The Checklist Manifesto: How to Get Things Right

by Atul Gawande

But the evidence suggests we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results.

This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to what ever problems might arise.

The family gave me the credit, and I wish I could have taken it. But the operation had been symphonic, a thing of orchestral beauty.

I’d have said it was just the good fortune of the circumstances—the accidental result of the individuals who happened to be available for the case and their particular chemistry on that particular afternoon. Although I operated with Zhi frequently, I hadn’t worked with Jay or Steve in months, Joaquim in even longer. I’d worked with Thor just once. As a group of six, we’d never before done an operation together. Such a situation is not uncommon in hospitals of any significant size.

That’s what the checklists from Toronto and Hopkins and Kaiser raised as a possibility. 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. So was another step that these checklists employed, one that was quite unusual in my experience: surgical staff members were expected to stop and make sure that everyone knew one another’s names.

The Johns Hopkins checklist spelled this out most explicitly. Before starting an operation with a new team, there was a check to ensure everyone introduced themselves by name and role: “I’m Atul Gawande, the attending surgeon”; “I’m Jay Powers, the circulating nurse”; “I’m Zhi Xiong, the anesthesiologist”—that sort of thing.

There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do.

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.

Yet here, in three separate cities, teams had tried out these unusual checklists, and each had found a positive effect.

the preoperative briefing led the team to recognize that a vial of potassium chloride had been switched with an antibiotic vial—a potentially lethal mix-up. In another, the checklist led the staff to catch a paperwork error that had them planning for a thoracotomy, an open-chest procedure with a huge front-to-back wound, when what the patient had come in for was actually a thoracoscopy, a videoscope procedure done through a quarter-inch incision.

None of these studies was complete enough to prove that a surgical checklist could produce what WHO was ultimately looking for—a mea sur able, inexpensive, and substantial reduction in overall complications from surgery. But by the end of the Geneva conference,

we had agreed that a safe surgery checklist was worth testing on a larger scale.

Boorman’s flight operations group is a checklist factory, and the experts in it have learned a thing or two over the years about how to make the lists work.

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.

Pilots nonetheless turn to their checklists for two reasons. First, they are trained to do so. They learn

from the beginning of flight school that their memory and judgment are unreliable and that lives depend on their recognizing that fact. Second, the checklists have proved their worth—they work. However much Pilots are taught to trust their procedures more than their instincts, that doesn’t mean they will do so blindly. Aviation checklists are by no means perfect. Some have been found confusing or unclear or flawed. Nonetheless, they have earned Pilots’ faith. Face-to-face with catastrophe, they are astonishingly willing to turn to their checklists. In the cockpit voice recorder transcript of the

CAPTAIN: You want me to read a checklist? FLIGHT ENGINEER: Yeah, I got it out. When you’re ready. CAPTAIN: Ready.

To Pilots, the checklists have proved worth trusting, and that is thanks to people like Boorman, who have learned how to make good checklists instead of bad. Clearly, our surgery checklist had a ways to go.

So you want to keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless.

What experts like Dan Boorman have recognized is that the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form.

We adopted mainly a DO-CONFIRM rather than a READ-DO format, to give people greater flexibility in performing their tasks while nonetheless having them stop at key points to confirm that

critical steps have not been overlooked. The checklist emerged vastly improved.

Every line of the checklist needed tweaking. We timed each successive version by a clock on the wall. We wanted the checks at each of the three pause points—before anesthesia, before incision, and before leaving the OR—to take no more than about sixty seconds, and we weren’t there yet.

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. Furthermore, an item critical to one expert might not be critical to another.

But compared with the big global killers in surgery, such as infection, bleeding, and unsafe anesthesia, fire is exceedingly rare.

The final WHO safe surgery checklist spelled out nineteen checks in all. Before anesthesia, there are seven checks. The team members confirm that the patient (or the patient’s proxy) has personally verified his or her identity and also given consent for the procedure. They make sure that the surgical site is marked and that the pulse oximeter—which monitors oxygen levels—is on the patient and working. They check the patient’s medication allergies. They review the risk of airway problems—the most dangerous aspect of general anesthesia—and that appropriate equipment and assistance for them are available. And lastly, if there is a possibility of losing more than half a liter of blood (or

the equivalent for a child), they verify that necessary intravenous lines, blood, and fluids are ready.

Lastly, the hospitals had to be willing to allow observers to measure their actual rates of complications, deaths, and systems failures in surgical care before and after adopting the checklist. Granting this permission was no small matter for hospitals. Most—even those in the highest income settings—have no idea of their current rates. Close observation was bound to embarrass some. Nonetheless, we got eight willing hospitals lined up from all over the globe.

We tracked performance of six specific safety steps: the timely delivery of antibiotics, the use of a working pulse oximeter, the completion of a formal risk assessment for placing an airway tube, the verbal confirmation

of the patient’s identity and procedure, the appropriate placement of intravenous lines for patients who develop severe bleeding, and finally a complete accounting of sponges at the end of the procedure. These are basics, the surgical equivalent of unlocking the elevator controls before airplane takeoff. Nevertheless, we found gaps everywhere. The very best missed at least one of these minimum steps 6 percent of the time—once in every sixteen patients. And on average, the hospitals missed one of them in a startling two-thirds of patients, whether in rich countries or poor. That is how flawed and inconsistent surgical care routinely is around the world.

Then, starting in spring 2008, the pilot hospitals began implementing our two-minute, nineteen-step surgery checklist. We knew better than to think that just dump...

was going to change anything. The hospital leaders committed to introducing the concept systematically. They made presentations not only to their surgeons but also to their anesthetists, nurses, and other surgical personnel. We supplied the hospitals with their failure data so the staff could see what they were trying to address. We gave them some PowerPoint slides and a couple of YouTube videos, one demonstrating “How to Use the Safe Surgery Checklist” and one—a b...

The introduction of names and roles at the start of an operating day proved a point of particularly divided view. From Delhi to Seattle, the nurses seemed especially grateful for the step, but the surgeons were sometimes annoyed by it. Nonetheless, most complied.

The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent.

The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.

Suppose, I said, this improvement wasn’t due to the checklist. Maybe, just by happenstance, the teams had done fewer emergency cases and other risky operations in the second half of the study, and that’s why their results looked better.

Suppose this was just a Hawthorne effect, that is to say, a byproduct of being observed in a study rather than proof of the checklist’s power.

The team took me through the results for each of the eight hospitals, one by one. In every site, introduction of the checklist had been accompanied by a substantial reduction in complications. In seven out of eight, it was a double-digit percentage drop. This thing was real.

In our eight hospitals, we saw improvements in administering antibiotics to reduce infections, in use of oxygen monitoring during operations, in making sure teams had the right patient and right procedure before making an incision. But these particular improvements could not explain why unrelated complications like bleeding fell, for example. We surmised that improved communication was the key. Spot surveys of random staff members coming out of surgery after the checklist was in effect did indeed report a significant increase in the level of communication. There was also a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications.

But Cook had put a check on his three-day list that ensured his team had reviewed the fine print of the company’s mandatory stock disclosures, and he discovered the secret.

The checklist doesn’t tell him what to do, he explained. It is not a formula. But the checklist helps him be as smart as possible every step of the way, ensuring that he’s got the critical information he needs when he needs it, that he’s systematic about decision making, that he’s talked to everyone he should. With a good checklist in hand, he was convinced he and his partners could make decisions as well as human beings are able. And as a result, he was also convinced they could reliably beat the market.

I asked him whether he wasn’t fooling himself. “Maybe,” he said. But he put it in surgical terms for me. “When surgeons make sure to wash their hands or to talk to everyone on the team”—he’d seen the surgery checklist—“they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.”

What Cook says is certain, however, was that in a period of enormous volatility the checklist gave his team at least one additional and unexpected edge over others: efficiency.

When he first introduced the checklist, he assumed it would slow his team down, increasing the time and work required for their investment decisions. He was prepared to pay that price. The benefits of making fewer mistakes seemed obvious. And in fact, using the checklist did increase the up-front work time. But to his surprise, he found they were able to evaluate many more investments in far less time overall.

With the checklist in place, however, he observed that he could move through investment decisions far faster and more methodically. As the markets plunged through late 2008 and stockholders dumped shares in panic, there were numerous deals to be had. And in a single quarter he was able to investigate more than a

hundred companies and add ten to his fund’s portfolios.

What makes these investors’ experiences striking to me is not merely their evidence that checklists might work as well in finance as they do in medicine.

Every idea, that is, except one: checklists.

One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.

Then there were the investors Smart called the “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.