40 pages • 1 hour read
Atul GawandeThe Checklist Manifesto: How to Get Things Right
Nonfiction | Book | Adult | Published in 2009A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Chapters 6-7Chapter Summaries & Analyses
Chapter 6 Summary: “The Checklist Factory”
After the recent failure of the checklist developed at Geneva, Gawande decides to learn more about the airline industry’s checklists. He visits Dan Boorman, a veteran pilot and the man in charge of developing aerospace manufacturer Boeing’s flight manuals. Gawande discovers that in the 200-page manual, only a few pages are dedicated to routine procedures. The remaining pages involve scenarios that have happened, and what one should do in the event of the unexpected. As a case study, Gawande examines a 1989 flight from Hawaii to New Zealand in which the cargo door was not latched properly. He explains the catastrophe that followed, including the nine people who were sucked out of the plane. In the end, the pilots were able to land the plane fast enough to save the other passengers. Boorman has made a profession of studying such disasters, the mistakes that cause them, and the ways in which pilots and attendants can respond if they ever find themselves in similar situations.
Boorman articulates the differences between good and bad checklists. Good checklists are clear and precise, without colors and other distractions. They are practical, guiding pilots through a crisis rather than replacing their own instincts. Gawande is given an opportunity to operate a flight simulator with Boorman’s assistance. In the simulator, Gawande is able to get a virtual experience of how a pilot’s checklist works in a typical flight. There is a hard copy at the ready, and an electronic version that appears on a screen. Gawande follows directions and is able to get the virtual plane to lift off. Once airborne, the simulator presents the cargo door problem (that of the 1989 flight from Hawaii to New Zealand) and again, a checklist appears. Gawande follows directions and is able to safely remove the plane from danger.
Gawande presents one more aviation-based case study. He details a 2008 British Airways flight that experienced engine failure just miles from London’s Heathrow airport. The landing was somewhat violent, but all crew and passengers survived. Investigators were initially perplexed, but ultimately concluded that the plane’s fuel lines had been blocked by ice crystals, due to the cold temperature at the time. After the investigation, the recommendation to idle rather than accelerate planes was added to flight manuals worldwide. Gawande marvels at the speed at which this recommendation was instituted, and again describes how Boorman distilled all urgent, pertinent information into a list. Chapter 6 concludes with Gawande describing a flight from Shanghai to Atlanta where the same fuel line problem happened again. Pilots followed their checklists and averted potential disaster without passengers even realizing what happened.
Chapter 7 Summary: “The Test”
Back in Boston, Gawande resumes his work developing a safe surgery checklist. Having learned from Boorman, Gawande decides his checklist should be a Do-Confirm-style checklist (completing a task, then checking one’s work) rather than a Read-Do-style checklist (reading and completing steps as one progresses in a task), because a Do-Confirm checklist offers more flexibility and is better situated for complex environments like the operating room. Gawande and his team devise a simulator, which he concedes is not particularly advanced. The team then simulates an operation with an assistant who serves as the patient. Everything is hypothetical, but the team discovers relevant findings while using the checklist—ranging from determining who has the authority to enforce a pause and read the checklist to properly accounting for the items on the list. Gawande also realized that the checklist needed a taxonomy, and there was much disagreement as to what was essential and what wasn’t. At a second WHO conference in London, people working on the safe surgery checklists questioned if checks should be installed to prevent operating room fires. Ultimately, they decided against this check and stuck to the essentials of surgery. The original checklist was designed to address the most common complications in surgery (application and failure of anesthesia, blood loss, and infection) and back-up plans. As the list was refined and finalized, it included 19 checks that were to be given at three specific times: prior to the application of anesthesia, prior to incision, and post-operation but prior to the patient being removed from the operating room.
With the checklist finalized, Gawande and his team, at the behest of the WHO, chose eight hospitals in various countries—including four affluent countries and four countries where poverty and minimal resources were the norm. Prior to implementing the checklist initiative, Gawande and his team researched current practices in the operating rooms of these eight hospitals, and their rates of complications (six to twenty-one percent). To Gawande’s surprise, upon perusing the hospitals’ records, two-thirds of them had missed at least one basic step before, during, or after surgery. This established a baseline from which Gawande and his team could determine if the checklist made a difference. Gawande then recounts his travels to the eight hospitals, from the United States to Tanzania. He observed the dire conditions of the hospital in Tanzania, and also saw how surgical procedures were both similar to and different from those of the United States. But no matter a hospital’s location, the purpose of surgery was, and still is, to provide relief.
Gawande returned home and after three months, the results of his research arrived. At first, he was skeptical because the results showed dramatic reductions in surgical complications, particularly those resulting from infection; deaths from surgical complications fell by 47%. Gawande once again posits that the checklist itself was not the sole cause of improvement—rather, the checklists fostered a more cohesive, team-oriented mindset.
Chapters 6-7 Analysis
For much of Chapter 6, Gawande visits Dan Boorman at the Boeing facility in Seattle, Washington—hence the title of the chapter, “The Checklist Factory.” As Gawande recounts their conversation, it becomes apparent that Boorman is a checklist expert. Boorman details the characteristics of bad and good checklists: “Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical […] They treat the people using the tools as dumb and try to spell out every single step” (120). The purpose of a checklist is not to take away from the expertise of those who adhere to them, but to guide and illustrate users. Gawande believes this misconception is what elicits reluctance and resistance to checklists in the first place. According to Boorman, “Good checklists…are precise. They are efficient, to the point, and easy to use even in the most difficult situations. […] they provide reminders of only the most critical and important steps” (120). The best checklists have limitations, so as to not distract users with extraneous information. Boorman also describes two styles of checklist: the Do-Confirm and the Read-Do. When adhering to Do-Confirm checklists, “team members perform their jobs from memory and experience […] They [then] pause to run the checklist and confirm that everything that was supposed to be done was done” (122). When adhering to Read-Do checklists, “people carry out the tasks as they check them off—it’s more like a recipe” (122). The two styles’ key difference is timing, something Gawande hadn’t considered prior to his own research.
Informed by Boorman and his own experience in a flight simulator, Gawande is finally able to implement his first checklist. He creates a simulation of an operation and realizes the checklist needs work: “An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use” (137). This conclusion brings him back to the drawing board, as The Applicability of Checklists in real-world scenarios is often complicated by the unexpected, the unknown. As Gawande hones his checklist, which involves collaborating with other surgeons to determine the essential components of a safe surgery, one can never be certain of how a checklist will function in a real operation. Like Boorman, Gawande must observe his checklists in use, so modifications can be made should the need arise. Gawande charged participating hospitals with the modified checklist, and beneficial results were immediate: “Using the checklist had spared more than 150 people from harm—and 27 of them from death” (154). Despite the success, Gawande does not become complacent and continues to find ways to create more efficient, effective checklists.
Related Titles
By Atul Gawande
