The Checklist Manifesto: Chapter Six: The checklist factory

Following our schedule, it’s time for chapter six.

Finally we met the mother of all checklists, aviation. We had a brief encounter a couple of chapters ago in which we witness the introduction of checklist in flying, but this time we have a more contemporary and systematic description on how checklists are used there.

What we suspected from chapter 5 is shown here, not every checklist is equal. Some ar badl:

There are good checlikst and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are practical. […] They treat the people using the tools as dumb and try to spell out every single step. (p. 120)


And some are good:

Good checklists, on the other hand, are precise. […] They do not try to spell out everything -a checklist cannot 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. (p. 120)


This part surprised me. I always had this impression of how checklist are supposed to be exhaustive and cover every single possible situation and element, but as Gawande argues here, when you try to do that you end up with bad checklists. He explains it in page 128:

It is common to misconceive how checklists function in complex lines of work. They are comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modes, they are saving thousands upon thousands of lives.

This chapter is full of relevant insights, for example, how critical is to check the checklist. As he argues in page 121 it is so easy to neglect a warning light (the plane has been re-checked several times and accidents only happen 1 in half a million flights) but pilots always look at their checklist when anything unexpected happened. The reason is twofold: first they have been trained for the very start to do that and second, they know that checklist are really worth check them. They have shown that they really work. As Gawande states:

Face-to-face with catastrophe, they are astonishingly willing to turn to their checklists (p. 121)

Following the observations in the chapter here are some ideas to design a good checklist:

1) To define a clear pause point in which the checklist is supposed to be used.

2) To decide in between a DO-CONFIRM checklist or a READ-DO checklist. In the DO-CONFIRM you already did what is needed by memory and check if you haven’t forget anything. In the READ-DO first you read and then you act.

3) A checklist should be in between 5 to 9 items, which is the limit of working memory. But, of course, it depends on the context.

4) The list should contain the “killer items”; that is the steps that are most dangerous to skip and can be forgotten.

5) Lists should be written in a very simple and exact language. They should also be look clear, free of clutter of fancy design.

6) Highly readable, using both lowercase and uppercase, and with a sans-serif font, such as Helvetica

7) Checklists have to be tested in the real world, where everything turns more complicated than expected.

I just realized I made a checklist on how to make checklist 🙂

Then the book goes on to explained us how a very peculiar accident with fuel in Polar routes was rapidly incorporated in civil aviation in just a month, using checklists. According to the author and the people interviewed for this chapter, the main reason for lessons learnt from mistakes take so long to be applied is basically that those lessons have not been translated into a simple, usable and systematic form.

And  final emotional observation: Gawande is a lucky bastard who I am sure had the time of his life while writing the book (like when he is invited to play with a professional flight simulator and try the  DOOR FWD CARGO exercise).

Will Dr. Gawande be able to apply these lessons to surgery? We’ll see it in the next chapter!






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