The Checklist Manifesto: How to Get Things Right

It's a little strange to say that I enjoyed a book about checklists, but it was great. The author's stories are meaningful and memorable, which made it a fast, engaging read. The case for using checklists is laid out convincingly, and it made me think about which of my workflows would benefit from having an associated checklist.

The KISS principle states that simplicity should be a key goal in design, and that unnecessary complexity should be avoided. When translated, KISS stands for "keep it short and simple." There are few authors today that are willing to tell the truth and be objective, while still maintaining credibility. I would like to address Atul Gawande's most recent entry and classic, "The Checklist Manifesto: How To Get Things Right." Gawande is also the author of Better and Complications, a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, an associate professor at Harvard Medical School and the Harvard School of Public Health, and leads the World Health Organization's Safe Surgery Saves Lives program. Quite an impressive resume Mr. Gawande has there; however, his ego never gets to him. His "down-to-earth" approach to the implementation of checklists is wholly inspirational. In The Checklist Manifesto, Gawande attempts to redefine society's mentality through his ability to write cleverly and eloquently while being objective and straight to the point. He supports his in-depth research and provides a variety of careers and fields where a simple checklist can be implemented. In fact, it works. Gawande establishes his cleverness and objectiveness early in the The Checklist Manifesto. He talks about a true story of how an anesthesiologist used the wrong concentration of potassium that he'd intended. In fact, the anesthesiologist used "a concentration one hundred times higher" (Gawande 6). The team did everything they could to try to stabilize the patient: "The surgical team was so shaken they weren't sure they could finish the operation. They'd not only nearly killed the man but also failed to recognize how. They did finish the procedure though" (Gawande 7). Now, you may be sitting there thinking "Why would it matter if they made a mistake? As long as the surgical team was able to save the patient, then it shouldn't matter, right?" Let me ask you this question: "Are we to rely on luck over and over again?" This was just one patient and a simple mistake almost killed the patient. By spending a few seconds (or even minutes) looking over and using a checklist, you can substantially minimize potential mistakes. Gawande also tells the reader of an instance in aviation where a Delta Air Lines flight from Shanghai to Atlanta with 247 people aboard almost crashed on November 26, 2008. The engine failed because of icy conditions. The pilot and copilot "got out their checklist and followed the lessons it offered" (Gawande 135). Because of what they did, the engine recovered and all 247 people were saved. "If you were having an operation, would you want the checklist to be used? A full 93 percent said yes" (Gawande 157). This was a survey taken by medical professionals. Gawande is consistent in being clever throughout The Checklist Manifesto and never loses his focus on the importance of checklists. Gawande is able to capture medicine in all of its complex and chaotic glory. He inspires all of us, doctor or not, to lose our ego, implement a simple checklist, and be better. Less is more. Keep it simple. I highly recommend The Checklist Manifesto by Atul Gawande to any reader because it can apply to the lives of just about anyone. Gene

Atul Gawande is a physician interested in improving surgical practice. He reviews surgical cases with disastrous outcomes that could have been prevented and cites research claiming that nearly half of deaths that occur in surgery are in fact preventable. We read a detailed analysis of a drowning accident in which the young victim's life was saved against all odds. Why? Because the hospital staff had discussed and practiced the procedures to treat cold-water drowning ahead of time. They used no new knowledge; they just coordinated and communicated more effectively. Gawande examines how human beings do things. There are two reasons we fail at complex tasks. The first is ignorance. We correct it by conducting research and building schools to increase our knowledge. The second and more common reason for failure is ineptitude--the right knowledge is available, but we do not apply it correctly. People continually forget, are distracted, or skip steps because they seem unimportant. This problem lurks below the radar; we don't recognize it, let alone try to solve it. Instead we send people off for more training to increase their knowledge. What is needed instead is a simple way to remind people of what they know at the right time to make a difference. We have an answer, we just aren't using it. "Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification, but also instill a kind of discipline of higher performance." The author examines checklists used by airline pilots, building contractors, investors and other physicians. In these professions work has become too complex for even a talented individual to perform alone. Teams of skilled experts must manage both communication and complexity to succeed. They do both with checklists. These checklists make people stop and think at "pause points" to ensure that the right things have been done. They get coworkers to bond as a team by requiring them to talk to each other. As a result, people become comfortable enough to speak up when they see a potential problem. Chapter Six, The Checklist Factory is the instructional meat of the book, with recommendations that help us develop good checklists. There are direct guidelines about brevity and clarity. There are also process guidelines about identifying common mistakes and fine-tuning a checklist with field testing. He distinguishes between READ-DO checklists, which march novices through the tightly specified steps of rote tasks, and DO-CONFIRM checklists, which provide checkpoints for experienced professionals solving complex problems in coordinated groups. Both have their place, but DO-CONFIRM checklists have the most potential to make a difference. There are barriers to checklist use. They have a serious user acceptance problem. Many accomplished professionals consider themselves virtuosos who don't need help from other people at all, let alone somebody else's checklist. To many others checklists seem too mundane to make a difference. The author works hard to persuade us. His own research on checklists in operating rooms finds significant drops in death rates, post-operative infections, and other outcome measures. He highlights successes at prominent hospitals to encourage wider acceptance, asks administrators to impose requirements, and calls on nurses to help change the culture of the operating room. The idea is slowly catching on. Gawande wishes we would move more quickly. "In the money business everyone looks for an edge. If someone is doing well, people pounce like starved hyenas to find out how. Almost every idea for making even slightly more money ... gets sucked up by the giant maw almost instantly. Every idea, that is except one: checklists." I learned some things from this book and highly recommend it. Give it at least a quick look, starting with Chapter 6. It has the potential to make you even better at what you do best.

Why, with all our expertise and training and technology, are there so many mistakes? Atul Gawande goes a long way toward answering this question. As it turns out, we can probably do vastly better at what we do by employing a humble, low-tech tool: the checklist. Through a variety of stories, the kind that make him such an entertaining read, Gawande demonstrates that it is not a lack of talent, or lack of desire to do a good job, or lack of expertise that diminishes outcomes. Rather, it is that our brains are not dependable or exhaustive record keepers. We can develop skill and create, but we forget. And depending on what we forget, that can have a dramatic effect on our outcomes. More expertise won't help. The age of the master builder, who knew everything about the structure being erected, has yielded to the age of the super-specialist where even the separate disciplines of medicine are being further split and differentiated. Surgeons are more educated and at least as skilled in their practice as architects and pilots are in theirs. So, why do so few buildings fail and planes crash and so many patients have complications? The answer may be alarmingly basic. My experience coaching investment advisors present me with exactly this conundrum, one reason I was drawn to the book as soon as I heard about it. As in medicine, financial professionals have more knowledge and skill than at any time in the past. And we routinely make mistakes. Leave things out. Forget stuff. Sometimes, it means a disappointed client. Sometimes it leads us to make an investment that hurts a portfolio. We have so much knowledge to track and catalog. Our brains routinely fail us in recalling what we need to know and when. Fortunately, we can utilize external tools to ensure we address all the critical issues, and it can be as simple as a piece of paper. But how do we design an effective list? How do we successfully integrate it into the activity we want to accomplish? And why, when the power and reliability of this device has been so widely proven, do we so ardently resist using it? These are questions Gawande explores in his engaging style. He works through those questions to assist the World Heath Organization in improving surgical outcomes globally. And demonstrates the challenges and rewards of developing and implementing checklists in his own practice. He doesn't tell us how to design our checklists, probably because he can't. Each situation will be custom. But in recounting the history and describing his own frustrations and successes, he shows us a path to make this tool our own.

As a physician, I found it to be not only an excellent read, but also a useful information tool for my day-to-day activity. I read most of his works! Gifted writer!

This was an interesting book. The stories of the medical situations that caused the author to develop and use checklists are incredible. If I ever have surgery i will be asking if they use checklists. The title, "The Checklist Manifesto", fits the theme of the book as to how important checklists can be. The weak part of the book is the follow through of the subtitle, "How to get things right". One would expect more of how to use checklists, how to develop checklists, and how to implement them. None of this really appears. The stories do give a hint as to what a checklist should be- short, easy to use, and versatile, but that is the extent of advice. The book is worth the read just from the the stories, but falls short of a "how to" book. So with the right expectation, I would recommend it.

This is a great book. I highly recommend it to anyone who is trying to get many things done. It's helpful with mindset and discipline.

The author, Dr Atul Gawande is an American general and endocrine surgeon, and public health researcher. I have been meaning to read and review his book for many years. What a fitting introduction to ‘The Checklist Manifesto: How to Get Things Right.’ Philosophers Samuel Gorovitz and Alasdair MacIntyre tackled the issue of why we fail at what we set out to do in the world. One reason, they explain is “necessary fallibility”, a consequence of some things in the world, and our lives, being beyond our understanding and control. But there is much that is not, and yet we fail at these too. Gorovitz and MacIntyre suggest that there are two reasons for this: ignorance and ineptitude (incompetence or clumsiness.) For most of human history, people’s lives have been lived largely in ignorance. However, over the last few decades, science has filled in enough knowledge to make our ‘ineptitude’ as much of a challenge as our ‘ignorance’ was in the past. Gawande’s context is the ineptitude in medicine. While our knowledge and sophistication has grown enormously, the struggle is still how to deliver on this know-how. The knowing-doing gap is found everywhere. From the frequent mistakes authorities make when disaster strikes, to the legal mistakes our lawyers make that are the result of little more than simple administrative errors. “Every day there is more and more to manage and get right and learn,” Gawande points out. With all we are required to manage, failure happens far more often - despite great effort rather than from a lack of it. Expertise has been seen as the solution to ineptitude in most areas of work – “they need more training!” and modern medicine has been no different. But capability clearly isn’t our primary difficulty; in most fields training is longer and more intense than ever. In the early twentieth century, you could practice medicine with only a high school diploma and a one-year medical degree. Today doctors have six years of university, and three to seven years of residency to practice paediatrics, surgery, neurology, or the like. Yet our failures remain frequent, but there is a solution – checklists. Though this seems almost ridiculous in its simplicity - especially to those of us who have spent years carefully developing ever more advanced skills - it has proven not to be. In 1935 the US Army was looking for the next generation long-range bomber. Boeing’s aluminium-alloy Model 299 was able to carry five times as many bombs as the army had requested, and could fly faster and farther than previous bombers. The army planned to order at least 65 planes until it stalled on a test flight, turned on one wing, and exploded. The crash, attributed to ‘pilot error, killed 2 of the 5 crew members. This prompted Boeing to come up with an ingeniously simple approach: they created a pilot’s checklist. It is worth noting that using a checklist for takeoff was about as odd as using a checklist to back out of your garage. However, flying this new plane was too complicated to be left to the memory of any person, no matter how expert. The test pilots made checklists for takeoff, flight, landing, and taxiing, and armed with the checklist, flew a total of 1.8 million miles without one accident. The army ultimately ordered almost 13,000 planes. Like flying, many areas of our lives and work have become “too much airplane for one person to fly.” Faulty memory and distraction are a constant danger in “all-or-none processes” like going to the shop to buy ingredients for a cake, piloting a plane through a takeoff, or treating a sick person in the hospital. “If you miss just one key thing, you might as well not have made the effort at all,” says Gawande. Another human danger you may well recognize, is allowing yourself to skip steps even when you remember them. You skip steps because it has never been a problem before – until one day it is. Checklists can provide protection against such lapses, as they remind us of the minimum necessary steps. Professors Zimmerman and Glouberman distinguish between 3 different kinds of problems: the simple, the complicated, and the complex. ‘Simple problems’ are ones like baking a cake from a recipe with a few basic techniques you need to learn. Master them and you most likely will have success. ‘Complicated problems’ are like sending a rocket to the moon. There is no straightforward recipe, and success usually requires many people and great expertise. Unanticipated problems are common, and timing and coordination become serious concerns. ‘Complex problems’ are like raising a child. You can’t repeat and perfect the process as you can with rockets. Every child is unique, and while expertise is valuable, it is not sufficient. The outcome remains highly uncertain. The value of checklists for simple problems is self-evident: that is why we have a shopping list. But much of the most critical work people do, is not simple. Checklists help prevent failure especially when the problems combine everything from the simple to the complex. The real value of checklists is in conditions of true complexity, where the knowledge requirements exceed that of any individual, and unpredictability reigns. Commands and control from the centre will fail. Under these conditions, not only are checklists a help, they are essential for success. In these complex situations where individuals must exercise their own judgement, this judgement will be enhanced by checklist procedures. Bad checklists are vague and imprecise, too long and hard to use. They are written as if the people using them are stupid, and they try to spell out every single step. Good checklists, are precise and begin with the premise that a checklist cannot fly a plane. That is why, faced with catastrophe, pilots are astonishingly willing to turn to their checklists. Checklists come in two forms: DO-CONFIRM and READ-DO. Using a DO-CONFIRM checklist, people do jobs from memory and experience, then stop and check. Using a READ-DO checklist, people carry out the tasks as they check them off, like a recipe. To get value from checklists, they must make sense for the particular situation. A rule-of-thumb is to keep it to between five and nine items, simply worded, and exact. Does this work? This was rigorously tested in the World Health Organization’s ‘safe surgery’ research across a variety of hospitals of different sizes, rich and poor, in countries from Tanzania to the US. In this carefully constructed study, a 2-minute, 19 step surgery checklist, resulted in an immediate drop in infection and mortality in thousands of operations in 8 participating hospitals. Major complications dropped 36%, and deaths fell by 47%. That is how much a checklist can add to the skills of highly trained, highly skilled surgeons. It is worth a serious try in your business. You will get startling results too. Readability Light ---+- Serious Insights High +---- Low Practical High +---- Low *Ian Mann of Gateways consults internationally on leadership and strategy, and is the author of the recently released Executive

The book takes off gruelingly, but picks up the pace and reads like an exciting quest in search of holy check list. The book has inspired me to introduce check lists in some routine tasks i perform at work.

Ottimo

Thought provoking not just in learning how risky surgery actually is, even what is considered routine in advanced Western hospitals, but also in discussing how we can learn from other disciplines. I am curious how these lessons can be applied to developing checklists in even more fields.

I’ve had the checklist manifesto in my “to-read” list for about 5 years now. It’s a book I’ve had reccomended to me many times and, in a nutshell, it’s a manifesto for the use of checklists. Atul Gawande who wrote it is a surgeon who has a history of process improvement projects. The checklist manifesto is his attempt to convince people that checklists, simple as they are, can massively improve the output quality and consistency of tasks that we repeat frequently. What is more surprising though, is that his research uncovers that even in areas where there are complex problems for which we can’t cheklist – checklists can help significantly in resolving complex and unforeseen problems. The thesis is simple. Checklists raise output quality and consistency. The reason they do this is simple – we overestimate our ability to routinely perform series of tasks dramatically. In scenarios where there is stress or complication, the rate at which we overestimate our ability rises dramatically. Gawande examines three key scenarios – flight checklists, large scale construction projects and his own home – the operating theater. IN each scenario, he tackles simple, routine problems and also complicated and complex problems. What emerges is a surprisingly strong case for checklists as a tool to ensure consistency, and to change behavior, and also as a tool to aid resolution in complex and unforeseen circumstances. The bottom line is that we are inadequate repeaters of routine tasks, people routinely skip steps for one of two reasons – either they just forget through distraction or inattention, or they don’t know about, or don’t believe in the efficacy of a step – so they skip it. In each of these cases, checklists function as a kind of spot audit – telling people that they didn’t perform a step, and ensuring that they do. In many cases, authority was granted to people responsible for overseeing the checklist to stop a process if people didn’t perform it as written. What followed in each case, was a dramatic improvement in performance – in one case, a US hospital system had 1500 fewer yearly deaths after introducing checklists to key procedures. Routine tasks aside, complex tasks were also found to benefit. IN routine simple and complicated tasks, the series of steps required to be carried out were documented in order so that they could be directly followed. In Complex tasks however, this wasn’t possible because what was required to be done was typically an emergent phenomenon like an accident or disaster and needed to be analysed and dearth with on the fly. While task based checklists were not capable of operating in this environment, what was shown to produce results was checklists describing mandating communication among team members and the best results were found in cases that included delegation of authority to act away from a central organisation. The book contains excellent tips on how to make checklists work. It boils down to keep them short, precise, and practical. They don’t over-describe – they provide reminders of only the most critical and important steps. The point of invocation of the checklist needs to be clear for it to be useful. Checklists also come in two distinct types – Do-confirm and read-do. One is about an audit of what you carried out, the other provides steps to follow – which you do in order and tick off. Checklists should also be a maximum of 5 to 9 items – which is cognitively about all we can handle. There is also some very specific advice on formatting – right down to fonts and typeset. One interesting point made repeatedly was that there were substantial improvements in the ability to cope with crises by teams that came together at the start of a surgery to work through the checklist. Checklists are the simplest way to protect you, and others, from you – and the systematic mistakes you make by believing that you’re systematic – when you’re not. They’re also the simplest way to get an advantage without being smarter or first, you can be more thorough – EVERY time

Atual Gawande is an American-raised indian Born surgeon practicing in Boston and he is also a writer for the New Yorker he has written 3 books, all three of them excellent. Complications his first is a revelation, better his middle one I enjoyed less, and this third one, the Checklist, is spellbindingly good Gawande is no mere doctor he was also a Rhodes Scholar (i.e seriously bright) earning a PPE in Oxford England in the late 90s. To me, it seems that this is the secret to his appeal, he is a seriously intelligent and gifted academic, who later turned to the practical art of surgery. So he is very well rounded. The central feature of his writing is to convey to the layperson that there are no easy choices, no bravura macho surgeons who can reliably fix everything. He is searingly honest about the shortcomings of medecine and his own shortcomings in particular, relaying again and again over all three books where he has screwed up, often very badly. These accounts read very well as fair accounts of how difficult it is to actually do any significant surgery on anyone without killing them, or making them iller. He is neither too harsh nor seeking to exculpate himself. He starts with the premise that (nearly) all doctors want to help, but that medecine can be horribly complicated and difficult, that they make mistakes and they are sometimes out of their depth, and that they are all learning on the job. What is magnificent about checklists is that, you'd think there wouldn't be much to say about them, that could hold your interest for very long. In this you'd be seriously wrong. it turns out that our prejudicial views on checklists (we don't like them and find them patronising) is in inverse proportion to how useful they are regardless of your levels of commitment to excellence, ingenuity or sheer brilliance. In the heat of an emergency many of the things that go wrong are EXACTLY the kinds of things that simple checklists can help you spot when your mind skips steps to focus on what you think is essential. in this book, Gawande focusses on the usefulness of checklists in medecine, commercial flying, architecture/engineering and finance and he does a masterful writerly job of keeping you engaged and enlgightened as he slowly builds a very compelling case for dropping the prejudice and adopting the checklist in more and more areas of life. One fascinating aside to me, is that the going through a checklist with other people (say before operating) was no mere mechanical procedure, but that it had a 'activating effect' of equalising the status and hierarchy of all concerned, suddenly you were no longer just some nurse or mere technician in awe of the surgeon. In fact, taking responsibility for your own part of the checklist made you a vital member of a team, and it was this team building spirit that made people work better together, think better and most importantly handle disasters with far greater focus as they knew each other and didn't waste time on blame or evasion. Much more commonly checklists even prevented disasters because since everyone felt part of a team, the junior members were not so intimidated into not pointing out errors which could later develop into disasters. It's a list on a piece of paper, but adhering to it in this public and collegiate way, had a profound impact on the psychology of the practitioners solidifying their sense of being part of a team and therefore being steadfast in calling things as they saw them, rather than simply deferring to authority and keeping quiet (a frequent cause of all types of disasters). Gawande is a good friend of Malcolm Gladwell, but he is no mere wannabe, Gawande has his own unique authorial voice and he comes across as a genuinely likeable, clever decent and highly sophisticated but down to earth human being. He is such a good writer that not least of his skills is how funny he sometimes is when he points out the absurdities of human foibles (especially his own) and of taking on any ambitious human endeavour. He is no pious preacher.