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BOOK REVIEW: How to make checklists work for you

Jun 15 2017 05:30
Ian Mann

The Checklist Manifesto: How to Get Things Right. Atul Gawande

The author, Dr Atul Gawande is an American general and endocrine surgeon, and public health researcher. I have been meaning to read and review his book for many years. What a fitting introduction to ‘The Checklist Manifesto: How to Get Things Right.’

Philosophers Samuel Gorovitz and Alasdair MacIntyre tackled the issue of why we fail at what we set out to do in the world. One reason, they explain is “necessary fallibility”, a consequence of some things in the world, and our lives, being beyond our understanding and control.

But there is much that is not, and yet we fail at these too. Gorovitz and MacIntyre suggest that there are two reasons for this: ignorance and ineptitude (incompetence or clumsiness.)

For most of human history, people’s lives have been lived largely in ignorance. However, over the last few decades, science has filled in enough knowledge to make our ‘ineptitude’ as much of a challenge as our ‘ignorance’ was in the past.

Gawande’s context is the ineptitude in medicine. While our knowledge and sophistication has grown enormously, the struggle is still how to deliver on this know-how.

The knowing-doing gap is found everywhere. From the frequent mistakes authorities make when disaster strikes, to the legal mistakes our lawyers make that are the result of little more than simple administrative errors.

“Every day there is more and more to manage and get right and learn,” Gawande points out. With all we are required to manage, failure happens far more often - despite great effort rather than from a lack of it.

Expertise has been seen as the solution to ineptitude in most areas of work – “they need more training!” and modern medicine has been no different. But capability clearly isn’t our primary difficulty; in most fields training is longer and more intense than ever.

In the early twentieth century, you could practice medicine with only a high school diploma and a one-year medical degree. Today doctors have six years of university, and three to seven years of residency to practice paediatrics, surgery, neurology, or the like.

Yet our failures remain frequent, but there is a solution – checklists.

Though this seems almost ridiculous in its simplicity - especially to those of us who have spent years carefully developing ever more advanced skills - it has proven not to be.

Pilot’s checklist

In 1935 the US Army was looking for the next generation long-range bomber. Boeing’s aluminium-alloy Model 299 was able to carry five times as many bombs as the army had requested, and could fly faster and farther than previous bombers. The army planned to order at least 65 planes until it stalled on a test flight, turned on one wing, and exploded.

The crash, attributed to ‘pilot error, killed 2 of the 5 crew members. This prompted Boeing to come up with an ingeniously simple approach: they created a pilot’s checklist. It is worth noting that using a checklist for takeoff was about as odd as using a checklist to back out of your garage.

However, flying this new plane was too complicated to be left to the memory of any person, no matter how expert. The test pilots made checklists for takeoff, flight, landing, and taxiing, and armed with the checklist, flew a total of 1.8 million miles without one accident. The army ultimately ordered almost 13 000 planes.

Like flying, many areas of our lives and work have become “too much airplane for one person to fly”.

Faulty memory and distraction are a constant danger in “all-or-none processes” like going to the shop to buy ingredients for a cake, piloting a plane through a takeoff, or treating a sick person in the hospital. “If you miss just one key thing, you might as well not have made the effort at all,” says Gawande.

Another human danger you may well recognise, is allowing yourself to skip steps even when you remember them. You skip steps because it has never been a problem before – until one day it is.

Checklists can provide protection against such lapses, as they remind us of the minimum necessary steps.

Professors  Zimmerman  and Glouberman distinguish between 3 different kinds of problems: the simple, the complicated, and the complex.

‘Simple problems’ are ones like baking a cake from a recipe with a few basic techniques you need to learn. Master them and you most likely will have success.

‘Complicated problems’ are like sending a rocket to the moon. There is no straightforward recipe, and success usually requires many people and great expertise. Unanticipated problems are common, and timing and coordination become serious concerns.

‘Complex problems’ are like raising a child. You can’t repeat and perfect the process as you can with rockets. Every child is unique, and while expertise is valuable, it is not sufficient. The outcome remains highly uncertain.

The value of checklists for simple problems is self-evident: that is why we have a shopping list. But much of the most critical work people do, is not simple. Checklists help prevent failure especially when the problems combine everything from the simple to the complex.

The real value of checklists

The real value of checklists is in conditions of true complexity, where the knowledge requirements exceed that of any individual, and unpredictability reigns. Commands and control from the centre will fail. Under these conditions, not only are checklists a help, they are essential for success. In these complex situations where individuals must exercise their own judgement, this judgement will be enhanced by checklist procedures.

Bad checklists are vague and imprecise, too long and hard to use. They are written as if the people using them are stupid, and they try to spell out every single step. Good checklists, are precise and begin with the premise that a checklist cannot fly a plane. That is why, faced with catastrophe, pilots are astonishingly willing to turn to their checklists.

Checklists come in two forms: DO-CONFIRM and READ-DO. Using a DO-CONFIRM checklist, people do jobs from memory and experience, then stop and check. Using a READ-DO checklist, people carry out the tasks as they check them off, like a recipe.

To get value from checklists, they must make sense for the particular situation. A rule-of-thumb is to keep it to between five and nine items, simply worded, and exact.

Does this work? This was rigorously tested in the World Health Organisation’s ‘safe surgery’ research across a variety of hospitals of different sizes, rich and poor, in countries from Tanzania to the US.

In this carefully constructed study, a 2-minute, 19 step surgery checklist, resulted in an immediate drop in infection and mortality in thousands of operations in 8 participating hospitals. Major complications dropped 36%, and deaths fell by 47%.

That is how much a checklist can add to the skills of highly trained, highly skilled surgeons. It is worth a serious try in your business. You will get startling results too.

Readability            Light ---+- Serious

Insights                  High +---- Low

Practical                 High +---- Low

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