The Checklist Manifesto: How to Get Things Right

Why do we fail?

Of course, there are many possible answers to this question, but in a 1970s essay, Samuel Gorovitz and Alysdair MacIntyre broadly observed that we fail either due to ignorance (we don’t know) or ineptitude (we did know or should’ve remembered, but failed to heed).

For much of human history, our failures were primarily those of ignorance. However, in modern times, our rapidly increasing knowledge has exceeded our capabilities to manage it all. In The Checklist Manifesto, surgeon Atul Gawande talks about a simple way of preventing these failures of ineptitude; a checklist.

How can something which is seemingly so trivial make such a difference in medicine or in yours or my daily life? As Atul describes it:

“Here, then, is the fundamental puzzle of modern medical care: you have a desperately sick patient and in order to have a chance of saving him you have to get the knowledge right and then you have to make sure that the 178 daily tasks that follow are done correctly — despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help ‘get this lady’s chest open.’ There is complexity upon complexity. And even specialization has begun to seem inadequate. So what do you do?” — Atul Gawande

Later in that same chapter, Atul goes on to describe the results of a pilot project across Michigan’s hospitals, in which surgical teams adopted a brief checklist at various stages of their procedures:

“[He] was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. … In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now — all because of a stupid little checklist.” — Atul Gawande

To me, that is staggering to consider. Doctors — and particularly surgeons — are some of society’s most intelligent, educated and driven people. Who would’ve imagined that something so simple could make such a profound difference?

Here are some of my key takeaways:

• Checklists are everywhere. In software development, we use checklists on a regular basis. One example is regression testing; large software projects may be composed of millions of lines of code, spanning thousands of files. Modifying any single component often causes unforeseen ripple effects elsewhere in the system. It can be very difficult to understand exactly how all of the various moving parts are interconnected. Therefore, when developers make changes, we often re-test all known functions of the system, in order to ensure that modifications didn’t produce unintended consequences.

  In surgery and in intensive care, the use of checklists routinely reduce errors and save lives. Checklists have enabled commercial airline pilots to safely perform dramatic landings in response to critical engine failures. They help some of the world’s most successful fund managers to calculate risk and provide guidance to builders of everything from cars to homes to skyscrapers.

• There are three kinds of problems; the simple, the complicated and the complex. Even in the midst of the complicated and complex, we are often overwhelmed by simple problems which are ideally suited for the checklist.
  

  [A] key step is to identify which kinds of situations checklists can help with and which ones they can’t. … Simple problems [are] ones like baking a cake from a mix. There is a recipe. Sometimes there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success.

  Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. Success frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent. Timing and coordination become serious concerns.

  Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all.” — Atul Gawande

• Checklists should be brief; they remind us only of the most critical and important steps that even experienced professionals can miss. Particularly when time is limited (in the event of an engine failure at 30,000 feet or cardiac arrest on the operating table), checklists must quickly cut to the point.
  

  “An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.” — Atul Gawande

• Checklists should be precise. The checklist must tell the reader exactly what to do or evaluate. (As an aside, David Allen talks about this in Getting Things Done; we are only free to act quickly and decisively once we’ve identified exactly what our next step is.)
• Checklists don’t replace critical thinking; they supplement it. In complicated and complex work, expertise remains valuable. I’ll never walk into a hospital, pick up a surgical checklist and successfully remove a tumor from someone’s adrenal gland. The idea is that a checklist helps a trained professional to ensure that she has taken care of the simple stuff so that she is free to focus on the complex stuff.
  

  “It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals.” — Atul Gawande

• Checklists aren’t fun, but they’re valuable even to highly-skilled experts. Before there was data to reinforce their value, Atul often had trouble selling the concept to surgeons, who felt that use of checklists would undermine their considerable skill and control of the operating room.

  Even for those of us who are willing to concede benefit, checklists are boring. Building a new website is fun! Releasing major new features is fun! Regression testing the whole thing from A-Z is not fun at all.

  “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. … 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

• Checklists require discipline and discipline is hard. Big ideas are cheap; executing them to perfection takes discipline. “God is in the details.”
  

  “Discipline is hard … We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. 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.” — Atul Gawande

• Checklists may also be used to coordinate communication. More than “build this” or “code that”, checklists can also remind us to circle up with fellow team members to talk about steps taken. Discussing them as a group provides opportunity to revisit concerns and receive helpful feedback.
  

  “They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.

  Man is fallible, but maybe men less so” — Atul Gawande

Personally, details are unequivocally not my strength. I like to think big picture; to ask what if and to dream. I have great ideas but don’t always execute them fully. I may write a great user interface, but then stumble with “trivial” minutiae that any ten-year old can grasp. For me, maybe more than most people, checklists are an absolute necessity.

Maybe my biggest takeaway from The Checklist Manifesto is that even for highly skilled and motivated professionals who are detail-oriented, checklists can still deliver massive value.

I enjoyed The Checklist Manifesto and generally enjoy reading anything written by Atul Gawande. Also, for more on the topic of lists in general and seeing benefit in your life, I recommend Getting Things Done by David Allen.