📚 The Checklist Manifesto by Atul Gawande

Author: Atul Gawande
Full Title:
The Checklist Manifesto
Finished Date:
November 2022
Amazon Link

Rating: 5 stars ⭐️⭐️⭐️⭐️⭐️

I give this book five stars twice over - once for the art of storytelling and once for the core message.

As a storyteller, Gawande masterfully weaves individual human experiences and stories into the tapestry of a larger narrative. The pacing, timing, and articulation of key pieces of the story dance like well-rehearsed choreography around a central altar: the checklist.

As a messenger, Gawande suggests humility and rationality guide medical professionals (each of us) to level up their (our) game. In jobs where mistakes have big stakes - pilots, surgeons, high-rise developers, billion-dollar hedge fund managers - carefully designed and tested checklists radically improve desired outcomes.

The logic, and the data to prove it, is irrefutable -- so why doesn't every serious professional use checklists?

Overarching Notes:

There are two reasons why we make mistakes:

  • 1) We have only "partial understanding" (gaps in knowledge)
  • 2) We have the knowledge, but don't apply it well (ineptitude)

To perform at a high level, especially when it really matters, is to do a set of tasks consistently and correctly.

The volume and complexity of what we know have exceeded our individual ability to deliver its benefits correctly, safely, or reliably.

In complex environments, there are two main difficulties

  • 1) fallibility of human memory and attention (especially in mundane)
  • 2) (irrationally) rationalizing skipping steps - thoroughness

^^Well-crafted checklists, diligently followed, establish a higher standard of baseline performance^^.

To prepare for situations checklists can't address,

  • push power to those closest to the problem
  • adapt based on experience and expertise
  • communicate to teammates and stakeholders
  • take responsibility

In conditions of true complexity, the knowledge required exceeds that of any one individual and unpredictability reigns.

To succeed in complex conditions, there is a mix of freedom and expectation.

Excellence can be found at the balance of:

  • freedom and discipline
  • craft and protocol
  • specialized ability and group collaboration

Saying one's name + discussing case details before beginning, even briefly, significantly improves teamwork scores

Activation phenomenon - giving people a chance to speak at the start activates engagement, responsibility, and willingness to speak up

Bad checklists are

  • Vague
  • Imprecise
  • Too long
  • Hard to use
  • Impractical
  • Talking down (vs lifting up)
  • Turn brains off (vs turning on)

Good checklists are

  • Precise
  • Efficient
  • Simple
  • Short (5-9 items & <90 seconds)
  • Easy to use (even in difficult situations)
  • Easy to read (single page / index card, large font)
  • Remind of most critical and important steps
  • Omitting intentionally
  • Practical

Effective checklists are used at clear pause points

Two kinds of checklists

  • DO-CONFIRM - team members perform their jobs from memory and experience, often separately, then stop at pause point to confirm each item was done
  • READ-DO - people carry out tasks as they check them off

^^Test checklists in the real world^^

Refining checklists inspires searching out patterns of mistakes and failures as well as successes

  • This is useful at every stage of mastery, including the absolute highest levels

From Geoff Smart, 6 types of investors

  • 1) Art Critics - assess entrepreneurs (almost at a glance) based on intuition and experience
  • 2) Sponges - soak up data streams (interviews, on-site visits, references, etc) then go with their gut
  • 3) Prosecutors - interrogate, test, and challenge, often with hypotheticals
  • 4) Suitors - more woo than on evaluate
  • 5) Terminators - see evaluation as doomed to failure and skip it
  • 6) Airline Captains - approach methodically with a checklist. Study past mistakes and lessons then build formal checks into their process. Disciplined not to skip steps.
  • Airline Captains have the best returns by far

^^It somehow feels embarrassing and beneath us to use a checklist^^

  • This is likely driven by a perception of lack of trust or lack of ability
  • Important: these are symptoms of bad checklists. Check the basics first

To overcome, use this powerful reframe

  • Checklists get the mundane off your mind so you can focus on mastery

Professional code of conduct (for those who accept responsibility for others):

  • Selflessness - I place the needs and concerns of those who depend on me above my own
  • Skill - I aim for excellence in knowledge and expertise
  • Trustworthiness - I take responsibility for my personal behavior toward charges
  • Discipline - I follow prudent procedures and work well with others

Include a "publish date" and change log for each checklist

Favorite Quotes:

"Knowledge has both saved us and burdened us."

"... checklists seem able to defend anyone, even the experienced, against failure ..."

  • I would modify this as "especially the experienced"

"[Checklists] are quick and simple tools aimed to buttress the skills of expert professionals."

Further areas [[To Research]]

[[Samuel Gorovitz]] and [[Alasdair MacIntyre]]'s short essay on the nature of human fallibility

[[Brenda Zimmerman]] of York University and [[Sholom Glouberman]] of the University of Toronto - two professors who study the science of complexity

[[Geoff Smart]], a Ph.D. psychologist once at Claremont Graduate University

  • His research project on investors
  • His book on hiring Who

Book Highlights

In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. (Location 110)

The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. (Location 117)

The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. (Location 119)

But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly. (Location 140)

Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. (Location 161)

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. (Location 183)

Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. (Location 304)

^^In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.^^ (Location 446)

^^A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter.^^ (Location 451)

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. (Location 455)

Checklists, he found, established a higher standard of baseline performance. (Location 497)

checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. (Location 593)

They ^^catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness^^. (Location 594)

Two professors who study the science of complexity—Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex. (Location 597)

must be prepared for unpredictable turns that checklists seem completely unsuited to address. (Location 624)

what to do when a difficult, potentially dangerous, and unanticipated anomaly suddenly appears on the fourteenth floor of a thirty-two-story skyscraper under construction. 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. (Location 908)

the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals. (Location 986)

They had made the reliable management of complexity a routine. That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. (Location 990)

set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how. (Location 993)

Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork—a kind of team huddle, as it were. (Location 1350)

The ^^researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.^^ (Location 1363)

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. (Location 1506)

They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. (Location 1508)

^^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 professionals using them could miss. Good checklists are, above all, practical. (Location 1509)

The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them. (Location 1512)

When you’re making a checklist, Boorman explained, you have a number of key decisions. (Location 1541)

You ^^must define a clear pause point at which the checklist is supposed to be used^^ (unless the moment is obvious, like when a warning light goes on or an engine fails). (Location 1541)

You ^^must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist^^. (Location 1542)

With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. (Location 1543)

With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation. (Location 1545)

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. (Location 1547)

But after about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things. People start “shortcutting.” Steps get missed. (Location 1549)

The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. (Location 1553)

Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.) (Location 1554)

no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently. (Location 1558)

The three checklists took no time at all—maybe thirty seconds each—plus maybe a minute for the briefing. The brevity was no accident, Boorman said. (Location 1587)

The ^^omissions were intentional^^, he explained. Although these are critical steps, experience had shown that professional pilots virtually never fail to perform them when necessary. So they didn’t need to be on the checklist—and in fact, he argued, shouldn’t be there. (Location 1613)

They are ^^quick and simple tools aimed to buttress the skills of expert professionals^^. (Location 1616)

The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form. (Location 1682)

This proved the most difficult part of the exercise. 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. (Location 1723)

Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place. (Location 1979)

Geoff Smart, a Ph.D. psychologist who was then at Claremont Graduate University, conducted a revealing research project. He studied fifty-one venture capitalists, people who make gutsy, high-risk, multimillion-dollar investments in unproven start-up companies. (Location 2140)

These were styles of thinking, really. He called one type of investor the “Art Critics.” They assessed entrepreneurs almost at a glance, the way an art critic can assess the quality of a painting—intuitively and based on long experience. (Location 2151)

“Sponges” took more time gathering information about their targets, soaking up whatever they could from interviews, on-site visits, references, and the like. Then they went with whatever their guts told them. (Location 2153)

The “Prosecutors” interrogated entrepreneurs aggressively, testing them with challenging questions about their knowledge and how they would handle random hypothetical situations. (Location 2155)

“Suitors” focused more on wooing people than on evaluating them. (Location 2156)

“Terminators” saw the whole effort as doomed to failure and skipped the evaluation part. (Location 2157)

“Airline Captains.” They took a methodical, checklist-driven approach to their task. Studying past mistakes and lessons from others in the field, they built formal checks into their process. They forced themselves to be disciplined and not to skip steps, even when they found someone they “knew” intuitively was a real prospect. (Location 2159)

Smart published his findings more than a decade ago. He has since gone on to explain them in a best-selling business book on hiring called Who. (Location 2170)

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. (Location 2174)

The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?). (Location 2229)

All learned occupations have a definition of professionalism, a code of conduct. (Location 2298)

First is an expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own. (Location 2300)

Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise. (Location 2302)

Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges. (Location 2302)

Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. (Location 2303)

Airline manufacturers put a publication date on all their checklists, and there is a reason why—they are expected to change with time. In the end, a checklist is only an aid. If it doesn’t aid, it’s not right. But if it does, we must be ready to embrace the possibility. (Location 2317)

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