New: The Checklists Effect

A surgeon discovered a revolutionary technique to save countless lives: checklists. What lesson can we learn from his discovery?

The World Health Organization

Many people wake up in the morning, check the coronavirus stats — how many tested positive, how many were hospitalized, what does the World Health Organization say — and try to shape their day around the information, like whether or not they should wear a mask or attend events.

In 2004, the World Health Organization was involved in solving a different problem: In those years, the number of surgeries skyrocketed: 230 million major surgeries were carried out that year — one for every twenty five people in existence. In fact, there were more surgeries than births that year.

However, there was also a tremendous rate of failure. The rate of death from surgery was between ten to one hundred times higher than death in childbirth. Annually, a million people died from complications after surgeries, and seven million remained invalids after botched operations.

Usually, the world health organization is involved in fighting plagues and pandemics, but they watched in worry as the numbers of deaths from medical procedures rose sharply. They turned to experts in the field, but the problem was that they couldn’t identify one single issue; there are more than twenty-five thousand types of medical procedures, and they didn’t even know where to begin.

The Checklist

In 2007, the organization turned to a world-expert in solving issues in hospitals; his name was Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston. He gathered specialists from all over the world to attempt to better the situation. At their conference, all sorts of ideas were raised. One suggestion was that rewards needed to be given to surgeons and staff in the operating rooms. However, that idea had been tried in the past, and it hadn’t proven to work. 

Then, one expert mentioned an experiment by the children’s hospital in Columbus, which had developed a checklist to avoid infections after the surgery. 

One of the details was regarding administering antibiotics. In surgeries on children, infections are the most common complication, and the best way to avoid them is to administer the correct antibiotics within sixty minutes before the incision. 

The timing is critical; if it is given more than sixty minutes before the process begins, it loses its potency; if it is given after the surgery begins, it is too late. But if it is administered during the proper time-window, it lowers the chance of infection by a full fifty percent!

However, this fact was often overlooked! In 2005, the hospital in Columbus discovered that over a third of patients didn’t receive antibiotics at the right time. Some received it too early, and others received it too late, and some didn’t even receive it at all. It turned out that specifically because it was such a basic task, many anesthesiologists overlooked it in the complicated and often chaotic beginnings of surgeries.

Now, the surgeon in Columbus was also a pilot. He decided to adopt the aviation approach: He made a “pre-incision checklist,” just like the checklist pilots go through before takeoff, and hung it in one of the operating rooms. The nurse was to confirm the identity of the patient, the correct side of his body, and also that he received the correct dose of antibiotics. 

However, it didn’t prove simple to get the staff to pause and consider the checklist before each operation. He gave presentations to the surgeons, the anesthesiologists and the nurses, and it still wasn’t enough. So he did something interesting. He fashioned a small metal “tent,” the perfect size to fit over the surgical instruments, and engraved on it the words, “Cleared for takeoff.”

The nurses were instructed to place the tent on the surgical knife, and remove it only upon going through the checklist. It made it very clear that the surgery could not begin before ensuring that everything was properly in place. 

After three months, the statistics changed considerably. Eighty-nine percent of patients now received the necessary antibiotics. After ten months, they reached one hundred percent. The checklist became routine and saved lives.

Atul Gawande, who was already a checklist advocate, heard these statistics and realized that he had fallen on a gold mine. A checklist would help the team make sure that protocols were properly followed. 

However, it wouldn’t solve everything. In surgery, there are always surprises that can’t be foreseen with checklists. A checklist is like a cake recipe. It will help a team ensure that nothing is carelessly overlooked. But how were they to ensure that unforeseen problems would be overcome as well?

The Protocols

A Jewish doctor from Toronto shared that in his hospital, they had discovered that the most important thing was teamwork. They created a protocol in which before each surgery, every person in the operating room must introduce himself with his name and role. It turned out that when people don’t know each other by name, they don’t really work together. They each focus on their own responsibilities and try not to get involved with the others. By introducing themselves, they broke the ice and made it a more comfortable work-situation.

Additionally, they would ask each member of the team if they had any concerns. This helped people pay more attention, point out problems and suggest solutions. It turned out that when you give people the opportunity to speak at the outset, it boosts their comfort level and their sense of responsibility. In this hospital, they discovered after implementing these procedures, the team work went from “good” to “exceptional,” and they saved many lives in the process.   

However, they also discovered that the most difficult part was to actually get people to follow the protocols. The surgeons said, “This is good for beginners, not for me; I know what needs to be done — after all, I’ve been in the operating room for twenty years, and I don’t need anyone’s advice.” This attitude was the single greatest obstacle for success. 

The Jewish Checklist 

My friends, I didn’t come here to give you a presentation on operating room protocol. This story is very relevant to our lives. 

Judaism has a checklist. It’s called the Shulchan Aruch, the Code of Jewish Law. Every Jew, from the moment he opens his eyes in the morning until the moment he closes them at night, has a checklist which he needs to go through. In the morning, he recites Modeh Ani, thanking G-d for a new day. He washes his hands, puts on tefillin, prays, etc. And this continues throughout the day, and throughout our lives.

Now, sometimes, people argue that they prefer to serve G-d in their own personal fashion. “Modeh Ani is good for preschoolers; I will thank G-d in my own way.”

Likewise, I often hear people say that they cannot understand the Ten Commandments. “I am myself a moral and ethical person. Do I really need to be told not to kill and not to steal? I have much higher morals than not killing and not stealing. I don’t cut corners at all!” 

Does such a person need to be told to honor his parents? He can do it on his own! He doesn’t need the Ten Commandments to remember those values.

But — hand on heart — how many times did we intend to call our parents when it just didn’t work out? We were busy, we were on a flight all day and when we had time they were already sleeping etc. etc. How often do we actually thank G-d for the life he gives us? 

The checklist effect helps even the best of us.

The Jewish Protocol

The problem is that a checklist is not enough. When Jews lived in the shtetl, the street itself was Jewish. For Jews living in Israel, Jewish holidays are a part of the calendar. Nobody works on Rosh Hashanah, the entire country shuts down on Yom Kippur, and you cannot avoid seeing the Sukkahs and Lulavs on Sukkot. Perhaps, for them, the checklist is enough. 

But when a Jew lives in a non-Jewish environment, the checklist itself is not enough to counter the powers that seek to drown him in assimilation. It might be a sports game that seems very important, or a college test that’s set for Yom Kippur that seems to have real implications on his future. Often, you are sure that G-d agrees with you that it takes precedent! 

These aren’t my own fabrications. Over the years, I’ve asked the kids in Hebrew School, “What will you do if your college gives you a test on Yom Kippur?” Many of them responded that in their opinion, G-d wants them to take the test, because He wants them to be successful. I was often shocked to hear the very ‘logical’ conclusions they presented. 

This is why teamwork is so important. 

First of all, the two parents need to be on the same page. It’s not enough for Judaism to be important for one parent. To raise Jewish children, the child needs to know that Judaism is important to both of them. But that’s also not enough. To raise Jewish children, they need to belong to a Jewish community. A child needs to see other children and other families who have similar values. He needs to be able to listen and learn from those who are older than him. 

This, my friends, cannot be done through zoom. A community can only exist when people are in the same room and build true friendships; zoom doesn’t do it.  

Beyond Both

People often tell me sadly about their children who assimilated. They say to me, “We don’t know how it happened.” And then, usually, comes the punchline: “We did all the right things…”

First of all, how can anyone honestly assert that they actually did ALL the right things? But let’s assume that it is true, and they did all the right things. They went through the entire checklist. Kiddush on Shabbos? Check. Synagogue attendance? Check. Jewish holidays? Check.

Still, raising a child takes more than a checklist. It also needs more than a team effort.

The Rebbe sometimes quoted a saying of the Sages, “The words of the heart cannot be  written on paper” (See Sanhedrin 35a). Emotions cannot be expressed in words. There is something deeper than what you say and do. The most important thing is the feelings that you wordlessly convey. The joy of celebrating a Jewish holiday. The emotions you feel during the shofar blowing. The joy and the dancing with the Torah on Simchas Torah. The excitement to light the chanukah candles. The deep concern whenever we hear troubling news about a war in Israel.

The chassidic movement came to the world to give a person “the words of the heart,” the Chassidic warmth and the enthusiasm to do a mitzvah. You could choose to sit at the seder and complain, “Again Matzah, again Maror?” People tell me, “When the kids were young, we used to light Chanukah candles, but now, what’s the point?”

Of course, we need checklists, and we need teamwork. But above all, we need the “words of the heart.” We need the Jewish warmth and enthusiasm for Yiddishkeit. Enthusiasm is contagious, and it’s a fire that will burn down the walls of exile and bring Moshiach.

Good Yom Tov.