The Checklist Manifesto: How to Get Things Right

I enjoyed this book immensely. It's about a lot more than the value of checklists, though it is absolutely about that. It's a practical treatise, though, on recognizing our own limitations and fallibilities. Even (or especially) if we are highly trained, specialized professionals. It has a lot to say about skepticism as the foundation of science, and how difficult it can be to remember that. Gawande relates the challenges he's faced in getting medical professionals to accept the benefits of this practice, even in the face of research--there is such a tendency to cling to intuition and gut reaction, even in the face of growing evidence that questions it.

Human beings make mistakes. It's a sad fact of life. Even intelligent, highly-trained people with lots and lots of experience at what they're doing make mistakes, especially in urgent or high-pressure situations. People get distracted at a crucial moment and miss a routine step, or they carry out routine steps on autopilot despite special circumstances that mean those steps should be skipped. Important information sometimes doesn't get to the people who need it most. People who notice problems sometimes don't say anything because they don't feel it's their place to speak up. And so on.

So, how do you deal with this? Well, enter the humble checklist. The airline industry has known about the power of a well-designed checklist for ages, but show more other areas that can seriously benefit from this practice have been slow to catch on, including Gawande's own field of surgery. But it turns out the introduction of checklists into the operating theater has astonishing, dramatic effects on reducing the rate of surgical complications and death from surgical complications. Of course, it has to be the right kind of checklist, and there's a real art to making them. A good checklist covers things that are important but easily missed, it fits quickly and easily into the natural workflow of the people using it, and, perhaps most critically, it increases communication among people who really need to make sure they're all properly informed and on the same page.

Gawande makes a strong, clear case for all of this, with a mixture of scientific data, case studies, personal anecdotes, and thoughtful examinations of how checklists are (or aren't) used in a variety of fields. You'd think this subject could get a bit dull, but Gawade's writing is vivid and readable, his experiences are relatable (even for those of us who aren't surgeons), and his examples and explorations are always interesting. I'd say this is a good read for anyone who is interested in how people get things done in general or in the practice of medicine in particular, and an essential one for anyone whose job involves making decisions about how to handle complex situations in which the stakes are high.

Rating: I'm going to give it a 4.5/5. Four of those stars are for being a good book, and the extra half-star is for being an important one. show less

One of the best books I've read this year. It had me in tears in a couple of spots, which is hard to explain given it's essentially an argument for creating checklists for complicated tasks. But Gawande's description of surgery and what his team discovered are so moving; you immediately see how this technique is applicable to so many circumstances, and he makes the real human costs and benefits of getting this right crystal clear. This is neither a "big business idea" book, nor a "harrowing medical stories" book, but a hybrid better than both.

Gawande makes an important point: checklists are valuable to experts, not just novices. And they are useful across industries and occupations. Airline pilots, structural engineers and safety inspectors regularly use them to good effect. They can either be "do-check" or "run-do" and are utilised at specific pause points within a task. Value investors sometimes use checklists. Gawande presents some evidence that those that do fare better than "gut instinct".

Surgeons, he believes, should take the leap and use checklists. The point could have been made even more strongly by detailing the cognitive bias which affects most professionals, the one that makes the majority think they are above average. Specific to medicine, Gawande suggests some show more of the possible reasons checklists are eschewed: the need for doctors to "own" patient care through their own expertise; the media's idolisation of individual heroism; and the condescension with which some doctors hold professionals such as nurses who might well promote checklists.

What I love, therefore, about Gawande's approach is his insistence that checklists are a means of teams improving outcomes, not one of trying to bolster individual performance. Teams should introduce each other by name. Checklists in surgery should be verbal and can be run by any member of the team. This encourages knowledge sharing and holistic thinking. Gawande posits that successful results to complex problems are mostly due to effective teamwork and communication, not the heroism or brilliance of any individual. This story I can believe. show less

What if we had a relatively easy way to improve outcomes in a wide variety domains, but the technique made us feel a little less smart? In this book, Gawande argues that checklists are such a tool. Checklists are ubiquitous in commercial flight; they are starting to make inroads in medicine. They can decrease the incidence of the problems they are targeted to to degrees that would be considered huge successes for other interventions.

Yet when checklists are introduced into a new setting, there is often resistance. Gawande offers two reasons. First, we often feel that we don't need the checklists -- we're smart, and it's not like the information they're conveying is new. Second, good checklists are hard to design, and bad checklists waste show more time and increase frustration.

So why do checklists help? We're talking about smart people -- doctors, pilots, engineers. Don't they know this stuff already? Aren't their jobs too complicated to be reduced to a checklist? Gawande differentiates between three types of problems: simple problems, complicated problems, and complex problems. Simple problems are those where knowing the right techniques and following the recipe will give the right result. Complicated problems require coordination and planning. The parts may be individually simple or complex, but even if they're all simple, the sheer overhead of getting everything done and at the right time makes the problem challenging. Complex problems are those where every instance brings new challenges. The tools you use for simple and complicated problems may help, but fundamentally, complex problems require novel problem solving.

Checklists shine in the domain of the complicated, in the areas where each step is one where a trained practitioner would say "I know how to do that", but where, in the hectic conditions of the real world, it can be hard to actually remember to do each of the steps. Seeing improved outcomes when checklists are used does not mean that the practitioners are unskilled. Instead, checklists free up capacity for thinking about the complex aspects of a problem.

Freeing up capacity is not the only value checklists provide when dealing with complex problems. They can also be used to improve problem solving in a team setting. Checklists can provide communication checkpoints which can help with problem solving. E.g., by adding a step that gives everyone on the team a chance to express concerns they have about a procedure, you can reduce the incidence of conformity biases where people tend to feel less confident in their doubts if everyone else is confident.

The other common issue with checklists is that they can be bad. As Gawande puts it, "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 to buttress the skills of expert professionals."

What this means in practice is that checklists should be short, five to nine items is a good rule of thumb. They should be triggered by unambiguous pause points, e.g., just before making the first incision in an operation. The wording should be simple and exact; as implied above, a checklist should not be telling you how to do something, just that you should do it. Most importantly, a checklist should be tested under realistic conditions.

When is it worth doing all of this work to create a good checklist? Checklists should be targeted to situations where intervention can significantly change the odds of a good outcome. If the consequences of something being done wrong are not bad, cut it out of the list. If something is so ingrained that practitioners truly never forget it, cut it out of the list. But if there's something that's sometimes forgotten and makes a noticeable difference in aggregate, then that is a good candidate for a checklist.

In case you can't tell, I really liked this book and the message it conveys. This is not just because the specific ideas about checklists are useful. This book also expresses one of my core beliefs about process: a good process is one which allows people to feel like they are spending more time on what is most meaningful. A good process reduces the time spent on bureaucracy. A good process is the equivalent of automation for things that cannot yet be automated. Checklists are a good process. show less

Celebrated surgeon and author Atul Gawande is sold on the importance of checklists in all areas of professional life. In The Checklist Manifesto, he goes into great detail to sell the reader on them as well. Ok, ok, I'm convinced!

Gawande shares anecdotes from the several professional fields, including medicine, construction, finance, and aviation to illustrate his point: checklists add value by preventing errors and helping teams work more efficiently. But although the usefulness of checklists is readily apparent, several barriers stand in the way of widespread implementation. One is the common view of the lone surgeon, pilot or other expert as an autonomous "hero" who does not need to rely on anything as mundane as a checklist. show more Another is the fact that said hero needs to give up some of his power in order for the checklist to work its magic. Throughout the book, I felt Gawande personally struggling with his own fallibility, although in every case, his patients survive.

I didn't really enjoy reading this book, and felt that its contents could have been reduced to a few pages in graduate business or public administration program textbooks. But then the checklist concept would not have gotten all the attention that it deserves. show less

This book is an interesting collection of anecdotes about how the humble checklist is essential for maintaining professionalism in a world where the sheer wealth of information and knowledge far exceeds what any one person can learn and implement on their own. As the division of labour has lead to ever more specialists, the success of any given project, from building a skyscraper to performing a surgical operation, relies on the consistant implementation of one's own specialist knowledge but also on good teamwork and effective communication.

When I started reading this book I was expecting more practical advice. I found the chapter about how a skyscaper is built, and built so that they never fall down, fascinating. It also showed that show more devising an effective checklist itself requires expertise, teamwork and trial and error. Atul Gawande effectively demonstrates the importance of communication and discipline in getting things right.

One of the most interesting parts of the book was when Atul Gawande discussed the emergency landing of the US Airways flight 1549 into the Hudson river. It was a good example of humanity's need for hero worship and I had accepted without question the news reports that the passengers were simply lucky to have a pilot who used to fly for the Air Force. The fact that no-one died is still incredible, it's just that the reason for this had little to do with Sullenberger's military history (as he himself kept saying) and much to do with the discipline of all the staff who followed procedures correctly (with help from checklists), computer assisted landing, training and experience from both pilots who communicated with each other and the cabin crew; and of course a little luck. show less