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"Getting the Steps Right is Hard"
on February 23, 2013
Atul Gawande is a physician interested in improving surgical practice. He reviews surgical cases with disastrous outcomes that could have been prevented and cites research claiming that nearly half of deaths that occur in surgery are in fact preventable. We read a detailed analysis of a drowning accident in which the young victim's life was saved against all odds. Why? Because the hospital staff had discussed and practiced the procedures to treat cold-water drowning ahead of time. They used no new knowledge; they just coordinated and communicated more effectively.
Gawande examines how human beings do things. There are two reasons we fail at complex tasks. The first is ignorance. We correct it by conducting research and building schools to increase our knowledge. The second and more common reason for failure is ineptitude--the right knowledge is available, but we do not apply it correctly. People continually forget, are distracted, or skip steps because they seem unimportant. This problem lurks below the radar; we don't recognize it, let alone try to solve it. Instead we send people off for more training to increase their knowledge.
What is needed instead is a simple way to remind people of what they know at the right time to make a difference. We have an answer, we just aren't using it. "Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification, but also instill a kind of discipline of higher performance."
The author examines checklists used by airline pilots, building contractors, investors and other physicians. In these professions work has become too complex for even a talented individual to perform alone. Teams of skilled experts must manage both communication and complexity to succeed. They do both with checklists. These checklists make people stop and think at "pause points" to ensure that the right things have been done. They get coworkers to bond as a team by requiring them to talk to each other. As a result, people become comfortable enough to speak up when they see a potential problem.
Chapter Six, The Checklist Factory is the instructional meat of the book, with recommendations that help us develop good checklists. There are direct guidelines about brevity and clarity. There are also process guidelines about identifying common mistakes and fine-tuning a checklist with field testing. He distinguishes between READ-DO checklists, which march novices through the tightly specified steps of rote tasks, and DO-CONFIRM checklists, which provide checkpoints for experienced professionals solving complex problems in coordinated groups. Both have their place, but DO-CONFIRM checklists have the most potential to make a difference.
There are barriers to checklist use. They have a serious user acceptance problem. Many accomplished professionals consider themselves virtuosos who don't need help from other people at all, let alone somebody else's checklist. To many others checklists seem too mundane to make a difference. The author works hard to persuade us. His own research on checklists in operating rooms finds significant drops in death rates, post-operative infections, and other outcome measures. He highlights successes at prominent hospitals to encourage wider acceptance, asks administrators to impose requirements, and calls on nurses to help change the culture of the operating room. The idea is slowly catching on.
Gawande wishes we would move more quickly. "In the money business everyone looks for an edge. If someone is doing well, people pounce like starved hyenas to find out how. Almost every idea for making even slightly more money ... gets sucked up by the giant maw almost instantly. Every idea, that is except one: checklists."
I learned some things from this book and highly recommend it. Give it at least a quick look, starting with Chapter 6. It has the potential to make you even better at what you do best.