The Checklist Manifesto
By Atul Gawande,
Metropolitan Books, 209 pages, $29.50
On Oct. 30, 1935, Boeing Corp. unveiled its new aluminum-alloy Model 299 bomber, which seemed the odds-on favourite to win a U.S. Army flight competition for the right to build the next-generation long-range bomber. It could carry five times as many bombs as the army had requested, and fly faster than any previous bomber and twice as far.
But the plane was complicated - "too much airplane for one man to fly," as a newspaper put it when the test flight crashed due to pilot error and two of the crew members perished. Douglas Aircraft Co. won the competition instead, although a few of Boeing's models were purchased as test planes, leading a group of pilots to meet to figure out how to make the plane safer. They decided the solution was not, as might be expected, more training but, instead, a simple checklist that pilots would follow before takeoff to eliminate error.
"Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of a garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert," writes Atul Gawande, a surgeon and staff writer at The New Yorker, in The Checklist Manifesto.
It worked. The pilots went on to fly the Model 299 a total of 1.8 million miles without an accident, the army eventually ordered 13,000 of the bombers, which became known as the B-17, and it provided a crucial air advantage in the Second World War.
As with the B-17, much of our work these days has hit a level of complexity where memory is insufficient. Whether it's surgeons like Dr. Gawande and their operating teams, software designers, financial managers, firefighters, police officers, construction managers or lawyers preparing a case, all face a series of steps that are required for success. If one is forgotten, they could crash and burn.
Indeed, at the start of this month, a surgical checklist became mandatory in every operation in Ontario, which traces back in part to a World Health Organization (WHO) committee under Dr. Gawande's chairmanship that found significant benefits from checklists.
But Dr. Gawande notes in the book that most of us believe our jobs are too complicated - or too important - to be reduced to a checklist. Besides, checklists are painstaking and not much fun. Although research shows that a checklist in a medical environment can save lives and for venture capitalists or investors boost the bottom line, we avoid them.
"There's something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow seems beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us - those we aspire to be - handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists," he writes.
But he immediately counters that widespread feeling with a story that suggests our idea of heroism needs updating. Again it's from aviation, but much more recent: the amazing landing of US Airways Flight 1549 on the Hudson River under the guidance of Captain Chesley B. (Sully) Sullenberger III, after the plane struck a flock of Canadian geese and lost both engines.
We initially assumed success resulted from Capt. Sullenberger's prowess as a glider pilot and his improvisational talent when the engines failed him. But Dr. Gawande goes through the logs to show how the pilot and co-pilot - who had never flown together - worked as a tight team after the crisis began, the co-pilot reading off the various points on the checklists established to handle such unusual occurrences. So the humble checklist played an important role - if not the crucial role - in guiding them through that episode.
Not all checklists, Dr. Gawande advises, are good. Some are vague and imprecise. They are too long and hard to use, with too many items to check, and thus impractical.
"They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat people using the tools as dumb and try to spell out every single step. They turn people's brains off rather than turn them on," he observes.
Good checklists are precise, but easy to use even in difficult situations. They don't try to spell everything out. A checklist, he notes, can't fly a plane. "Instead, they provide reminders of only the most critical and important steps - the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical," he explains. Good checklists also encourage co-operation. They nudge people to work together.
Much of the book is focused on checklists for surgery - including a detailed look at the development of the WHO checklist on safe surgical care - and he highlights the importance of teamwork in an operating room. A checklist ensures that nothing is forgotten in that pressured environment. As well, surgery has become specialized, so there are often many surgeons working together, along, of course, with nurses.
Simply including on the checklist the requirement that everybody introduce themselves before the operation seems to create an atmosphere of collaboration among the specialist physicians, and the nursing staff are also then more willing to point out to a surgeon when he or she is about to slip up. In construction, Dr. Gawande found that the checklists used for major buildings also include practices designed to ensure communication.
The subject and title of the book might suggest it's written in bullet form, like a checklist, but nothing could be further from the truth. In New Yorker style that readers of Malcolm Gladwell, in particular, will be familiar with, he makes all his points through stories. He gives you an evocative manifesto that will convince you of the importance of checklists in important routine processes - including your investments, by the way - but, ironically, he doesn't break from his writerly style even to provide you with a checklist of how to construct a checklist, which some of us might have enjoyed.
In Addition: Grant McCracken, a research affiliate at MIT who also taught at McGill University, believes companies need someone like him - a cultural anthropologist - to divine what is happening with all the dizzying trends swirling in the marketplace. In Chief Culture Officer (Basic Books, 262 pages, $33.95), he stresses that CEOs don't want "a charming survey of contemporary culture" from the new high-level executive he is proposing every company establish. But the book, unfortunately, is that: a charming - highly charming, actually - survey of contemporary culture that I suspect most executives would find a waste of time. And for understanding the marketplace, it may convince them that having a chief marketing officer, as is the current practice, is sufficient, if not preferable, to a culture wizard.
Just In: Two new books look at the strengths U.S. President Barack Obama brings to his position: Leadership The Barack Obama Way (McGraw-Hill, 273 pages, $30.95) by leadership development consultant Shel Leanne, and Inside Obama's Brain (Portfolio, 278 pages, $31), by freelance journalist Sasha Abramsky.
Leadership experts Marshall Goldsmith and John Baldoni and editor Sarah McArthur bring contributions from various authorities in The AMA Handbook Of Leadership (Amacom, 269 pages, $35.95).
Harvey Schachter