The Checklist Manifesto

While I was writing my other post The Power of Checklists OR I Don’t Care How Many Years You Went to School, You Still Have to Follow the Process I was trying to learn more about Gawande’s view on checklists. So I started rereading The Checklist Manifesto. In the introduction of the book, he actually writes an actual manifesto which I’ll try to summarize here — quoting liberally.

In the 1970s, Samuel Gorovitz and Alasdair MacIntyre published a short essay called “Toward a Theory of Medical Fallibility” where they looked at the different ways that doctors fail. They broke it down into two categories: ignorance (not knowing something) and ineptitude (not able to do something well that you knew how to do).

First, let’s look at ignorance:

I was struck by how greatly the balance of ignorance and ineptitude has shifted. For nearly all of history, people’s lives have been governed primarily by ignorance. This was nowhere more clear than with the illnesses that befell us. We knew little about what caused them or what could be done to remedy them. But 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.

Furthermore, if someone had a heart attack, we had little idea of how to treat it. We’d give some morphine for the pain, perhaps some oxygen, and put the patient on strict bed rest for weeks—patients weren’t even permitted to get up and go to the bathroom for fear of stressing their damaged hearts. Then everyone would pray and cross their fingers and hope the patient would make it out of the hospital to spend the rest of his or her life at home as a cardiac cripple.

But now we’ve conquered a good portion of ignorance — and greatly increasing the amount of ineptitude:

But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly. Just making the right treatment choice among the many options for a heart attack patient can be 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 have 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.

And this goes beyond medicine:

Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result, so has our struggle to deliver on them. You see it in the frequent mistakes authorities make when hurricanes or tornadoes or other disasters hit. You see it in the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screw ups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge.

Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. What do you mean half of heart attack patients don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors? It is not for nothing that the philosophers gave these failures so unmerciful a name —ineptitude. Those on the receiving end use other words, like negligence or even heartlessness….

The capability of individuals is not proving to be our primary difficulty, whether in medicine or elsewhere. Far from it. Training in most fields is longer and more intense than ever. People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own—whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves. It is not clear how we could produce substantially more expertise than we already have. Yet our failures remain frequent. They persist despite remarkable individual ability.

And then we get to the manifesto itself:

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things.

Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.

It is a checklist.

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