The Checklist Manifesto_ How to Get Things Right - Atul Gawande [20]
I have been thinking about these matters for a long time now. I want to be a good doctor for my patients. And the question of when to follow one’s judgment and when to follow protocol is central to doing the job well—or to doing anything else that is hard. You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way. The value of checklists for simple problems seems self-evident. But can they help avert failure when the problems combine everything from the simple to the complex?
I happened across an answer in an unlikely place. I found it as I was just strolling down the street one day.
It was a bright January morning in 2007. I was on my way to work, walking along the sidewalk from the parking lot to the main entrance of my hospital, when I came upon a new building under construction for our medical center. It was only a skeleton of steel beams at that point, but it stretched eleven stories high, occupied a full city block, and seemed to have arisen almost overnight from the empty lot that had been there. I stood at one corner watching a construction worker welding a joint as he balanced on a girder four stories above me. And I wondered: How did he and all his co-workers know that they were building this thing right? How could they be sure that it wouldn’t fall down?
The building was not unusually large. It would provide 150 private hospital beds (so we could turn our main tower’s old, mostly shared rooms into private beds as well) and sixteen fancy new operating rooms (which I was especially looking forward to)—nothing out of the ordinary. I would bet that in the previous year dozens of bigger buildings had been constructed around the country.
Still, this one was no small undertaking, as the hospital’s real estate manager later told me. The building, he said, would be 350,000 square feet in size, with three stories underground in addition to the eleven stories above. It would cost $360 million, fully delivered, and require 3,885 tons of steel, thirteen thousand yards of concrete, nineteen air handling units, sixteen elevators, one cooling tower, and one backup emergency generator. The construction workers would have to dig out 100,000 cubic yards of dirt and install 64,000 feet of copper piping, forty-seven miles of conduit, and ninety-five miles of electrical wire—enough to reach Maine.
And, oh yeah, I thought to myself, this thing couldn’t fall down.
When I was eleven years old, growing up in Athens, Ohio, I decided I was going to build myself a bookcase. My mother gave me ten dollars, and I biked down to the C&E Hardware store on Richland Avenue. With the help of the nice man with hairy ears behind the counter, I bought four pine planks, each eight inches wide and three-quarters of an inch thick and cut to four feet long. I also bought a tin of stain, a tin of varnish, some sandpaper, and a box of common nails. I lugged the stuff home to our garage. I carefully measured my dimensions. Then I nailed the two cross planks into the two side planks and stood my new bookcase up. It looked perfect. I sanded down the surfaces, applied the stain and soon the varnish. I took it to my bedroom and put a half dozen books on it. Then I watched the whole thing fall sideways like a drunk tipping over. The two middle boards began pulling out. So I hammered in a few more nails and stood the bookcase up again. It tipped over the other way. I banged in some more nails, this time coming in at an angle, thinking that would do the trick. It didn’t. Finally, I just nailed the damn thing directly into the wall. And that was how I discovered the concept of bracing.
So as I looked up at this whole