail was also automatically sent to the main contractor and anyone who might potentially be required to sign off. Each party was given three days to confirm that the proposed solution was okay. And everyone needed to confirm that the proposed solution was okay. And everyone needed to confirm they'd communicated, since the time taken for even this small fix could change the entire sequence in which other things needed to be done."
71. Building complexity has increased, yet completion time has decreased by 1/3 during Joe Salvia's career.
71. Number of building in the US. "...we have nearly five million commercial buildings, almost one hundred million low-rise homes, and eight million or so high-rise residences. We add somewhere around seventy thousand new commercial buildings and one million new homes each year."
71. Building failure. "According to a 2003 Ohio State University study, the United States experiences an average of just twenty serious "building failures" per year. That's an annual avoidable failure rate of less than 0.00002 percent."
72. Two types of checklists in construction. "...the first building checklist I saw, the construction schedule on the right-hand wall of O'Sullivan's conference room, was exactly that. It spelled out to the tiniest detail every critical step the tradesmen were expected to follow and when--which is logical if you're confronted with simple and routine problems; you want the forcing function.
But the list on O'Sullivan's other wall revealed an entirely different philosophy about power and what should happen to it when you're confronted with complex, nonroutine problems--such as what to do when a difficult, potentially dangerous, and unanticipated anomaly suddenly appears on the fourteenth floor of a thirty-two-story skyscraper under construction. 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."
73. Inspectors. "...although inspectors do what they can to oversee a building's construction, mostly they make certain the builders have the proper checks in place and then have them sign affidavits attesting that they themselves have ensured that the structure is up to code. Inspectors disperse the power and the responsibility.
"It makes sense," O'Sullivan said. "The inspectors have more troubles with the safety of a two-room addition from a do-it-yourselfer than they do with projects like ours. So that's where they focus their efforts.""
78. Walmart and Katrina. "They were able to supply water and food to refugees and even to the National Guard a day before the government appeared on the scene. By the end Wal-Mart had sent in a total of 2,498 trailer loads of emergency supplies and donated $3.5 million in merchandise to area shelters and command centers.
"If the American government had responded like Wal-Mart has responded, we wouldn't be in this crisis," Jefferson Parish's top official, Aaron Broussard, said in a network television interview at the time."
79. Under conditions of true complexity: "...efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either--that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation--expectation to coordinate, for example, and also to measure progress toward common goals.
This was the understanding people in the skyscraper-building industry had grasped. More remarkably, they had learned to codify that understanding into simple checklists. They had made the reliable management of complexity a routine.
That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how.
I came away from Katrina and the builders with a kind of theory: under conditions of complexity, not only are checklists a help, they are 'required' for success. There must always be room for judgment, but judgment aided--and even enahnced--by procedure."
81. Jody Adam's resturant Railto in Boston. "Adams and her staff served 150 people in five hours. That night they made a roasted tomato soup with sweated onions and garlic; squid ink ravioli filled with a salt cod ebrandade on a bed of squash blossoms and labster sauce; grilled bluefish with corn relish, heirloom tomatoes, and pickled peppers; slow-roasted duck marinated in soy sauce, balsamic vinegaf, mustard, rosemary, and garlic...
Sitting there, I saw remarkable expertise. Half of Adam's staff had been to culinary school. Few had less than a decade of experience. They each had a kitchen specialty. There was a pastry chef, baker, grill chef, fry cook, dessert chef, sous chef, sommelier--you get the picture. Through the years, they had perfected their technique. I couldn't fathom the subtleties of most of what they did."
82. Checklists. "First there was the recipe--the most basic checklist of all. Every dish had one. The recipes were typed out, put in clear plastic sleeves, and placed at each station. Adams was religious about her staff's using them. Even for her, she said, "following the recipe is essential to making food of consistent quality over time."
Tacked to a bulletin board beside the dessert station was what Adams called her Kitchen Notes--e-mails to the staff of her brief observations about the food. The most recent was from 12:50 the previous night. "Fritters--more herbs, more garlic...more punch," it said. "Corn silk in corn! Creamed corn side on oval plates--not square! Mushrooms--more shallots, garlic, and marsala. USE THE RECIPES!"
84. Communication of orders to staff. "The sous chef, who serves as a kind of field officer for operations, read the tickets off as they came in.
"Fire mushrooms. Fire mozz. Lobo on hold. Steak very well done, no gluten, on hold."
"Fire" meant cook it now. "On hold" meant it was a second course. "Lobo" was the lobster. The steak needed to be cooked all the way through and the customer had a gluten allergy. A read-back was expected to confirm that the line cooks had head the order right.
"Fire mushrooms. Fire mozz," said one.
"Lobo on hold," said the seafood cook.
"Steak very well done, no gluten, on hold," said the grill chef.
84. Pow wow. "Everyone gathers in the kitchen for a quick check to discuss unanticipated issues and concerns--the unpredictable. The night I was there, they reviewed the reservation count, two menu changes, how to fill in for a sick staff member, and a sweet sixteen party with twenty girls who were delayed and going to arrive in the midst of the dinner rush. Everyone was given a chance to speak, and they made plans for what to do."
85. Final check. "Every plate had to be reviewed by either her or the sous chef before it left the kitchen for the dining room."
92.93. World Health Organization. Search for a guidebook on global health programs. "They came up with instances like the smallpox vaccination campaign that eradicated the scourge from the world in 1979 and the work of Dr. John Snow famously tracing a deadly 1854 London cholera outbreak to water in a public well. When the disease struck a London neighborhood that summer, two hundred people died in the first three days. Three-quarters of the area's residents fled in panic. Nonetheless, by the next week, some fix hundred more died. The dominant belief was that diseases like cholera were caused by "miasmas"--putrefied air. But Snow, skeptical of the bad-air theory, made a map of where the deceased had lived and found them clustered around a single water source, a well in Soho's Broad Street. He interviewed the bereaved families about their habits. He made a careful statistical analysis of possible factors. And he concluded that contaminated water had caused the outbreak. (It was later discovered that the well had been dug next to a leaking cesspit.) Snow persuaded the local council to remove the wateer well's pump handle. This disabled the well, ended the spread of the disease, and also established the essential methods of outbreak investigation that infectious disease specialists follow to this day.
All the examples, I noticed, had a few attributes in common: They involved simple interventions--a vaccine, the removal of a pump handle. The effects were carefully measured. And the interventions proved to have widely transmissible benefits--what business types would term a large ROI (return on investment) or what Archimedes would have called, merely, leverage."
95. Steven Luby. Slum illness prevention in Karachi. The distribution of soap. "Luby and his team reported their results in a landmark paper published in the Lancet in 2005. Families in the test neighborhoods received an average of 3.3 bars of soap per week for one year. During this period, the incidence of diarrhea among children in these neighborhoods fell 52 percent compared to that in the control group, no matter which soap was used. [soap by P&G called Safeguard with and without triclocarban, an antibacterial agent] The incidence of pneumonia fell 48 percent. And the incidence of impetigo, a bacterial skin infection, fell 35 percent. These were stunning results."
97. The success was due to instructions on how and when to use the soap. "The field-workers gave specific instructions on hand-washing technique--on the need to wet both hands completely, to lather well, to rinse all the soap off, even if, out of necessity, as the published report noted, "hands were typically dried on participants' clothing." The instructions also got people used to washing at moments when they weren't used to doing so. "Before preparing food or feeding a child is not a time when people think of washing," Luby explained. The soap itself was also a factor. "It was really nice soap," he pointed out. It smelled good and lathered better than the usual soap people bought. People liked washing with it. "Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not." Lastly, people liked receiving the soap. The public health field-workers were bringing them a gift rather than wagging a finger. And with the gift came a few basic ideas that would improve their lives and massively reduce disease."
99. 2005. Columbia Children's Hospital. 1/3 of appendectomy patients failed to recieve antibiotic injections at the right time or not at all. "The hospital's director of surgical administration, who happened to be not only a pediatric cardiac surgeon but also a pilot, decided to take the aviation approach. He designed a preincision "Cleared for Takeoff" checklist that he put on a whiteboard in each of the operating rooms. It was really simple. There was a check box for the nurse to verbally confirm with the team that they had the correct patient and the correct side of the body planned for surgery--something teams are supposed to verify in any case. And there was a further check box to confirm that the antibiotics were given (or else judged unnecessary, which they can be for some operations)."
"...he designed a little metal tent stenciled with the phrase 'Cleared for Takeoff' and arranged for it to be placed in the surgical instrument kits. The metal tent was six inches long, just long enough to cover a scalpel, and the nurses were asked to set it over the scalpel when laying out the instruments before a case. This served as a reminder to run the checklist before making the incision. Just as important, it also made clear that the surgeon could not start the operation until the nurse gave the okay and removed the tent, a subtle cultural shift. Even a modest checklist had the effect of distributing power."
100. "The surgical director measured the effect on care. After three months, 89 percent of appendicitis patients got the right antibiotics at the right time. After ten months, 100 percent did. The checklist had become habitual--and it had also become clear that team members could hold up an operation until the necessary steps were completed."
100. Surgical checklists. Richard Reznick, chairman of surgery at the University of Toronto. "He explained that his hospital had completed a feasibility trail using a much broader, 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.
The checklist also included what they called a "team briefing." The team members were supposed to stop and take a moment simply to talk with one another before proceeding--about how long the surgeon expected the operation to take, how much blood loss everyone should be prepared for, whether the patient had any risks or concerns the team should know about. "
101. Martin Makary, John Hopkins pancreatic surgeon. "...showed us an eighteen-item checklist that he'd tested with eleven surgeons for five months at his hospital. Likewise, a group of Southern California hospitals within the Kaiser health care system had studied a thirty-item "surgery preflight checklist" that actually predated the Toronto and Hopkins innovations. All of them followed the same basic design. "
Surgery's four big killers. "infection, bleeding, unsafe anesthesia and... the unexpected"
The first three can be avoided by using a checklist. The unexpected can be avoided by group discussion. "...to be ready as a team to identify and address each patient's unique, potentially critical dangers."
102. Brian Sexton. John Hopkins psychologist. "...he surveyed more than a thousand operating room staff members from hospitals in five countries--the United States, Germany, Israel, Italy, and Switzerland--and found that although 64 percent of the surgeons rated their operations as having high levels of teamwork, just 39 percent of anesthesiologists, 28 percent of nurses, and 10 percent of anesthesia residents did. Not coincidentally, Sexton also found that one in four surgeons believed that junior team members should not question the decisions of a senior practitioner."
108. Everyone knowing each other's names and concerns before an operation improves teamwork performance. "
Sexton. "...he and his team buttonholed surgical staff members outside their operating rooms and asked them two questions: how would they rate the level of communications during the operation they had just finished and what were the names of the other staff members on the team? The researchers learned that about half the time the staff did not know one another's names. When they did, however, the communications ratings jumped significantly.
The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an "activation phenomenon." Giving people a chance to say something at the start seemed to activate their sense of participation and responsibilities and their willingness to speak up."
"....in three separate cities, teams had tried out these unusual checklists, and each had found a positive effect."
109. Checklist's effects on teamwork. "Eleven surgeons had agreed to try it in their cases--seven general surgeons, two plastic surgeons, and two neurosurgeons. After three months, the number of team members in their operations reporting that they "functioned as a well-coordinated team" leapt from 68 percent to 92 percent.
At the Kaiser hospitals in Southern Califoria, researchers had tested their checklist for six months in thirty-five hundred operations. During that time, they found that their staff's average rating of the teamwork climate improved from "good" to "outstanding." Employee satisfaction rose 19 percent. The rate of OR nurse turnover--the proportion leaving their jobs each year--dropped from 23 to 7 percent. And the checklist appeared to have caught numerous near errors. In one instance, the preoperative briefing led the team to recognize that a vial of potassium chloride had been switched with an antibiotic vial--a potentially lethal mix-up. In another, the checklist led the staff to catch a paperwork error that had them planning for a thoracotomy, an open-chest procedure with a huge front-to-back wound, when what the patient had come in for was actually a thoracoscopy, a videoscope procedure done through a quarter-inch incision.
At Toronto, the researchers physically observed operations for specific evidence of impact. They watched their checklist in use in only eighteen operations. But in ten of those eighteen, they found that it had revealed significant problems or ambiguities--in more than one case, a failure to give antibiotics, for example; in another, uncertainty about whether blood was available; and in several, the kinds of unique and individual patient problems that I would not have expected a checklist to help catch."
114. Daniel Boorman. Boeing. Vetern pilot that's developed checklists and flight deck controls. One of the flight deck designers for the 787 Dreamliner, including its pilot controls, displays, and system of checklists. Studied thousands of crashes and near-crashes.
120. "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.
The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them."
122. When making a checklist, Boorman explained "...you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. 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 check-list 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. Boorman didn't think one had to be religious on this point.
"It all depends on the context," he said. "In some situations you have only twenty seconds. In others, you may have several minutes.
But after about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things. People start "shortcutting." Steps get missed. So you want to 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 (Data establishing which steps are most critical and how frequently people miss them are highly coveted in aviation, though not always available.)
The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)
[in regard to a disgaurded first draft for surgical procedure] To some extent, we had covered this territory in drafting our surgery checklist. No question, it needed some trimming, and many items on the list could be sharper and less confusing. I figured we could fix it easily. But Boorman was adamant about one further point: 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. First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.
This is not easy to do in surgery, I pointed out. Not in aviation, either, he countered. You can't unlatch a cargo door in midflight and observe how a crew handles the consequences. But that's why they have flight simulators, and he offered to show me one. "
133. "One study in medicine, for example, examined the aftermath of nine different major treatment discoveries such as the finding that the pneumococcus vaccine protects not only children but also adults from respiratory infections, one of our most common killers. On average, the study reported, it took doctors 'seventeen years' to adopt the new treatments for at least half of American patients.
What experts like Dan Boorman have recognized is that the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form. If the only thing people did in aviation was issue dense, pages-long bulletins for every new finding that might affect the safe operation of airplanes--well, it would be like subjecting pilots to the same deluge of almost 700,000 medical journal articles per year that clincicians must contend with. The information would be unmanageable.
But instead, when the crash investigators [for British Airways flight 38 from Beijing to London] issued their bulletin--as dense and detailed as anything we find in medicine--Boorman and his team buckled down to the work of distilling the information into its practical essence. They drafted a revision to the standard checklists pilots use for polar flights. They sharpened, trimmed, and puzzled over pause points--how are pilots to know, for instance, whether an engine is failing because of icing instead of something else? Then his group tested the checklist with pilots in the simulator and found problems and fixed them and tested again.
It took about two weeks for the Boeing team to complete the testing and refinement, and then they had their checklist. They sent it to every owner of a Boeing 777 in the world. Some airlines used the checklist as it was, but many, if not most, went on to do things slightly differently, so do airlines, and they are encouraged to modify the checklists to fit into their usual procedures. (This customization is why, when airlines merge, among the fiercest battles is the one between the pilots over whose checklists will be used.) Within about a month of the recommendations becoming available, pilots had the new checklist in their hands--or in their cockpit computers. And they used it.
How do we know? Because on November 26, 2008, the disaster almost happened again. This time it was a Delta Air Lines flight from Shanghai to Atlanta with 247 people aboard. The Boing 777 was at thirty-nine thousand feet over Great Falls, Montana, when it experieced "an uncommanded rollback" of the right No. 2 engine--the engine, in other words, failed. Investigation later showed that ice had blocked the fuel lines--the icing theory [that caused the crash landing of flight 33] correct--and Boeing institued a mechanical change to keep it from happening again. But in the moment, the loss of one engine in this way, potentially two, over the mountains of Montana could have been catastrophic.
The pilot and copilot knew what to do, though. They got out their checklist and followed the lessons it offered. Because they did, the engine recovered, and 247 people were saved. It went so smoothly, the passengers didn't even notice.
This, it seemed to me, was something to hope for in surgery."
137. Surgical procedure DO-CONFIRM checklist. Simulation. They agreed the circulation nurse call the start, similar to that of a co-pilot checklisting for the pilot.
"Every line of the checklist needed tweaking. We timed each successive version by a clock on the wall. We wanted the checks at each of the three pause points--before anesthesia, before incision, and before leaving the OR--to take no more than about sixty seconds, and we weren't there yet. If we wanted acceptance in the high-pressure environment of operating rooms, the checklist had to be swift to use. We would have to cut some lines, we realized--the non-killer items.
This proved to be the most difficult part of the exercise. An inherent tension exists between brevity and effectiveness. Cut too much and you won't have enough checks to improve care. Leave too much in and the list becomes too long to use. Furthermore, an item critical to one expert might not be critical to another. In the spring of 2007, we reconvened our WHO group of international experts in London to consider these questions. Not surprisingly, the most intense disagreements flared over what should stay in and what should come out."
140. Final WHO safe surgery checklist. "...spelled out nineteen checks in all. Before anesthesia, there are seven checks. The team members confirm that the patient (or the patient's proxy) has personally verified his or her identity and also given consent for the procedure. They make sure the the surgical site is marked and that the pulse oximeter--which monitors oxygen levels--is on the patient and working. They check the patient's medication allergies. They review the risk of airway problems--the most dangerous aspect of general anesthesia--and that appropriate equipment and assistance for them are available. And lastly, if there is a possibility of losing more than half a liter of blood (or the equivalent for a child), they verify that necessary intravenous lines, blood, and fluids are ready.
After anesthesia, but before incision, come seven more checks. The team members make sure they've been introduced by name and role. They confirm that everyone has the correct patient and procedure (including which side of the body--left versus right) in mind. They confirm that antibiotics were either given on time or were unnecessary. They check that any radiology images needed for the operation are displayed. And to make sure everyone is briefed as a team, they discuss the critical aspects of the case: the surgeon reviews how long the operation will take, the amount of blood loss the team should prepare for, and anything else people should be aware of; the anesthesia staff review their anesthetic plans and concerns; and the nursing staff review equipment availability, sterility, and their patient concerns.
Finally, at the end of the operation, before the team wheels the patient from the room, come five final checks. The irculating nurse verbally reviews the recorded name of the completed procedure for accuracy, the labeling of any tissue specimens going to the pathologist, whether all needles, sponges, and instruments have been accounted for and whether any equipment problems need to be addressed before the case. Everyone on the team also reviews aloud their plans and concerns for the patient's recovery after surgery, to ensure information is complete and clearly transmitted."
143. 8 hospital were selected in the world for the checklist implementation: rich nations: University of Washington Medical Center in Seattle, Toronto General Hospital in Canada, St. Mary's Hospital in London, Auckland City Hospital in New Zealand.
low or middle income countries: Philippines General Hospital in Manila, Prince Hamza Hospital in Amman, Jordon, St Stephen's Hospital in New Delhi, St. Francis Designated District Hospital in Ifakara, Tanzania.
144. Before the launch. "We collected data on the surgical care in up to four operating rooms at each facility for about three months before the checklist went into effect. It was a kind of biopsy of the care received by patients across the range of hospitals in the world. And the results were sobering.
Of the close to four thousand adult surgical patients we followed, more than four hundred developed major complications resulting from surgery. Fifty-six of them died. About half the complications involved infections. Another quarter involved technical failures that required a return trip to the operating room to stop bleeding or repair a problem. The overall complication rates ranged from 6 percent to 21 percent. It's important to note that the operating rooms we were studying tended to handle the hospital's more complex procedures. More straight forward operations have lower injury rates."
145. Found room for improvement. "None of the hospitals, for example, had a routine approach to ensure that teams had identified, and prepared for, cases with high blood-loss risk, or conducted any kind of preoperative team briefing about patients. We tracked performance of six specific safety steps: the timely delivery of anti-biotics, the use of a working pulse oximeter, the completion of a formal risk assessment for placing an airway tube, the verbal confirmation of the patient's identity and procedure, the appropriate placement of intravenous lines for patients who develop severe bleeding, and finally a complete accounting of sponges at the end of the procedure. These are basics, the surgical equivalent of unlocking the elevator controls before airplane takeoff. Nevertheless, we found gaps everywhere. The very best missed at least one of these minimum steps 6 percent of the time--once in every sixteen patients. And on average, the hospitals missed one of them in a startling two-thirds of patients, whether in rich countries or poor. That is how flawed and inconsisten surgical care routinely is around the world."
Implementation. "...starting in spring 2008, the pilot hospitals began implementing our two-minute, nineteen-step surgery checklist. We knew better than to think that just dumping a pile of copies in their operating rooms was going to change anything. The hospital leaders committed to introducing the concept systematically. They made presentations not only to their surgeons but also to their anesthetists, nurses, and other surgical personnel. We supplied the hospitals with their failure data so the staff could see what they were trying to address. We gave them some PowerPoint slides and a couple of YouTube videos, one demonstrating "How to Use the Safe Surgery Checklist" and one--a bit more entertaining--entitled "How Not to Use the Safe Surgery Checklist," showing how easy it is to screw everything up.
We also asked the hospital leaders to introduce the checklist in just one operating room at first, ideally in procedures the chief surgeon was doing himself, with senior anesthesia and nursing staff taking part. There would surely be bugs to work out. Each hospital would have to adjust the order and wording of the checklist to suit its particular practices and terminology. Several were using translations. A few had already indicated they wanted to add extra checks. For some hospitals, the checklist would also compel systemic changes--for example, stocking more antibiotic supplies in the operating rooms. We needed the first oups using the checklist to have the seniority and patience to make the necessary modifications and not dismiss the whole enterprise.
Using the checklist involved a major cultural change, as well--a shift in authority, responsibility, and expectations about care--and the hospitals needed to recognize that. We gambled that their staff would be far more likely to adopt to the checklist if they saw their leadership accepting it from the outset."
156. Results. "In January 2009, the 'New England Journal of Medicine' published our study as a rapid-release article. Even before then, word began to leak out as we distribute the findings to our pilot sites. Hospitals in Washington State learned of Seattle's results and began trying the checklist themselves. Pretty soon they'd formed a coalition with the state's insurers, Boeing, and the governor to systematically introduce the checklist across the state and track detailed data. In Great Britain, Lord Darzi, the chairman of surgery at St. Mary's Hospital, had meanwhile been made a minister of health. When he and the country's top designate to WHO, Sir Liam Donaldson (who had also pushed for the surgery project in the first place), saw the study results, they launched a campaign to implement the checklist nationwide.
The reaction of surgeons was more mixed. Even if using the checklist didn't take the time many feared--indeed, in several hospitals teams reported that it saved them time--some objected that the study had not clearly established 'how' the checklist was producing such dramatic results. This was true. In our eight hospitals, we saw improvements in administering antibiotics to reduce infections, in use of oxygen monitoring during operations, in making sure teams had the right patient and right procedure before making an incision. But these particular improvements could not explain why unrelated complications like bleeding fell, for example. We surmised that improved communication was the key. Spot surveys of random staff members coming out of surgery after the checklist was in effect did indeed report a significant increase in the level of communication. 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.
Perhaps the most revealing information, however, was simply what the staff told us. More than 250 staff members--surgeons, anesthesiologists, nurses, and others--filled out an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did no take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.
Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.
Then we asked the staff one more question. "If you were having an operation," we asked, "would you want the checklist to be used?"
A full 93 percent said yes."
159. Make a product, like a robot, to improve health, and people will demand it.
160. Improving checklists. "Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognize the opportunity, the two-minute WHO checklist is just a start. It is a single, broad-brush device intended to catch a few problems common to all operations, and we surgeons could build on it to do even more. We could adopt, for example, specialized checklists for hip replacement procedures, pancreatic operations, aortic aneurysm repairs, examining each of our major procedures for their most common avoidable glitches and incorporating checks to help us steer clear of them. We could even devise emergency checklists, like aviation has, for nonroutine situations--such as the cardiac arrest my friend John described in which the doctors forgot that an overdose of potassium could be a cause.
Beyond the operating room, moreover, there are hundreds, perhaps thousands, of things doctors do that are as dangerous and prone to error as surgery. Take, for instance, the treatment of heart attacks, strokes, drug overdoses, pneumonias, kidney failures, seizures. And consider the many other situations that are only seemingly simpler and less dire--the evaluation of patient with a headache, for example, a funny chest pain, a lung nodule, a breast lump. All involve risk, uncertainty, and complexity--and therefore steps that are worth committing to a checklist and testing in routine care. Good checklists could become as important for doctors and nurses as good stethoscopes (which, unlike checklists, have never been proved to make a difference in patient care.) The hard question--still unanswered--is whether medical culture can seize the opportunity."
161. Comparing test pilots of the 1950s to that of medicine today. "Test pilots had to have focus, daring, wits, and an ability to improvise--the right stuff. 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.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do--in surgery, emergency care, ICU medicine, and beyond--more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity--the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that's what rankles many people.
162. "...good clinicians will not be able to dispense with expert audacity. Yet we should also be ready to accept the virtues of regimentation."
164. Mohnish Pabrai of Pabrai Investment Funds in Irvine, California. "Pabrai made a list of mistakes he'd seen--ones Buffett and other investors had made as well as his own. It soon contained dozens of different mistakes, he said. Then, to help him guard against them, he devised a matching list of checks--about seventy in all. One, for example, came from a Berkshire Hathaway mistake he'd studied involving the company's purchase in early 2000 of Cort Furniture, a Virginia-based rental furniture business." Cort Funiture failed as its profits were based on businesses in the dot-com boom/bust.
177. Sharpest checklists Atul viewed. "...a checklist for engine failure during flight in a single-engine Cessna airplane--the US Airways situation, only with a solo pilot. It is slimmed down to six key steps not to miss for restarting the engine, steps like making sure the fuel shutoff valve is in the OPEN position and putting the backup fuel pump switch ON. But step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE. Because pilots sometimes become so desperate trying to restart their engine, so crushed by the cognitive overload of thinking through what could have gone wrong, they forget his most basic task. FLY THE AIRPLANE. This isn't rigidity. This is making sure everyone has their best shot at survival."
183. "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. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.
That's perhaps why aviation has required institutions to make discipline a norm. The preflight checklist began as an invention of a handful of army pilots in the 1930s, but the power of their discovery gave birth to entire organizations. In the United States, we now have the National Transportation Safety Board to study accidents--to independently determine the underlying causes and recommend how to remedy them. And we have national regulations to ensure that those recommendations are incorporated into usable checklists and reliably adopted in ways that actually reduce harm.
185. Donald Berwick, president of the Institute for Healthcare Improvement in Boston. "We're obsessed in medicine with having great components--the best drugs, the best devices, the best specialists--but pay little attention to how to make them fit together well. Berwick notes how wrongheaded this approach is. "Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence," he says. He gives the example of a famous thought experiment of trying to build the world's greatest car by assembling the world's greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. "What we get, of course, is nothing close to a great car; we get a pile of very expensive junk" [Note: Unless the parts are modular and integrated into a universally standardized system design]
"Nonetheless, in medicine that's exactly what we have done. We have a thirty-billion-dollar-a-year National Institutes of Health, which has been a remarkable powerhouse of medical discoveries. But we have no National Institute of Health Systems Innovation alongside it studying how best to incorporate these discoveries into daily practice--no NTSB equivalent swooping in to study failures the way crash investigators do, no Boeing mapping out the checklists, no agency tracking the month-to-month results.
The same can be said in numerous other fields. 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. "
186. Model 299 pilots accepted fallibilities and used checklists. "They too could have decided just to "try harder" or to dismiss a crash as the failings of a "weak" pilot."