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256 CHAPTER 7 • ImPRovEmEnT sTRATEgy

Gawande tells the story of Peter Pronovost – a specialist in critical care at Johns Hopkins
Hospital – who, in 2001, tried to reduce the number of patients who were becoming infected on
account of the use of intravenous central lines. There are five steps that medical teams can take
to reduce the chances of contracting such infections. Initially, Pronovost simply asked nurses to
observe whether doctors took the five steps. What they found was that at least a third of the time
they missed one or more of the steps. So nurses were authorised to stop doctors who had missed
out any of the steps and, as a matter of course, ask whether existing intravenous central lines
should be reviewed. As a result of applying these simple checklist-style rules, the ten-day line-
infection rates went down from 11 per cent to zero. In one hospital it was calculated that, over a
year, this simple method had prevented 43 infections, 8 deaths and saved about $2 million. Using
the same checklist approach, the hospital identified and applied the method to other activities.
For example, a check in which nurses asked patients about their pain levels led to untreated
pain reducing from 41 per cent to 3 per cent. Similarly, the simple checklists method helped
the average length of patient stay in intensive care to fall by half. When Pronovost’s approach
was adopted by other hospitals, within 18 months 1,500 lives and $175 million had been saved.
Gawande describes checklists used in this way as a ‘cognitive net’ – a mechanism that can
help prevent experienced people from making errors due to flawed memory and attention,
and ensure that teams work together. Simple checklists are common in other professions. Civil
engineers use them to make certain that complicated structures are assembled on-schedule.
Chefs use them to make sure that food is prepared exactly to the customers’ taste. Airlines use
them to make sure that pilots take-off safely and also to learn from, now relatively rare, crashes.
Indeed, Gawande is happy to acknowledge that checklists are not a new idea. He tells the story
of the prototype of the Boeing B17 Flying Fortress that crashed after take-off on its trial flight
in 1935. Most experts said that the bomber was ‘too complex to fly’. Facing bankruptcy, Boe-
ing investigated and discovered that, confronted with four engines rather than two, the pilot
forgot to release a vital locking mechanism. But Boeing created a pilot’s checklist, in which the
fundamental actions for the stages of flying were made a mandated part of the pilot’s job. In
the following years, B17s flew almost two million miles without a single accident. According to
Gawande, even for pilots (many of whom are rugged individualists) it is usually the application
of routine procedures that saves planes when things go wrong, rather than the ‘hero-pilotry’ so
fêted by the media. It is discipline rather than brilliance that preserves life. In fact, it is discipline
that leaves room for brilliance to flourish.

Knowledge management
Central to the idea of improvement is the importance of learning how to do things
better. And central to learning how to do things better is the idea of ‘knowledge’, where
knowledge is defined as:

‘facts, information, and skills acquired through experience or education; the theoretical or
practical understanding of a subject’. 9
Note how the definition stresses the source of knowledge, and distinguishes between
two sources – experience (doing things) and education (explaining or describing what
experience has taught you for the benefit of other people). Doing something may lead
you to know more about it, but having to articulate it or explain it makes your knowl-
edge more valuable because it can be shared with others. It is this process of formalis-
ing experience that distinguishes between what is often called ‘tacit’ knowledge and
‘explicit’ knowledge.

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