Make a List. Check It Twice

The Checklist Manifesto:
How to Get Things Right
By Dr. Atul Gawande
Metropolitan Books; 209 pp; $24.50

Dr. Atul Gawande, a surgeon and New Yorker writer, had a huge impact on the health-care reform debate last summer when he wrote about wide regional disparities in Medicare spending. The article focused on McAllen, Tex., one of the country's priciest health-care markets. Gawande's conclusion—that doctors in McAllen charge more not because their patients are sicker or their care is better but simply because they can—caught the attention of reform forces across the nation. President Barack Obama had his entire staff read it.

Gawande may end up wielding influence again with his new book The Checklist Manifesto: How to Get Things Right. He starts the book by explaining how a simple five-item checklist in the operating room can dramatically reduce hospital-acquired infections, which kill 99,000 Americans a year.

But the scope of the book goes well beyond medicine. With The Checklist Manifesto, Gawande has entered Gladwell-land. Fellow New Yorker writer Malcolm Gladwell has produced three best sellers—The Tipping Point, Blink, and Outliers—by stacking up detailed, seemingly unrelated anecdotes to bolster a larger, universal thesis. Gawande follows the same blueprint, examining all manner of disparate tasks, from flying a plane to building a skyscraper, to show how checklists can improve outcomes. Read this book and you might find yourself making checklists for the most mundane tasks—and be better off for it.

Gawande tells scarifying stories about the things that go wrong in operating rooms. Despite all the training and high-tech tools, doctors can forget the most basic steps, and chaos ensues. That's just as true in a range of other fields, from finance to government. "The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably," writes Gawande. Unless, of course, we use checklists.

Gawande proves his point through a steady accretion of examples, starting with the Boeing (BA) B-17. In 1935 the bomber crashed on its first test flight because it proved too complex for the skilled test pilot to manage. The U.S. Army Air Corp ordered planes from Douglas instead, and Boeing nearly went bankrupt. But some test pilots believed in the B-17. They came up with a takeoff checklist to guide a pilot through all the crucial steps to get the plane airborne. Checklists in hand, pilots went on to fly the B-17 for more than 1.8 million miles without an accident. The army ultimately ordered 13,000 B-17s, giving the U.S. a decisive air advantage in World War II. And pilot checklists became universal.

Dr. Peter Pronovost, a critical care specialist at Johns Hopkins, devised his own operating room checklist in 2001. On a plain sheet of paper he wrote out five steps doctors and nurses in the OR should follow, all "no-brainers," as Gawande puts it: Wash your hands with soap, sterilize the patient's skin, put sterile drapes over the entire patient, wear a mask, gown, and gloves, and put a sterile dressing over incisions. Within a year the rate of infections related to IV tubes at the hospital went from 11% to zero. Only two such infections occurred over the next 15 months. Michigan instituted Pronovost's five steps in every hospital in the state, and within three months infections related to IV tube insertions dropped 66%.

It's not always so easy. Gawande tells of his own efforts to set up a similar but expanded checklist at his hospital, Brigham & Women's in Boston. Turns out his first effort was far too complex and had to be abandoned within hours. It took many more tries, and lots of research, to get it right.

Once you nail them, however, checklists can create heroes, Gawande claims. For proof he gives us US Airways (LCC) Flight 1549, which famously landed on the Hudson River in January 2009 after hitting a flock of geese near New York's LaGuardia airport. Captain Chesley B. Sullenberger III has been hailed worldwide for the seemingly miraculous landing. But Gawande shows that Sullenberger and his co-pilot followed a detailed emergency checklist that multiplied his chances of pulling it off. The experienced crew recognized that it required teamwork, preparation, and discipline to bring the plane down safely. "This is what it means to be a hero in the modern era," says Gawande.

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