Who doesn’t like making a list, even a simple one, to get organized? In this American bestseller, author Atul Gawande shows how a simple task, such as crafting a checklist, can save money and time and avoid mistakes. Modern life and technology have brought us innovative solutions, but we are still subject to human failures in various work and personal situations. Air crashes, bad investments that lead to financial ruin and wrong medical diagnoses, for example. We are all vulnerable to failure. In this book, the author proposes to use checklists to reduce the probability of these failures in our lives and work, and he shows us how it is simple and direct. If you want to learn how to optimize your tasks and avoid common and unnecessary mistakes, then read this book with us!
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Increased World’s Complexity
Modern medical care is an excellent example of how professional areas of specialty have developed with the information revolution. Doctors are now educated and experienced in their fields of expertise, but increased specialization has many consequences.
Professionals are getting so busy in their areas of competence that some basic and preventable problems are happening.
Medical care in the 21st century is impressive. Lives of patients who a few years ago would have faced certain death are now saved every day. For all this advancement, however, a surprising number of patients are still dying because of human error.
The World Health Organization estimates there are more than 13,000 different diseases, syndromes, and injuries. For almost all of them, science provides a means of helping – either by curing disease or by reducing the evil and misery involved.
The problem is that for each situation, treatment can change. Doctors have about 6,000 remedies and about 4,000 medical and surgical procedures from which to choose. This number is too high for anyone, even for someone trained.
The Development Of Specialization In Medicine
Specialty areas were further divided and focused into subspecialties. For example, there were once anesthesiologists in charge of pain control and patient stability during operations. Today there are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists and many others.
In the early 20th century, you could receive a license to practice medicine if you had a high school diploma and a one-year medical degree. By the end of the 20th century, to become a doctor, you needed a college degree, a four-year medical degree, and an additional residency training in one area of practice – such as pediatrics, surgery, neurology, among others. Nowadays, even this level of preparation may be inadequate.
Most doctors also do other programs that involve additional training of one or two years. Doctors do not begin to practice independently until they are in their mid-thirties or more.
Checklists Help In a Complex Environment
Many industries nowadays have increased in complexity similar to the medical sector. Much of what designers, financial managers, firefighters, police officers and doctors do now is too complex to be solved only with memory. The solution is to integrate the more systematic use of checklists in daily operations.
In a complex environment, experts have to deal with two major difficulties:
- Human memory can fail in dire situations or under pressure. When you are making a cake, for example, you may be distracted by a phone call and forget to add an essential ingredient. When you have a vomiting patient and a family member wondering what is going on, you may forget to check the patient’s pulse.
- It’s also easy to forget a few steps because most of the time they will not be critical. You may think that for the last 50 patients you saw, measuring their vital signs was not important. Not checking the pulse may work very well until one day a problem could have been avoided in time if you had performed this routine procedure.
Checklists protect against these two scenarios. By making the minimum steps necessary to be explicit and verified, you encourage discipline that can increase your performance levels. They ensure professionals apply their knowledge and expertise in the right way.
Most assume that checklists only work in repetitive and routine situations, but this is not true. Consider the example of what happened when Hurricane Katrina hit New Orleans on August 29, 2005. Within a few hours, the city’s phone lines, cell and power towers fell, making communication very difficult. At the same time, the levees that protected the city ruptured.
A FEMA (Federal Emergency Management Agency) agent got on a helicopter and flew over New Orleans and reported the flooding. He witnessed several residents trapped on rooftops and many bodies floating in the water. He filled out an urgent report by email because all other means of communication didn’t work.
The only problem with that was that the top FEMA officials did not use e-mail, so they did not know about the emergency until they saw TV images the next day. By then, 80% of the city was flooded. For days, the federal, state and local governments debated who should react, while the situation continued to deteriorate.
In contrast, Wal-Mart had 126 stores closed in the New Orleans region. CEO Lee Scott told everyone: “This company will respond to this disaster. Many of you will need to make decisions above the level. Make the best decision you can with the information that is available, and most importantly do the right thing. “Within 48 hours, 20,000 Wal-Mart employees and their families had been accounted for, and the company’s priority became to find out what it could do to help the people of New Orleans.
Acting alone, Wal-Mart managers began distributing diapers, water, and ice to residents affected by the flood.
Wal-Mart organized an emergency response team, which also included a member of the Red Cross and within two days they took trucks with food, water, and emergency equipment to New Orleans. Officials set up mobile pharmacies that provided free medicines. In the end, Wal-Mart sent New Orleans 2,498 trucks with emergency supplies and donated more than $ 3.5 million worth of goods to shelters and command centers.
The moral of this story is not the idea that the private sector is better than the public sector in dealing with complex situations. Many businesses in New Orleans were unprepared to deal with the situation, and the local police and firefighters did an incredible job serving the communities.
The real lesson was that, under highly complex situations, a centralized decision chain does not work very well. Instead, you have better results by planning what needs to happen in a simple checklist, and then giving individuals the freedom to act and adapt, while following specified guidelines.
Lists work very well in complex situations because they strike a balance between different virtues. Lists help us achieve a balance by providing a set of checks to ensure that essential and critical things have are not ignored while also ensuring that people work to achieve shared goals. Another good feature about checklists is that they can be used to coordinate the activities of different teams quickly and concisely.
Checklists In Medicine
Checklists may seem like a simple concept in a complex world, but they obviously work. Good lists take the obvious routine tasks out of your mind so that you can focus on the difficult things. They may work in all industries – and will work even better in the future, with increasing complexity of things.
In 2001, Peter Pronovost, an intensive care specialist at John Hopkins Hospital, was frustrated with the incidence of central line infection in intensive care. He created a simple checklist of the steps that needed to be taken to prevent infection.
As simple as the steps look, the ICU nurses noted that doctors were often in such a hurry that they ignored a step or two. With this information, Pronovost persuaded the hospital administration to allow nurses to prevent doctors from putting central lines if they ignored a checklist step.
The nurses were also encouraged to ask doctors every day if they could remove the patients’ lines, so they would not stay longer than necessary.
This step reduced the likelihood of untreated pain from 41% to 3%. Pronovost was described as a “genius” by his colleagues because he had the idea of integrating a task list or a checklist into the daily routine of everyone working in the ICU.
Still, as he began touring the country to show his checklists to doctors, nurses, and administrators, few showed an interest in adopting the idea. Doctors were offended by the idea of using a list at work, and the idea of filling in another document seemed problematic to them.
Finally, in 2003, the hospital administration approached Pronovost to test checklists at the ICU’s in the state of Michigan. They agreed to give hospitals a small financial bonus to participate in the program. Each hospital had a project manager and a senior executive to run the program. They also persuaded Arrow International, one of the largest manufacturers of centerlines, to produce a new centerline kit with surgery drapes and antiseptic soap.
Checklists In Aviation And The Financial Market
For experts using checklists, their efficiency can be seen in commercial aviation. The current generation of commercial pilots carries pocket guides that have numerous checklists. They include “standard” checklists for daily airline operations and unusual checklists that cover every emergency situation imaginable. There are hundreds of checklists in each pilot’s pocket guide.
On January 17, 2008, while a British Airways flight was approaching London after 11 hours of travel, both engines failed at 200 meters high and about 3 kilometers away from the airport. As the plane landed, the wheels collapsed and the main landing gear was ripped out and into the passenger compartment. This malfunction caused more than 1400 liters of gas to flow, but fortunately, there was no explosion, and the 152 passengers and crew were able to land safely.
Investigators scanned the entire plane to try to determine what caused the crash. They removed the engines, the fuel system, and dismantled the plane piece by piece.
They found no engine defects, no fuel line obstruction, no tank debris, and no problem with valves or fuel delivery systems. The fuel tests also found no anomalies or obvious faults. Finally, after months of investigation, they developed a theory that the path followed by the plane could have caused the crash.
Although this explanation seemed uncertain, eight months after the accident, it was all that the investigators were able to deduce. They suggested that some maneuvers during flight could have avoided the problem.
Whenever an engine loses power, the pilot’s first instinct is to accelerate further to increase momentum. If there are ice crystals in the fuel line, speeding up the engine will only make the situation worse. The researchers determined that if the pilots had left the engine idle for a while, the fuel flow would have been reduced, and the internal heat of the plane would have melted the ice in a few seconds, allowing the engine to recover.
In September 2008, the Federal Aviation Administration issued a detailed document on the new procedures to be followed by pilots to prevent ice from accumulating in polar flights and recovery in case of engine failure freeze. They required pilots to learn this document and incorporate teaching into their flight instructions.
Within two weeks, Boeing broke this document down into modifications to create checklists for use by pilots around the world.
All airlines have started using Boeing’s checklist. Consequently, all companies have adopted the new procedures within 30 days. This adaptation was possible thanks to the availability of checklists, which turned the document into action and steps to follow.
Checklists may seem attractive to commercial aviation and medicine, but the business world is too complex for checklists, right?
Well, consider the world of finance, where investors are under pressure to buy stocks.
The problem happens when you are trying to buy stock in a company. Getting into a liberal mindset is easy. You get to focus on the money you will earn rather than doing a systematic review that is very important. It is much more fun to think about the Ferrari you are going to buy with your profits than to consider the financial reports, or do the risk analysis, or analyze the prospects report of the industry.
Even the most successful investor, Warren Buffet, and his investment partner Charles Munger, still make mistakes when investing. However, some investors are improving their performance by developing checklists that need to be done before investing. A pre-investment checklist is excellent because it forces you to be more systematic and not get carried away by the enthusiasm and heat of the moment.
What kind of items would be in an investment checklist? An investor has developed his list analyzing every investment Warren Buffet has made. His checklist includes items like:
- Have you examined the financial statements of the last ten years of the company?
- Did you investigate all the risks and liabilities of the company?
- Have you examined the history of the team of managers?
- Do you know the competitors of the company?
- Have you considered the future of the market in which this company does business?
- Have you noticed whether employees are selling their shares?
- Have you read all the footnotes in the financial statement?
- Have you analyzed whether cash flow and costs match the reported data?
Using these checklists, savvy investors have discovered that they approach their investment activities more efficiently and successfully. The checklist approach to investing helped them achieve amazing results.
Developing Solutions With Checklists
In January 2007, the World Health Organization held a two-day meeting at its Geneva headquarters in Switzerland to consider how to reduce the complications of more than 230 million operations conducted worldwide each year.
Instead of publishing a WHO Report with official standards for surgical care, they decided to develop a safe surgery checklist. After a few years, they agreed on a list of 19 steps:
- Seven checks before anesthesia – confirming patient identity, consent, marking the surgical site, checking for allergies and availability of blood and equipment.
- Seven checks after anesthesia and before the incision – checking that all team members know everyone, checking that they have the right patient and correct procedure, checking that antibiotics have administered, that radiology images are available and that everyone knows which will happen during the operation.
- Five final tests before the patient leaves the room – if all sponges and instruments are present, plans and concerns for patient recovery.
This safe surgery checklist was then used in eight hospitals around the world, beginning in spring 2008. The results of this pilot study were released in October 2008:
- Major surgery complications at all eight hospitals fell 36% after the introduction of the checklist.
- Deaths fell by 47%. From 435 to only 277.
- Infections fell almost by half.
When the results of the study were published in January 2009, many became interested. More than 12 countries have publicly committed to implementing versions of the Safe Surgery Checklist in their hospitals.
Still, by the end of 2009, only 10% of all US hospitals adopted the checklist or did anything about it. The constant resistance to adopting a life-saving method proves that it’s hard for some professions to accept the use of checklists.
It is notable that in recent years systems have become increasingly complex and it is likely that this trend will not stop. Increasing complexity is a current tendency in markets. With this increase in complexity, it is difficult for the human being to memorize without fail all the paths and possibilities that he or she needs to follow in daily tasks.
That’s why checklists work as a way to help professionals in a variety of areas, or even people’s personal lives, contributing to reducing mistakes.
No matter what market you work in, checklists work very well on routine tasks and even on unexpected tasks. Start writing checklists right now and do your homework with much more success!