The Checklist Manifesto: How to Get Things Right

by Atul Gawande

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: 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.

There is a particularly tantalizing aspect to the building industry’s strategy for getting things right in complex situations: it’s that it gives people power. In response to risk, most authorities tend to centralize power and decision making.

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.

No, 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.

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.

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.

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. They pause to run the checklist and confirm that everything that was supposed to be done was done. 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.

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.

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.

a checklist has to be tested in the real world,

Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognize the opportunity, the two-minute WHO checklist is just a start.

All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. The codes are sometimes stated, sometimes just understood. But they all have at least three common elements. 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. Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise. Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges.

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

We have most readily turned to the computer as our aid. Computers hold out the prospect of automation as our bulwark against failure. Indeed, they can take huge numbers of tasks off our hands, and thankfully already have—tasks of calculation, processing, storage, transmission. Without question, technology can increase our capabilities. But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building,

“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,”