On 14th January, 2009, shortly after take-off from La Guardia Airport in New York, US Airways Flight 1549 encountered a flock of Canada geese and lost power to both engines.  Readers may remember what happened next: the aircraft crash-landed in the Hudson River – and every individual aboard was rescued alive.  I remember reading at the time that pilot was perhaps the best-qualified individual possible to have executed this manouevre: unflappable and hugely experienced, his quick thinking and derring-do saved over 160 lives.  Atul Gawande’s new book, on the other hand, argues that what happened on that day had almost nothing to do with heroism.

By Greg L [CC-BY-2.0], via Wikimedia Commons
By Greg L [CC-BY-2.0], via Wikimedia Commons

He quotes the crew members, and the captain himself:

‘I want to correct the record right now.  This was a crew effort.’  The outcome, he said, was the result of teamwork and adherence to procedure as much as of any individual skill he may have had.”

Gawande argues that meticulous discipline and a methodical approach were the keys to this unusual success.  The book reveals the place of checklists, not just in landing a plane in a river, but in many other disciplines, particularly medicine.

I bought ‘The Checklist Manifesto’ on the merits of Gawande’s Better, which I reviewed in January; I was not disappointed.  While Better offered meditative discussions of a number of ways to improve, this book pursued one line of argument as it followed Gawande’s exploration of the merits of checklists and their application in complex situations.  Based in medicine, chapters digressed to discuss the employment of checklists in the construction of skyscrapers and aviation safety.  Their key function lies in helping to overcome practitioners’ tendencies to omit critical actions and to improve communication within teams.

Checklists are designed to provide simple, swift and effective reminders in complicated procedures.  They should not seek to cover everything: ideally, as few as seven or eight items, those most important or most likely to be missed.  A good checklist takes no longer than about ninety seconds, at a ‘pause point’ at which participants can briefly take stock.  They are designed to ensure important steps which may be overlooked under pressure, like giving patients the correct antibiotic at the right time, are carried out.  Their other function is to reinforce communication, remoulding individuals into teams, such that nurses are more likely to speak up if they notice a surgeon’s error.  In sum, although Gawande faced the objection that this deprofessionalises practitioners, checklists should support them.

While Gawande took time to iron out problems in the initial design of checklists, I was not surprised to read that it was their implementation which proved challenging.  The chapter entitled ‘The First Try’ concludes:

By the end of the day, we had stopped using the checklist.  Forget making this work around the world.  It wasn’t even working in one operating room.”

Used to managing change, after initial failure, Gawande turned to practice in order to come up with a workable solution.  In honing the checklist, he notes the importance of brevity – and consequently, a requirement to cut the “non-killer items.”  This is not a scientific procedure – it rests on his colleagues’ judgment as to the most important actions and those most desirable.  He also highlights the importance of fitting the checklist to existing contexts: in British hospitals, for example, anaesthetic is given at a different stage in the operation to American ones; the checklists needed are different.

Gawande encountered a degree of opposition as part of a World Health Organisation team introducing this change: “We were thrown out of operating rooms all over the world.  ‘This checklist is a waste of time.'”  Smart enough to roll with the punches, he asked hospital managers to avoid enforcing changes and allowed surgeons to recognise their merits individually.  Examples of success swiftly accumulated around the world: catching ‘stupid’ mistakes and increasing teamwork within operating theatres.  In his own surgery, ‘catches’ he mentions include that of a patient with respiratory problem about which the anaesthesiologist knew, but only raised due to the checklist.  On another occasion, reading from his script, he asked:

‘Has the antibiotic been given within the last sixty minutes…’
‘Oh, right, um, yes, it will be,’ the anesthesia resident replied.”

Gawande was encouraged that 80% of those asked as part of his WHO study found the checklist easy to use and agreed it had improved the safety of care (78% had observed it preventing error).  Yet he wondered what was missing for the remaining 20%.  A final question reassured him: “If you were having an operation would you want the checklist to be used?”

A full 93% said yes.”

I’ve written before about my suspicion of analogies to medicine, but I suspect teachers could use these insights.  The complexity of teaching and the pressure we are under make small mistakes and omissions a frequent occurrence.  My first thought, with which I have begun experimenting, is a lesson-planning checklist.  An equivalent check just as students are settling into the opening task of a lesson might work well too.  Another logical application would be in child protection.  I also wonder how they could be used for students: I have employed ‘preflight checklists’ in students’ writing for a while, but as part of lengthy redrafting.  What brief checks might we ask students to make?

These improvements are not trendy or exciting, but they can cut infection rates dramatically, ensure training is followed, and save lives.  Gawande’s conclusion examines just one case of his own however, in which a routine operation turned disastrously wrong as he tore the vena cava of his patient.  He’d expected no complications, but the checklist said the operating room should have a supply of blood prepared.

They hadn’t been, it turned out.  So the blood bank got the four units ready.  And as a result, from this one step alone, the checklist saved my patient’s life.”

Checklists have great power: what more can teachers do with them?

Update – September 2015

My interest in checklists grew to such an extent that I wrote a book about how to use them in teaching – including a collection for teachers and school leaders.  Available now to pre-order, out in January 2016.


Further reading

This book: The Checklist Manifesto

Also by Atul Gawande: Better: my review, the book

Andy Day has written a wonderful post with his trademark humility and reflection, introducing checklists and offering a number of examples of how his school has used them for heads of department.

For the last word on introducing and implementing change, try Switch