Checklist Manifesto! Team-Learning & Communication

“Cleared for Takeoff in the OR!”
What do surgery and flying airplanes have in common? Answer: they’re complex systems, wherein no one person can manage all the multiple events, problems, component parts. And, the way to improve the chances of success is to improve communication, in the OR and in the cockpit – or in any complex organization.

In his book Checklist Manifesto, Atul Gawande once again astounds with cutting-edge thinking, making connections between unexpected domains, and presenting tools for improving organizational effectiveness. I’ve blogged about his previous books, Better and Complications – and his new book is a suspenseful page-turner. Did you ever wonder what’s in those black boxes on airplanes, which are used to reconstruct mishaps during flights? Ever wonder who listens to those things and what they learn from them? Gawande is your guide – and then he applies the concepts to medicine. It’s all about learning from mistakes: how can we glean the learnings and apply them to the future?


Imagine that you’re working on a construction site building a skyscraper (yeah, it’s a trip reading this book!) How do they coordinate all those systems – electrical, structural, mechanical, etc? Well, they have a construction schedule that lists all of the thousands of tasks, the timeline, and who’s responsible. But how do they handle the unexpected problem that inevitably arises? They have a second schedule called a “submittal schedule”, that details tasks of communication: who needs to talk to whom, by when, who else needs to know about this? Two checklists that work wonders and help manage the complexity.

Just out of curiosity, doctor, how do the nurses, doctors and all the specialists in the Operating Room fare on communication? Turns out that oftentimes surgical teams don’t know each other’s names. The checklist includes – get this – having everyone introduce themselves!! The researchers found that that one element improves the way the team works together (no surprise there). It also helps if you go around and let each person express whatever concerns s/he has about this patient and this surgery. Getting people to say their name and to voice their concern increases their willingness to speak up during the surgery, which can only benefit the outcome.

“Cleared for takeoff”!

That’s all part of the checklist (introduce yourself, express any concern). Before they start the surgery, the nurses have to prepare the surgical instrument kits. The innovation of the checklist was to put a checklist in the kit, to remind them to go through it. There’s also a card (a metal tent) in the kit called “Cleared for takeoff”! Before they can start operating, they have to go through the checklist, and the nurse has to remove the metal tent. That metal tent ensures that the operation doesn’t start until the nurse gave the OK and removed the tent. The other brilliant piece of this? It’s the nurse who gives the OK rather than the doctor, which Gawande calls “a subtle cultural shift”.

Remember those Crucial Conversations (the book by Patterson, Grenny et. al.)? That book talks about how you get the nurses to have those crucial, difficult conversations with the doctors, which is difficult in the hierarchical culture of hospitals and operating rooms. I’m sure Gawande is aware of this, just curious that he doesn’t mention it in this book. You clearly need to train nurses to speak up, to give them the authority, to make it OK to speak up, to get doctors used to listening to the nurses. Now, armed with both books, and both sets of skill building, these clinicians will be better able to handle the unexpected – and those surgical errors should go way down! (The research already shows the improvement).

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