The Checklist Manifesto
Atul Gawande has been a staff writer at The New Yorker since 1998. He has won the Lewis Thomas Prize for Writing about Science. Additionally, he has won a MacArthur Fellowship, two National Magazine Awards, and AcademyHealth’s Impact Award for highest research impact on health care. In 2020, after two years as CEO, he was named chairman of Haven. Haven is a health-care venture focussed on improving health outcomes and patient experience. He also works as a general and endocrine surgeon at Brigham and Women’s Hospital in Boston. Finally, he is the chair of two organizations. Firstly, Ariadne Labs, a joint center for health systems innovation. Plus, Lifebox, a nonprofit organization making surgery safer globally.
The Checklist Manifesto argues that we can do better by using the simplest of methods: the checklist. Atul Gawande reveals what checklists can do, what they can’t, and how they could bring about striking improvements in various fields. From medicine and disaster recovery to professions and businesses of all kinds, checklists have fantastic potential. Crucially, Gawande’s insights are making a difference. Already, a simple surgical checklist from the World Health Organization has been adopted in more than twenty countries. This has been called the most significant clinical invention in thirty years.
Top 10 Insights from the Book
1. The successful use of complex and advanced technology requires too many simple tasks to remember, and that using a checklist is a simple solution.
2. The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.
3. We are not built for discipline, we are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.
4. The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.
5. Checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net.
6. Checklists catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.
7. One essential characteristic of modern life is that we all depend on systems—on assemblages of people or technologies or both—and among our most profound difficulties is making them work.
8. Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognised the opportunity, the two-minute WHO checklist is just a start.
9. Mistakes and failures happen when (i) we lack the skills, knowledge or experience for a task, or (ii) we have the requisite skills and knowledge but fail to apply them correctly.
10. Drafting an effective checklists in 3 parts: (i) pre-planning, (ii) developing the checklist and (iii) testing your checklist in the real-world.
Chapter 1 – The Problem of Extreme Complexity
We live in a specialist era of clinicians who hone in on one skill until they are better than everyone else. They have two benefits over ordinary specialists: a better understanding of the details and the ability to handle the particular task’s complexities. Complex procedures are too often underestimated. This underestimation could be for the sake of ego or naivety. Gawande suggests you need to objectively analyze these complexities and understand the steps required to overcome these complexities. The process has become so complex that work must be specialized. Subsequently, you need specific individuals delegated to these tasks. Plus, checklists are a necessity to ensure that nothing essential is left out.
The necessity of checklists also applies to company processes. If a company develops a new, innovative product, then all aspects of development, manufacturing, and release must be described. If something is forgotten, then there can be severe consequences. For example, people could be injured, reputations could be damaged, and money could be lost. For companies, they must accept that no job is too complex to divide into a checklist. A checklist is a safety net that encourages better results. If a change is needed, the checklist will not be incorrect.
Chapter 2: The Checklist
“Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything–a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps–the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.”
Experts face two major difficulties in a dynamic climate. The first is the inaccuracy of human memory and attention. This issue is particularly true of routine items that are readily ignored for pressing events. Also, an insidious challenge is that irrespective of memory, people will skip steps. Certain steps do not always matter in complex processes. Checklists tend to prevent such errors. They highlight the essential steps required for success.
In December 2006, The Keystone Initiative released a groundbreaking article in the New England Journal. They found that the central line infection rate for Michigan’s ICUs decreased by 66 percent during the first three months of the project. The hospitals saved over $175 million in expenses and over fifteen hundred lives in the first eighteen months of the Keystone initiative. For many years, successes were sustained. The key to this success was a simple checklist.
Chapter 3: The End of the Master Builder
“The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.”
There are also complex issues that can be broken down into a collection of basic steps. You need both work lists and contact lists in these circumstances. Imagine a crew landing on an airplane and how catastrophic this dynamic, intense situation could be if those onboard did not communicate with others. The captain would not know if it was clear to land. Plus, the co-pilot would not know when or if to take over. Finally, the airmen would not know when to carry out security measures.
Complex task teams require seamless communication. In this example, the flight crew could follow a checklist. However, this checklist is useless unless they communicate clearly. The communication can be strengthened with steps to improve the flow of information in the checklist.
Firstly, Gawande speaks about a team “huddle.” These huddles are an opportunity for team members to introduce themselves at the start of a procedure. Additionally, these team members can also discuss any possible complications. Studies have shown that people who don’t know each other’s names don’t work well together. This is why a huddle has been included in the author’s Safe Surgery Saves Live checklist as an obligatory move. This more communicative teamwork approach has previously been associated with a reduction in medical complications.
In pressured circumstances, communication within teams is vital. Teams are more effective when they have predefined opportunities to connect.
Chapter 4: The Idea
True complexity is where the information needed is greater than anybody possesses. Hence, unpredictability prevails. In these instances, attempts are made to dictate each move from the middle. People need space for action and adjustment. Checklists provide many checks to ensure that clear but important items are not missed. Additionally, checklists provide other checks to ensure people speak, organize, and embrace accountability while maintaining the capacity to handle unpredictability.
Checklists also help prevent noticeable yet potentially severe errors. When treating a man for what he believed to be a shallow rod wound, an operating theater team in San Francisco experienced desperate circumstances. Only when a patient began to lose blood after the surgeon’s incision did they notice the injury was a foot long. No medical staff remembered to ask what sort of rod had injured the man. The patient had received this injury at a Halloween costume party.
The patient survived the injury. However, medical errors and misinformation occur with frightful regularity. Similar errors could be associated with severe complications or deaths. More than 50 million surgeries are carried out annually in the United States. More than 150,000 of these patients die after their surgery. Studies indicate that nearly half of these complications and fatalities can be prevented. To solve this, Gawande recommends using a checklist instead of investing millions in state of the art medical technology.
Chapter 5: The First Try
The key to succeeding on your first try is keeping things simple and communicating effectively. The author provides the example of a checklist created by a hospital to prevent surgical infections. They identified four unexpected complications associated with surgeries. The key to tackling all of these was effective team communication.
One of the common mistakes made during first tries is silent disengagement. This is an effect described by the psychologist Brian Sexton. Silent disengagement results in a lack of accountability among surgical team members. Instead of preventing issues, people just blame their mistakes on a lack of communication. So, you must include a step in your checklist where team members talk with each other. This is what Gawande learned during his first try of applying his checklist.
Chapter 6: The Checklist Factory
Characteristics of Specific Checklists
Poor checklists are ambiguous and inaccurate. Generally, these checklist types are created by individuals who do not know the conditions in which they are deployed. They approach people with these tools and attempt to justify each move. Instead of turning on, they turn the minds of people off.
Conversely, successful checklists are correct. Even in the most complicated circumstances, they are effective and easy to use. These checklists are concise and coherent, so they do not have to describe all. These checklists only include the most significant and crucial actions. Above all, good checklists are helpful.
One of the main facets of a checklist is the ‘killer products’ content. These are simple actions that could be catastrophic if not completed. Daniel Boorman is a veteran pilot who manufactured Boeing aviation checklists. He claimed that a checklist should consist of only five to nine desirable steps. Additionally, there should be a time limit on how long the checklist takes.
Deciding How You Want to Compile Your Checklist
You have various choices to make when you compile a checklist. A simple pause point must be established where the checklist can be adopted. However, this pause point is unrequired if the moment is obvious, like when a warning light goes on, or an engine fails. You need to determine whether you want a guide for the DO-CONFIRM or a READ-DO. Team participants execute their duties independently, often using a DO-CONFIRM checklist. They stop, though, and interrupt and run the checklist to ensure that all the work to be completed has been done.
Conversely, people execute the activities with a READ-DO inspection list. This is more like a recipe. However, you have to select the form that makes more sense to the scenario for every new checklist produced. As stated earlier, a rule of thumb for length is between 5 and 9 objects. This is the memory limit. This length also prevents shortcutting. After roughly 60-90 seconds, people start taking shortcuts with checklists. Subsequently, you want to make the list short by concentrating on the “killer items.” The killer items are the riskiest actions you can take that are often ignored. The text should be clear and precise, and professional vocabulary should be used. Even the checklist’s aesthetic is significant. For example, your checklist should preferably fit on one page. It must be clear of excessive colors.
The functioning of checklists in dynamic working lines is generally misconceived. They are not detailed manuals. They should not be used to build a skyscraper or to get an aircraft out of trouble. Instead, they are brief and convenient tools built to improve the expertise of specialists.
Chapter 7: The Test
After learning from other checklist experts, Gawande decided to revise the WHO checklist. He decided that a test run was the best way to identify areas that needed improvement. The test included 19 checks before being sent out to 8 sites for a test run. These sites were medical centers with different equipment. The outcome was that care had improved on every site after implementation of the checklist. 20% of the professionals described the list as difficult to use. That said, 93% wanted the checklist to remain.
Chapter 8: The Hero in the Age of Checklists
“One essential characteristic of modern life is that we all depend on systems—on assemblages of people or technologies or both—and among our most profound difficulties is making them work.”
Berwick notes anyone who studies systems instantly realizes that optimizing is not an easy road to system greatness. We are fascinated with the medication with the fantastic components. We are fascinated with the best medicines, the best equipment, and the best specialists. However, we pay no attention to how to make it work together properly.
We Need Teams Rather than Heroes
It’s the team that really matters in dynamic and risky circumstances. Engineering was established some time before master builders supervised building projects. However, the execution of a single building project today demands the interaction of experts. These experts must be concerned with everything from equipment and steel to the handling of water and rodents.
In coping with crises and urgent circumstances, teams are particularly valuable. The media welcomed Chesley B. Sullenberger in 2009 as “Captain America.” He was considered the miracle crash-landing hero when nobody was injured after the Hudson River plane crashed. Sullenberger maintained that it was a joint effort. It became apparent that without Sullenberger, First Officer Jeffrey Skiles, and the rest of the crew, the aircraft would not have landed. It was the joint effort that facilitated this heroic act.
When faced with difficulty or uncertainty, we must understand that sometimes, several individuals’ acts and abilities are more effective in a complicated procedure.
Chapter 9 – The Save
After improving the checklist and continuing to see positive results, Gawande ends the book with some reservations. He didn’t have full faith in the checklist as a tool for surgeons until it saved a person’s life. In 2007, Gawande had a close call with a patient. They experienced complications that they had prepared for because of the checklist. So, they had a supply of blood ready to keep the patient alive for the remainder of the surgery. The checklist genuinely saved this person’s life. After this, Gawande was a true believer in the power of the checklist.
“We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.”
– Atul Gawande