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The Checklist Manifesto: How to Get Things Right Hardcover – December 22, 2009
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The New York Times bestselling author of Being Mortal and Complications reveals the surprising power of the ordinary checklist.
We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies―neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third.
In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds.
An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, The Checklist Manifesto is essential reading for anyone working to get things right.
Amazon Exclusive: Malcolm Gladwell Reviews The Checklist Manifesto
Malcolm Gladwell was named one of TIME magazine's 100 Most Influential People of 2005. He is most recently the author of What the Dog Saw (a collection of his writing from The New Yorker) as well as the New York Times bestsellers Outliers, The Tipping Point, and Blink. Read his exclusive Amazon guest review of The Checklist Manifesto:
Over the past decade, through his writing in The New Yorker magazine and his books Complications and Better, Atul Gawande has made a name for himself as a writer of exquisitely crafted meditations on the problems and challenges of modern medicine. His latest book, The Checklist Manifesto, begins on familiar ground, with his experiences as a surgeon. But before long it becomes clear that he is really interested in a problem that afflicts virtually every aspect of the modern world--and that is how professionals deal with the increasing complexity of their responsibilities. It has been years since I read a book so powerful and so thought-provoking.
Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don't know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it's just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists--literally--written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.
The danger, in a review as short as this, is that it makes Gawande’s book seem narrow in focus or prosaic in its conclusions. It is neither. Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious. Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help. --Malcolm Gladwell
From Publishers Weekly
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.
- Publisher : Metropolitan Books; First edition (December 22, 2009)
- Language : English
- Hardcover : 224 pages
- ISBN-10 : 0805091742
- ISBN-13 : 978-0805091748
- Item Weight : 11.2 ounces
- Dimensions : 5.6 x 1 x 8.2 inches
- Customer Reviews:
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Philosophers Samuel Gorovitz and Alasdair MacIntyre tackled the issue of why we fail at what we set out to do in the world. One reason, they explain is “necessary fallibility”, a consequence of some things in the world, and our lives, being beyond our understanding and control.
But there is much that is not, and yet we fail at these too. Gorovitz and MacIntyre suggest that there are two reasons for this: ignorance and ineptitude (incompetence or clumsiness.)
For most of human history, people’s lives have been lived largely in ignorance. However, over the last few decades, science has filled in enough knowledge to make our ‘ineptitude’ as much of a challenge as our ‘ignorance’ was in the past.
Gawande’s context is the ineptitude in medicine. While our knowledge and sophistication has grown enormously, the struggle is still how to deliver on this know-how.
The knowing-doing gap is found everywhere. From the frequent mistakes authorities make when disaster strikes, to the legal mistakes our lawyers make that are the result of little more than simple administrative errors.
“Every day there is more and more to manage and get right and learn,” Gawande points out. With all we are required to manage, failure happens far more often - despite great effort rather than from a lack of it.
Expertise has been seen as the solution to ineptitude in most areas of work – “they need more training!” and modern medicine has been no different. But capability clearly isn’t our primary difficulty; in most fields training is longer and more intense than ever. In the early twentieth century, you could practice medicine with only a high school diploma and a one-year medical degree. Today doctors have six years of university, and three to seven years of residency to practice paediatrics, surgery, neurology, or the like.
Yet our failures remain frequent, but there is a solution – checklists.
Though this seems almost ridiculous in its simplicity - especially to those of us who have spent years carefully developing ever more advanced skills - it has proven not to be.
In 1935 the US Army was looking for the next generation long-range bomber. Boeing’s aluminium-alloy Model 299 was able to carry five times as many bombs as the army had requested, and could fly faster and farther than previous bombers. The army planned to order at least 65 planes until it stalled on a test flight, turned on one wing, and exploded. The crash, attributed to ‘pilot error, killed 2 of the 5 crew members. This prompted Boeing to come up with an ingeniously simple approach: they created a pilot’s checklist. It is worth noting that using a checklist for takeoff was about as odd as using a checklist to back out of your garage.
However, flying this new plane was too complicated to be left to the memory of any person, no matter how expert. The test pilots made checklists for takeoff, flight, landing, and taxiing, and armed with the checklist, flew a total of 1.8 million miles without one accident. The army ultimately ordered almost 13,000 planes.
Like flying, many areas of our lives and work have become “too much airplane for one person to fly.”
Faulty memory and distraction are a constant danger in “all-or-none processes” like going to the shop to buy ingredients for a cake, piloting a plane through a takeoff, or treating a sick person in the hospital. “If you miss just one key thing, you might as well not have made the effort at all,” says Gawande.
Another human danger you may well recognize, is allowing yourself to skip steps even when you remember them. You skip steps because it has never been a problem before – until one day it is.
Checklists can provide protection against such lapses, as they remind us of the minimum necessary steps.
Professors Zimmerman and Glouberman distinguish between 3 different kinds of problems: the simple, the complicated, and the complex.
‘Simple problems’ are ones like baking a cake from a recipe with a few basic techniques you need to learn. Master them and you most likely will have success.
‘Complicated problems’ are like sending a rocket to the moon. There is no straightforward recipe, and success usually requires many people and great expertise. Unanticipated problems are common, and timing and coordination become serious concerns.
‘Complex problems’ are like raising a child. You can’t repeat and perfect the process as you can with rockets. Every child is unique, and while expertise is valuable, it is not sufficient. The outcome remains highly uncertain.
The value of checklists for simple problems is self-evident: that is why we have a shopping list. But much of the most critical work people do, is not simple. Checklists help prevent failure especially when the problems combine everything from the simple to the complex.
The real value of checklists is in conditions of true complexity, where the knowledge requirements exceed that of any individual, and unpredictability reigns. Commands and control from the centre will fail. Under these conditions, not only are checklists a help, they are essential for success. In these complex situations where individuals must exercise their own judgement, this judgement will be enhanced by checklist procedures.
Bad checklists are vague and imprecise, too long and hard to use. They are written as if the people using them are stupid, and they try to spell out every single step. Good checklists, are precise and begin with the premise that a checklist cannot fly a plane. That is why, faced with catastrophe, pilots are astonishingly willing to turn to their checklists.
Checklists come in two forms: DO-CONFIRM and READ-DO. Using a DO-CONFIRM checklist, people do jobs from memory and experience, then stop and check. Using a READ-DO checklist, people carry out the tasks as they check them off, like a recipe.
To get value from checklists, they must make sense for the particular situation. A rule-of-thumb is to keep it to between five and nine items, simply worded, and exact.
Does this work? This was rigorously tested in the World Health Organization’s ‘safe surgery’ research across a variety of hospitals of different sizes, rich and poor, in countries from Tanzania to the US. In this carefully constructed study, a 2-minute, 19 step surgery checklist, resulted in an immediate drop in infection and mortality in thousands of operations in 8 participating hospitals. Major complications dropped 36%, and deaths fell by 47%.
That is how much a checklist can add to the skills of highly trained, highly skilled surgeons. It is worth a serious try in your business. You will get startling results too.
Readability Light ---+- Serious
Insights High +---- Low
Practical High +---- Low
*Ian Mann of Gateways consults internationally on leadership and strategy, and is the author of the recently released Executive
Worth the read, especially from a lean manufacturing perspective.
One need not have a medical background as all his books are well written in everyday, easily understood language.
He uses real life stories to illustrate the critical point he is making. I didn't know about Walmart's heroic efforts to save lives during Katrina's horrific takeover of New Orleans. The CEO boldly communicated from the top down through every level of Walmart employees, telling them they would be called on to make decisions far beyond their usual jobs. "Just do the right thing; take care of people."
The communication, the feeling of esprit de corps led to in one instance to a female employee mounting a bulldozer and driving through a water laden store picking
up every useful item that wasn't soaked. After delivering items to people needing help outside the store, she turned around with her dozer and went back in for another load.
Kudos to Walmart for demonstrating the power of communication, the results of building a united team and then
giving authority to members of the team.
This particular book is a fine example of how checklists work not only in medicine but across other professions as well. His stories of how buildings are built, how planes fly and how investment fund managers make selections was fascinating.
I highly recommend this book written by a humble man who just happens to be a brilliant critical thinker deserving of every accolade he has received.
Top reviews from other countries
Atul Gawande has presented compelling evidence that checklists can have a dramatic impact on quality of care and healthcare outcomes. He has shown that this is repeatable around the world and not just in the poorer regions. If an aircraft pilot fails, he goes down with the plane. If the same consequence was applied to the failure of a medical consultant - we'd have checklists in every hospital tomorrow!
He has given me food for thought around the use of checklists in my own work. I feel inspired to develop one at least for myself which I may then be able to pass on to my team.
I enjoy the philosophical approach he has to life, medicine and writing.
I thoroughly recommend this book as not only thought provoking but also an enjoyable read.
I enjoyed the methodical approach of following Atul on his journey, trying to get to the crux of checklists, how (or if!) they are beneficial to situations and how a balance can be struck between having sufficient information to be useful whilst not overbearing the user to the point where the list becomes disregarded. He uses examples such as investment fund managers, third world disease prevention schemes, professional kitchens, and of course hospitals whilst using various statistics to bring the narrative to life.
A number of real world disasters are cited which keep the book gripping and interesting, and help to outline the reality the checklists aren’t to make the user into a methodical robot, but how it helps to strike a balance between communication, delegation and preparation. The bottom line of the theme is that the effects of using checklists are subtle taken on an individual situation basis, but in unlikely circumstances or taking the statistical data over a large number of samples, a clear picture gets painted. Checklists, particularly in the context of surgery or plane mishaps, are fundamental to team cohesion and just by taking the simple of step of introducing names before surgery or a flight can have a profound effect on achieving desirable outcomes.
I enjoyed reading this book and would recommend it, it does provoke thought into how checklists could be used in other situations and the problem of the human ego that leads dismissal of procedures that can have profound beneficial effects.