The Checklist Manifesto: How to Get Things Right
by Atul Gawande
You might think, “everybody knows how to make a list.” But checklists aren’t those kinds of lists, and this book is about more than list-making.
As well as explaining the whys and hows of checklists, the book explores how they help us deal with the complexities professionals face today – managing complex situations that call for complex responses. And face these demands knowing what we know about human fallibility.
Complex environments present us with two main challenges. First, human memory and attention are fallible. We are prone to overlook mundane matters, especially under pressure. Distractions and faulty memory are especially hazardous in “all-or-none” situations where if you miss just one essential detail, it’s as if you didn’t try at all.
Second, people sometimes convince themselves that it’s OK to skip steps even when they remember them, which is equally dangerous. Sometimes — maybe most of the time — some steps don’t matter until one day there’s a case when they do.
Checklists can help protect anyone from these kinds of errors. They remind us of the minimum steps we need to follow and make those steps explicit.
They act as a kind of mental safety net. In addition to aiding memory, they help us catch the lapses we all experience from time to time, such as those involving attention and thoroughness.
And besides helping with verification, they also instill a discipline that drives higher performance.
Atul Gawande is the author of several bestselling books in addition to The Checklist Manifesto. He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and a professor at the Harvard Medical School and the Harvard School of Public Health.
The book is organized into nine chapters and includes an appendix with several examples of checklists and a checklist for making checklists.
This summary reflects my takeaways from a useful book I recommend to others. Reading a summary isn’t a substitute for reading the book. There’s much more than I can cover here. Plus, this is my interpretation. If these ideas resonate with you, I encourage you to get a copy of the book from your favorite bookseller. Here are the Amazon links: eBook | Audiobook | Print
There are three kinds of problems in the world: simple, complicated, and complex. Baking something following a recipe is a simple problem. Sending a rocket into space is a complicated problem. But responding to a natural disaster such as the aftermath of a hurricane is an example of a complex problem. Follow the recipe correctly, and the results are almost guaranteed. Once you’ve launched your first rocket, you can take what you learned and repeat the process to send other rockets. But every hurricane is different.
With complexity comes risk. And a typical response to risk is to centralize power and decision-making authority – to go the command-and-control route. A command-and-control mentality is a recipe for disaster in complex situations.
Attempts to dictate every step from the center will fail under true complexity, where the knowledge required surpasses the knowledge of any one individual. There needs to be room for people to adapt and act as well as an expectation of communicating, coordinating and measuring progress toward common goals. “[That] requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration.”
To achieve that balance, checklists must take two forms. First is a set of checks to ensure that the mundane but crucial items are not overlooked. Second, ensure that people talk and coordinate. Expect them to accept responsibility, but empower them to navigate the nuances and unpredictabilities using their experience and judgment.
Under conditions of complexity, checklists are not just helpful but essential. But they need to be deployed with the appropriate management philosophy. A philosophy where judgment is not only allowed but assisted and enhanced by good procedure, not replaced by procedure.
Complex situations are fraught with non-routine issues, and the best approach is to push decision-making out to the periphery. Give people the freedom to respond and adapt based on their expertise and experience. In return, expect them to respond to the situation, communicate with each other, coordinate appropriately within and without, and take responsibility for their actions. And act knowing that higher-ups will support their best judgment calls and actions.
Dealing with Human Fallibility
The volume and complexity of information we need to know and apply correctly have exceeded our abilities to do so reliably. Human memory and attention are fallible, especially regarding routine matters that are easily overlooked when we’re under pressure. That is, without the external support of checklists and teamwork.
Some things we want to do are simply beyond our capacity, but for those things within our reach, there are two causes of failure: The first is ignorance. We may error because the world and its workings are only partially understood by science or the current state of knowledge. The second is ineptitude. The knowledge exists, but we fail to apply it correctly. It’s what some may call negligence.
Knowledge can be augmented by teamwork — bringing the collective intelligence of the team to bear on the situation and encouraging team members to speak up. Researchers found that nurses are more likely to offer solutions when they are given a chance to introduce themselves and express their concerns at the beginning of a procedure. They called it an “activation phenomenon.” Giving people the opportunity to speak at the start activated their sense of participation and responsibility. Knowledge is only available if team members speak up.
Checklists facilitate competence. Checklists help us avoid the problems of fallible memories and flagging attention.
What Checklists Do
- Checklists provide an explicit outline of the steps required to complete a process successfully.
- They help with memory recall. They remind us of the minimum steps we must take.
- They are instrumental in managing “all or none” processes – situations where if you miss even just one important thing, you may as well not have tried at all.
- They are an aid, not a substitute for professional judgment. Checklists protect even experienced professionals from failure.
- They instill a kind of discipline that enhances performance. In addition to verifying that critical steps have been completed, researchers also found that using checklists establishes a higher standard of baseline performance.
The Benefits of Checklists
The book provides many examples of the benefits of checklists, one of which involves a study of venture capitalists. Those that use a checklist-driven approach when buying companies make better investment decisions. The checklist users had more than double the return on investment compared to their non-checklist counterparts. And they needed to take fewer corrective interventions to protect their investments, such as replacing the management team after the acquisition.
When creating a new checklist from scratch, you must make two decisions: (1) What type of checklist does the situation call for? (2) When is the appropriate “pause point” to use the checklist?
There are two types of checklists: DO-CONFIRM and READ-DO.
- With a DO-CONFIRM checklist, you rely on memory and experience to perform the tasks. But there’s a built-in pause point to run the checklist and ensure everything is completed.
- A READ-DO checklist is much like a recipe. You follow the checklist and check off the tasks as they are completed.
Make them concise. Don’t try to cover everything. Focus on the most critical steps, especially the “killer items” – the most dangerous steps to skip that are sometimes overlooked.
Keep them short — five to nine items, which is the limit of our working memory. It should fit on one page. It’s not a how-to guide. It’s a quick and straightforward tool that complements the skills of expert professionals.
Keep them clutter-free. Use a plain font and upper and lowercase, and no unnecessary colors.
Make them precise. Use simple and exact wording in the language of the profession. It has to be immediately understandable under challenging circumstances.
Keep them practical. It’s a reminder of the most crucial steps, those that even highly skilled professionals may overlook.
Those closest to the action should create the checklists. In one example, when doctors and nurses created their checklists, the consistency of care improved to the point that intensive care stays were cut in half.
All professions have a code of conduct that involves selflessness, skill, and trustworthiness. Aviation adds discipline to that list — discipline in following prudent procedures and working with others. Beyond ticking boxes, the checklist philosophy is about building a culture of discipline and teamwork.
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