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Q&A with Dr. Atul Gawande author of The Checklist Manifesto (Part I)

July 1, 2011
Dr. Atul Gawande

The complexity of knowledge  in modern life has exceeded our ability to deliver on it correctly and safely. Earlier this year, Linkage sat down with Dr. Atul Gawande and discussed how a solution as simple as a checklist can help streamline many complex situations.

 Linkage: Please explain how the checklist manifesto can help leaders lead more effectively?

Dr. Atul Gawande: One interesting basic concepts is that leaders understand that building teams, and not just successful individuals, is more and more what we have to do to cope with complexity. 

Teams often accept a 95-96 percent success rate and that is just not good enough when you have to make 20 different things work well.  A 5 percent failure rate at any one of those points along the way or even a 1 percent failure rate is enough to doom your costs, your processes and, when you’re responsible for people, to hurt people.

The difference between even a 99 percent success and a 99.9 percent success in medicine is the difference between being at the top of the Bell Curve and being only mediocre.  In delivering packages–FedEx figured this out– they could not have failure rates, except down at the Six Sigma level, and enumerating where those failures and defects really were, was a starting point.

The second part for leadership is then recognizing that accomplishing success against those failures is not as difficult as we imagine it to be, that it can be as simple as just asking that people design checks for themselves that can make things work.  And there’s a certain incredulity that this can be powerful.  But over and over again, we see that dumb mistakes are the most common ones.

Can you talk about specific industries or companies where checklists really have been applied effectively?

As amazing as the aviation world is, I have to say the most amazing to me has really been in skyscraper construction.  In skyscraper construction, people are dealing with constantly evolving technologies and huge numbers of contractors from a variety of different technical expertise areas.  They are specialists.

I visited a skyscraper that was being built in downtown Boston and it was going to be over 30-stories high.  It was up to the 14th floor the day I visited and they had 500 workers onsite from 60 different subcontractors.  I imagine it would to be like having a patient who had 500 different people involved from 60 different specialists.  How do they work in the right way at the right time?

Up to 1920, building buildings was done by what they called a master builder.  The master builder would know everything, would do the architecture, would do the engineering and then would do the contracting and oversee it all from start to finish.  That was how St. Peter’s Basilica was built.  That was how the U.S. Capitol was built.

But when they started making skyscrapers, they found that it was more knowledge than one person could ever hold in their head.  They just couldn’t keep up.  And by the end of the 1920s, the master builder was dead and gone.  Instead, it was separated into architecture and engineering and contracting and now into subspecialties in all of these areas.

And then, the failures began to come from them not working together and they created checklists.  On that day I visited, they had their day of checks on the wall, that, you know, the steel girders would arrive and the crane would not arrive to put the steel girders up until the delivery had been there.  And they had the checks in place to make sure one thing happened before the other.

But the other thing was they had a second set of checks, because they recognized that their processes were so complex that they were bound to have failures that they did not anticipate, and that was a set of communications checks that they had, just making sure that the structural engineer got together with the elevator engineer and met at a certain point along the way, because they just knew there were going to be failures and they wanted them to solve them quickly and efficiently.

The building of skyscrapers now takes a third of the time that it used to take in the 1970s.  They have automated these processes of having the checks in place in such a sophisticated manner that it has transformed the whole industry.

And, I think, we’re only beginning to learn some of what they’re accomplishing and applying it in some other fields.

Do you think there is an opportunity to use checklists for just addressing issues such as managing chronic conditions as well?

Yes.  So, one of the things that came out of nuclear power was that when they ran control rooms that just had a simple checklist that was on paper, it did not work as well as when you had a team verbally go through a checklist.  It was like a hundred times more effective when you had people talk to one another to go through a check than it was if you just asked someone to do a bunch of tick boxes on a piece of paper.

And in the care of chronically ill patients or anything that’s outside of the hospital or emergency room, it’s often just the doctor on their own.

We’re now trying this.  We are designing a checklist in a project for patients with terminal cancer.  And part of what we’re learning we have to do is actually engage the patient in the checklist, that the patient and the doctor together hold the checklist and go through it together as a team and that makes it much more likely than counting on the doctor to do the tick boxes.

I think we have to be creative in our environments where there are places that it’s just one person on their own.  Some industries have turned to using a cell phone check-in, where you just call in a cell phone to run a checklist over the phone with a supervisor at a certain pause point along the way and that allows them to give a lot of autonomy to the person at the frontline.  You do what you’re going to do out there today, but call me at 3:00 and we’ll just run a series of checks to make sure that the basics are taken care of.

And I think we could apply some of these ideas in health care and, certainly, it can be taken to other fields as well.

We have another question come to us from a viewer at  Could you expand on the elements of how to create a checklist?  Where do you get started?

It really comes out of a sense of understanding, first of all, where your failures are and then you have a couple of choices as you enumerate.  You know that, you know, there are certain things that are not happening that ought to be happening.  And then, it’s being creative about why.

If you understand it’s because people are either forgetting things or didn’t understand, necessarily remember or understand what the best practices are under those situations, you then have to identify how you can intervene in that moment.  You have to really be there at the frontline to see what their work is like.

There are two kinds of checklists and I talk about it in the book.  There’s what’s called the “Do-Confirm Checklist” and the “Read‑Do Checklist”.

Do-confirm means that you have one person or often it’s a group of people who do their own thing, but then get together to make a check at a certain point to confirm that they really did what they had set out to do.

And the Read-Do Checklist is something that you read it and do it line by line.  In an airplane crisis with the engines going out and you’re trying to restart the engines, it’s read-do.  Read this, do this.  Read this, do this.

Whereas, in certain kinds of other situations, perhaps, you know, in the course of a day in a Starbucks, it may be a series of things that are really much more like a Do-confirm.  You’re giving them autonomy to do the things they ought to be able to do.  They can train, they understand, but then a confirmatory step at certain points along the way, halfway through a day or something like that. 

You have mentioned in your discussions the idea that checklists are there more for us to avoid failure than to actually pressure on a win.

They’re built around failure, it’s true, and it can sound really negative to try and do that.  It’s making the most out of your failures.

But part of the interesting thing is that achieving the win, achieving that top-flight success is about getting from 99 percent success to 99.95 percent success or 99.99 percent success and that’s squeezing out those last little bits of failure.  But often what that means is making a team that can feel like they’re really clicking on all gears, that they’re really able to all execute and that comes from the communication.

And I see this in my operating room.  Part of the interesting thing is we’re going through our checks, but we’re also very swiftly – it’s like a huddle before a game in football – well, a huddle before a play in football.  We all end up on the same page.  We know what we each other are doing and we really start to feel like a pit crew and it ends up being more fun.  We feel more powerful and more effective in what we’re doing.  And people start wanting to work with me.  It changes who selects to come into my operating room.  It’s a very interesting process.

So, it’s not just drumming out the negative, the failures.  It’s reaching for this kind of concept of being just a well-oiled machine.

A practicing surgeon and an accomplished writer, teacher and speaker, Dr. Atul Gawande is number five in the thinkers category for the 2010 TIME 100, . He was also chosen for the Foreign Policy’s Top 100 Global Thinkers 2010. He received the MacArthur Fellowship, popularly known as the “genius prize,” for his writing and his efforts to improve surgical practice. Atul is the author of three bestselling books on medicine, culture and human experience. He is the Research Director for the BWH Center for Surgery and Public Health, a practicing surgeon, and a staff writer for The New Yorker magazine. 

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