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Problems with Protocols: Checklists, although valuable in some settings, are a menace in others.

Posted: 2010-01-21

Book Review: The Checklist Manifesto
By Atul Gawande
Metropolitan, 209 pages, $24.50

Ohanian Comment: Review from the Wall Street Journal, Jan. 21, 2010. As I read this book, which has plenty of good stories, I kept worrying about how Standardistos would try to apply it to teaching. I pretty much agree with this review. I would add that Gawande makes the critical point that "some things we want to do are simply beyond our capacity. We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is--and will remain--outside our understanding and control."

When patient care in ICUs was studied, researchers learned that the average patient required 178 individual actions per day...and every one of them posed risks. We should think about how many individual actions students require per day. How many individual actions do they get under NCLB? RttT? LEARN (sic)? What risks to students do these federally mandated checklists impose? Gawande acknowledges that the medical community has upwards of 150,000 deaths following surgery every year--more than three times the number of road traffic fatalities. And at least half these deaths are avoidable.

Where are the headlines about this? And the Congressional committees passing legislation to control how surgeons do their jobs? Or how about paying surgeons whose patients die less? Gawande is quick to point out something teachers are not allowed to say: "The results are strongly affected by how sick patients are to begin with."

How sick and how rich.

by Philip Howard

Atul Gawande, a Harvard surgeon and New Yorker staff writer, has recently become a leading voice in public health policy. His essay last year on the high cost of care in McAllen, Texas--where entrepreneurial doctors overuse expensive imaging machines—helped explain why fee-for-service reimbursement systems may need to be overhauled. His 2007 essay on how stupid mistakes in surgery can be largely eliminated through the use of pre-operative checklists was a startling reminder of the big effects that simple reforms can have. He has now expanded the essay into a book, The Checklist Manifesto, in which he seeks, less successfully, to generalize the checklist lesson to many other human activities.

Checklists first became common in aviation, where pilots found that minor oversights in sophisticated planes led to tragic crashes. Boeing lost a bid to provide bombers to the Army in 1935 when its "flying fortress" crashed in the test—the pilot had forgotten to unlock the tail rudder. Flying today involves formal checklists and oral confirmation among pilots, air-traffic controllers and anyone else involved in air travel.

Dr. Gawande is at his best when telling stories from the operating room. A body cavity fills with blood because the surgeon—Dr. Gawande himself—has mistakenly cut an artery. But the nurse has dutifully complied with her checklist and has made sure that four units of blood are readily available. The public-health implications of formal checklists in surgery are remarkable. At Johns Hopkins, strict cleanliness protocols reduced central-line infection rates (for example, infections caused by inserting a catheter into a vein) from 11% almost to zero. When hospitals in Michigan tried the protocols, the results were equally dramatic, saving hundreds of lives.

So far, so good. But Dr. Gawande wants to make a bigger point: that formal checklists, if not exactly holding the secret to human success, will make a major difference in many other aspects of life, such as business and law: "Checklists seem able to defend everyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws."

Here The Checklist Manifesto becomes less persuasive. Dr. Gawande tells the story of how Wal-Mart was heroic in the aftermath of Hurricane Katrina, authorizing local managers to do whatever it took to help people. One manager drove a bulldozer through her ruined store to retrieve supplies. Dr. Gawande attributes this delegation of authority to a checklist. But giving someone the authority to use her judgment means relying on individual creativity and improvisation—the opposite of a checklist. Dr. Gawande contrasts the Wal-Mart example with the centralized bureaucracy of the Federal Emergency Management Agency. But bureaucracy is nothing but checklists. That's part of what's wrong with modern government—officials go through the day with their heads in a rulebook, dutifully complying with whatever the lists require instead of thinking about what makes sense.

In fact, many aspects of modern life suffer from too many checklists. Teachers, for example, are shackled to lists and protocols that prevent them from doing their jobs properly (e.g., disciplining students). Complying with the requirements of due process—a kind of legal checklist intended to protect against abuses of police power—has corroded the authority of teachers to maintain basic standards of order and respect.

The utility of formal protocols, according to organizational experts, varies with the nature of the activity—some activities are highly systemized, like engineering, and others dependent on the judgment and personality of the individual. Spontaneity and imagination are important in many jobs, including teaching and management of all kinds. Dr. Gawande seems to assume that formal checklists will be an unalloyed benefit. But most people can think of only one thing at once: If they're thinking about a checklist, they may not be focusing on solving the problem at hand. Many tasks require trial and error—not checklists designed to avoid error. "Hell, there ain't no rules around here," Thomas Edison famously said. "We're trying to accomplish something."

Dr. Gawande closes The Checklist Manifesto with the story of the crash landing on the Hudson River, in January 2009, of a US Airways plane that had lost its power in both engines. It was undoubtedly a good thing that every member of the crew had been drilled in various procedures. But the "miracle on the Hudson" happened because Capt. "Sully" Sullenberger focused on flying the plane, not a checklist on how to fly the plane. As William Langewiesche put it in his account of the incident, "Fly by Wire": "There was no time for the ditching checklist. . . . Across a lifetime of flying, Sullenberger had developed an intimacy with these machines that is difficult to convey. He did not sit in airplanes so much as put them on. He flew them in a profoundly integrated way, as an expression of himself." Capt. Sullenberger himself described the final moments this way: "The earth and the river were rushing towards us. I was judging our descent rate and our altitude visually. At that instant, I judged it was the right time. I began the flare for landing. I pulled the side-stick back, farther back, finally full aft, and held it there as we touched the water."

Accomplishment is personal. That's why giving people the freedom to take responsibility is so important. Organizational techniques can be useful—we all rely on checklists informally—but formal protocols can disrupt focus and undermine success in many life activities. Dr. Gawande is right to note that checklists are indispensable in situations where a small mistake can lead to tragic consequences, as in surgery. But his call for a broad checklist regime would be counterproductive—fraught with all the dangers of bureaucracy and excessive law.

Mr. Howard, a lawyer, is the author of "Life Without Lawyers: Restoring Responsibility in America" (Norton).

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