The Checklist Manifesto: How to Get Things Right

by Atul Gawande

“necessary fallibility”—some things we want to do are simply beyond our capacity.

Gorovitz and MacIntyre point out, we have just two reasons that we may nonetheless fail. The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works.

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

But sometime over the last several decades—and it is only over the last several decades—science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.

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.

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.

create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.

Meanwhile, Blue Cross Blue Shield of Michigan agreed to give hospitals small bonus payments for participating in Pronovost’s program. A checklist suddenly seemed an easy and logical thing to try.

So a key step is to identify which kinds of situations checklists can help with and which ones they can’t. 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.

Simple problems, they note, are ones like baking a cake from a mix.

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.

Complex problems are ones like raising a child.

feature of complex problems: their outcomes remain highly uncertain.

engineers call “forcing functions”: relatively straightforward solutions that force the necessary behavior—solutions like checklists.

“submittal schedule.” It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another—on X date regarding Y process.

So the builders reduced their margin of error the best way they knew how—by taking a final moment to make sure that everyone talked it through as a group.

“The biggest cause of serious error in this business is a failure of communication,” O’Sullivan told me.

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.

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.

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a 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

“That’s not my problem” is possibly the worst thing people can think,

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.

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

The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.”

they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss.

You must define a clear pause point at which the checklist is supposed to be used

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop.

With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off

A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.

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.

Ideally, it should fit on one page.

To begin with, we rarely investigate our failures.

The system freed him to focus on other critical tasks,

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.

In medicine, for instance, if I want my patients to receive the best care possible, not only must I do a good job but a whole collection of diverse components have to somehow mesh together effectively.