Book Review:

The Checklist Manifesto

The book shows importance of learning from other fields and industries, such as the airline industry. Not only does their black box record technical and cockpit data but pilots are encouraged – and willing – to record near misses. The aim is always to learn and prevent similar happening in the future, not to blame and punish – which simply encourages people to avoid responsibility and hide mistakes.

A key requirement emphasised in this book is being prepared to challenge and change existing cultures – after all, imagine getting surgeons, used to autonomy, based on years of training and expertise, to have to use and fill in a checklist! And the detailed use of an item by item checklist can seem painstakingly laboured and slow when (as is often the case) the team is working on an emergency operation

Gawande did not have an easy ride: what looks obvious now, and is a massive contribution to successful surgery, was not the view when he started on his mission; he had to deal with resistance, trial and error, and even an unwillingness or forgetfulness among many to use it. Too many involved had a high regard for their own judgement, and a low regard for their degree of tiredness and attention to detail. That checklists have made such a massive difference is not just due to their effectiveness, but the Gawande’s persistence, resilience and leadership.

A key element of the checklist is for those involved to introduce each other and clarify their roles – so if a crisis occurs, everyone works as a powerful team – even if they’ve never worked together before

Easy to follow procedures, properly applied may not reduce complexity, but they will reduce ineptitude. In a world in which complexity is bound to increase, and therefore discrete specialisms will flourish, a way of integrating such knowhow and knowledge is vital, to protect against and minimise ineptitude.

Repetition of the same task, activity or action generates boredom; over-complacency that ‘I’m doing it right’ almost by instinct, rather than by checking. And if the task is routine, it’s easier to switch off, and get distracted. If you’ve gone to the same shelf to find the same size and coloured bottle in the same place 200 times, you are more likely to assume that a bottle of the same size and colour in the same place is as it has always been – perhaps without checking the label.

In the early days, if a senior surgeon skipped or missed a step on the checklist, junior staff felt unable or willing to point this out to the surgeon – for fear of being reprimanded, ridiculed or worse. A key contribution to the success of the checklist was to create both a condition and a requirement by the hospital to give everyone not only the authority to intervene, but the requirement to do so. The checklist, rather than anyone’s seniority or experience, was sacrosanct.

Generally speaking, experts value autonomy; they often feel more certain of their facts, and having deferred gratification through length training, may often want to use that pent up expertise by using their own judgement. Some also feel that the expertise qualifies them to ‘know best’, and it is clearly a key part of job satisfaction to have the reputation and even kudos of being deferred to as ‘an expert’. So not only do experts value their vocation, and trust it; they tend to be more dismissive of procedures and processes that they have not formulated for themselves, and seem to be created by people on a far lower salary and job grade than themselves. To some, it seemed not only a restriction of their power, but a questioning of their authority. So in the early days, expert autonomy versus documented procedure was never going to be a fair fight…