The Checklist Manifesto: How to Get Things Right

by Atul Gawande

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

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. There is a recipe. Sometimes there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success. 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. Success frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent. Timing and coordination become serious concerns. Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child,

Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all.

Checklists can provide protection against such elementary errors.

Plus, people are individual in ways that rockets are not—they are complex. No two pneumonia patients are identical. Even with the same bacteria, the same cough and shortness of breath, the same low oxygen levels, the same antibiotic, one patient might get better and the other might not. A doctor must be prepared for unpredictable turns that checklists seem completely unsuited to address. Medicine contains the entire range of problems—the simple, the complicated, and the complex—and there are often times when a clinician has to just do what needs to be done. Forget the paperwork. Take care of the patient.

You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way. The value of checklists for simple problems seems self-evident.

Both aspects are tricky. In designing a building, experts must take into account a disconcertingly vast range of factors: the makeup of the local soil, the desired height of the individual structure, the strength of the materials available, and the geometry, to name just a few. Then, to turn the paper plans into reality, they presumably face equally byzantine difficulties making sure that all the different tradesmen and machinery do their job the right way, in the right sequence, while also maintaining the flexibility to adjust for unexpected difficulties and changes.

“You know the geometric theory of what is best, but not the practical theory of what can be done,”

There was the matter of cost, for example, about which he had not a clue. The size and type of materials he put in changed the cost of the project, it turned out. There was also the matter of aesthetics, the desires of a client who didn’t want a column standing in the middle of a floor, for instance, or blocking a particular sightline. “If engineers were in charge, every building would be a rectangular box,”

“A building is like a body,” he said. It has a skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring. All together, he explained, projects today involve some sixteen different trades.

Perhaps it’s the large number of people who would die if his roof collapsed under the weight of snow. Or perhaps it’s the huge amount of money that would be lost in the inevitable lawsuits.

whatever the reason, architects, engineers, and builders were forced long ago—going back to the early part of the last century—to confront the fact that the Master Builder model no longer worked. So they abandoned it. They found a different way to make sure they get things right.

There, on the walls around a big white oval table, hung sheets of butcher-block-size printouts of what were, to my surprise, checklists.

As I peered in close, I saw a line-by-line, day-by-day listing of every building task that needed to be accomplished, in what order, and when—the fifteenth-floor concrete pour on the thirteenth of the month, a steel delivery on the fourteenth, and so on.

The construction schedule was essentially one long checklist.

Since every building is a new creature with its own particularities, every building checklist is new, too.

a succession of day-by-day checks that guide how the building is constructed and ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way.

But here was a situation that hadn’t been anticipated on the construction checklist: the tilting of the upper floors.

“variances can occur.”

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. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While

The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction—who had to share (or “submit”) particular kinds of information

But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.

Cleanup was arranged, the schedule was adjusted, and everyone signed off.

In the face of the unknown—the always nagging uncertainty about whether, under complex circumstances, things will really be okay—the builders trusted in the power of communication.

They didn’t believe in the wisdom of the single individual, of even an experienced engineer. They believed in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem and then letting the watchers decide what to do.

Joe Salvia had earlier told me that the major advance in the science of construction over the last few decades has been the perfection of tracking and communication.

Nonetheless, some chance of error and unpredictability always remains in projects of this complexity.

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 building owner met with the architect, someone from the city buildings department, the structural engineers, and others. They reviewed the idea and all the calculations behind it. They confirmed that every concern they could think of had been addressed. Then they signed off on the plan, and the skyscraper was built.

They trust instead in one set of checklists to make sure that simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems.

The construction industry’s checklist process has clearly not been foolproof at catching problems. Nonetheless, its record of success has been astonishing.

That’s usually what checklists are about—dictating instructions to the workers below to ensure they do things the way we want.

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. That is what works.

mostly they make certain the builders have the proper checks in place and then have them sign affidavits attesting that they themselves have ensured that the structure is up to code. Inspectors disperse the power and the responsibility.

It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible.

“This company will respond to the level of this disaster,” he was remembered to have said in a meeting with his upper

your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.”

Senior Wal-Mart officials concentrated on setting goals, measuring progress, and maintaining communication lines with employees at the front lines and with official agencies when they could.

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 ...

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 and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know

how.

I came away from Katrina and the builders with a kind of theory: under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgmen...

But as I saw at Rialto, it’s discipline—uncelebrated and untelevised—that keeps the kitchen clicking. And sure enough, checklists were at the center of that discipline.

There seemed no field or profession where checklists might not help. And that might even include my own.

How could we possibly attempt to address so many different issues in so many different places?

But he was convinced doing something was better than doing nothing at all.

Procter & Gamble considered the study something of a disappointment. His research team had found no added benefit from having the antibacterial agent in the soap.

Plain soap proved just as effective. Against seemingly insuperable odds, it was more than good enough. Plain soap was leverage. The secret, he pointed out to me, was that the soap was more than soap. It was a behavior-change delivery

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