The Checklist Manifesto: How to Get Things Right

by Atul Gawande

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

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.

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

First, how could they be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly?

construction schedule was essentially one long checklist.

What results is remarkable: 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.

submittal schedule.” It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks.

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.

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.

Mission Command

Boeing’s “flight philosophy.”

Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.

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.

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.

READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe.

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.

killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless. (Data

wording should be simple and exact, Boorman went on, and use the familiar language of the profession. 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.

checklist has to be tested in the real world,

quick and simple tools aimed to buttress the skills of expert professionals.

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.

DO-CONFIRM rather than a READ-DO format,

more small-scale testing—just one case at a time.

The final WHO safe surgery checklist spelled out nineteen checks in all. Before anesthesia, there are seven checks.

After anesthesia, but before incision, come seven more checks.

Finally, at the end of the operation, before the team wheels the patient from the room, come five final checks.

tracked performance of six specific safety steps:

“How to Use the Safe Surgery Checklist

“How Not to Use the Safe Surgery Checklist,”

Using the checklist involved a major cultural change, as well—a shift in authority, responsibility, and expectations about care—and the hospitals needed to recognize that.

leadership

All learned occupations have a definition of professionalism, a code of conduct.

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.