Book Review | Atul Gawande's Checklist Manifesto

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Got around to reading Atul Gawande’s Checklist Manifesto a full 3 years after reading an excerpt from his book in the New Yorker and finished it yesternight in a few hours.

Gawande starts the book by stating right away why in spite of all the vast knowledge we have at our disposal we fail at what we set out to do in the world. He says there are 2 reasons: Ignorance (We only have a partial understanding of how things work), and Ineptitude (We have the knowledge yet fail to apply it correctly). He makes a strong case for the checklist and how it could address both these situations of human fallibility. 

He digs into the history of the checklist in the aviation industry, how in 2001 Dr Pronovost at the John Hopkins medical centre borrowed this concept to attack the problem of infections in the central lines. Gawande then looks at how skyscrapers are built and surprise! They have checklists too. Well, not exactly checklists with boxes against them to tick mark but detailed plans and procedures and processes. Project Management 101, anyone?

One chapter in the book also focuses on decentralisation of power and the requirement for a seemingly contradictory mix of freedom and expectation. In this chapter, he focuses Hurricane Katrina and its devastating effect in New Orleans, how the government responded and the response from Walmart. 

The federal government wouldn’t yield the power to the state government. The state government wouldn’t give it to the local government. And no one would give it to people in the private sector.

Walmart’s CEO on the other hand gave out simple instructions: “Make the best decision that you can with the information that’s available to you at the time, and above all, do the right thing.” This meant Walmart store managers acting on their own authority were able to respond quickly, sometimes even before the government appeared on the scene.

The most simplest takeaway from this tale could be: The private sector is better than the public sector in handling complex situations. However, Gawande emphasises that this is not the intention - where government got mired in bureaucracy (processes, procedures, step-by-step instructions aka checklists) and overwhelmed by the decisions that had to be made, Walmart was able to push power away in a decentralised manner and enable and empower people on the ground through a system of co-ordination, communication and co-operation. In a circuitous manner, that is exactly what checklists should enable. 

The book’s emphasis on the need for checklists and how checklists are a great way to make teams work together (amply illustrated through the book through many incidents from the aviation and medical industry) reminds me of 2 instances that happened in Mangalore.

One, the Air India Express plane crash on May 22, 2010. Both pilots had been aware of the wrong flight path since they were both heard saying “Flight is taking wrong path and wrong side”, while the aircraft’s instruments had given repeated warnings of this. Seconds before the crash, the co-pilot had advised the Captain thus: “Go around Captain.” Probably, the co-pilot was asking his captain to abort landing. But it was too late. 

Two, my friend’s uncle Ashok who met a tragic end due to some grave negligence on the part of the doctors and the hospital. There were 2 patients that day in the hospital both with similar names but different ailments. Mistaking one for the other, the doctors conducted the wrong surgery on the wrong side on the wrong patient. Uncle Ashok died of complications a few days later. 

In the first case, did the Captain not pay attention to the co-pilot because of rigid hierarchical structures? In the second incident, the negligence and seeming incompetence of the medicos is hard to stomach. Would mandating that everyone in the OR follow a checklist have not led to the mishap? In the book, Gawande talks of a surgery checklist that is further divided into 3 parts - pre-op, during op and post-op. This includes everything from the obvious to the easy to miss: Everyone in the OR should introduce themselves, confirm which side of the body they’re working on, etc.

At one point, Gawande careens into Malcom Gladwell territory. He has chanced upon this brilliant tool called Checklists and he’s now going to make  these checklists work for every situation and mould every situation to have a checklist. After the aviation checklists and  skyscraper checklists and medical checklists, there is much talk of checklists for WHO and checklists for VCs and fund managers. Soon, there will be a checklist for checklists.

Software companies have detailed test cases - these can be looked at as checklists, manufacturing companies have quality testing protocols - again checklists. Essentially what Gawande is implying but doesn’t talk about in as many words is the need for well-defined processes and procedures, and in some cases institutionalisation of these processes. Used right and tactfully, checklists can be the checks and balances in system. Or they could go the way of the bureaucracy: the reason red-tapeism exists.