The Checklist Manifesto: How To Get Things Right

by Atul Gawande

“activation phenomenon.”

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.

When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). 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.

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.

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

The 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. (He went so far as to recommend using a sans serif type like Helvetica.)

no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected.

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals.

Prince Hamza Hospital in Amman, Jordan, a new government facility built to accommodate Jordan’s bursting refugee population;

“How to Use the Safe Surgery Checklist”

“How Not to Use the Safe Surgery Checklist,”

In Jordan, the working environment was also at once recognizable and alien, but in a different way. The operating rooms in Amman had zero frills—this was a still-developing country and the equipment was older and heavily used—but they had most of the things I am used to as a surgeon, and the level of care seemed very good. One of the surgeons I met was Iraqi. He’d trained in Baghdad and practiced there until the chaos following the American invasion in 2003 forced him to flee with his family, abandoning their home, their savings, and his work. Before Saddam Hussein, in the last years of his rule, gutted the Iraqi medical system, Baghdad had provided some of the best medical care in the Middle East. But, the surgeon said, Jordan now seemed positioned to take that role and he felt fortunate to be there. I learned that more than 200,000 foreign patients travel to Jordan for their health care each year, generating as much as one billion dollars in revenues for the country.

What I couldn’t work out, though, was how the country’s strict gender divide was negotiated in its operating rooms. I remember sitting outside a restaurant the day I arrived, studying the people passing by. Men and women were virtually always separated. Most women covered their hair. I got to know one of the surgery residents, a young man in his late twenties who was my guide for the visit. We even went out to see a movie together. When I learned he had a girlfriend of two years, a graduate student, I asked him how long it was before he got to see her hair. “I never have,” he said. “C’mon. Never?” “Never.” He’d seen a few strands. He knew she had dark brown hair. But even in the more modern dating relationship of a partly Westernized, highly educated couple, that was it. In the operating rooms, all the surgeons were men. Most of the nurses were women. The anesthetists split half and half. Given the hierarchies, I wondered whether the kind of teamwork envisioned by the checklist was even possible. The women wore their head scarves in the operating rooms. Most avoided eye contact with men. I slowly learned, however, that not all was what it seemed. The staff didn’t hesitate to discard the formalities when necessary. I saw a gallbladder operation in which the surgeon inadvertently contaminated his glove while adjusting the operating lights. He hadn’t noticed. But the nurse had.

“You have to change your glove,” the nurse told him in Arabic. (Someone translated for me.) “It’s fine,” the surgeon said. “No, it’s not,” the nurse said. “Don’t be...

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.

In January 2009, the New England Journal of Medicine published our study as a rapid-release article.

“If you were having an operation,” we asked, “would you want the checklist to be used?” A full 93 percent said yes.

Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.

Since the results of the WHO safe surgery checklist were made public, more than a dozen countries—including Australia, Brazil, Canada, Costa Rica, Ecuador, France, Ireland, Jordan, New Zealand, the Philippines, Spain, and the United Kingdom—have publicly committed to implementing versions of it in hospitals nationwide.

They don’t time the market. They don’t buy according to some computer algorithm. They do intensive research, look for good deals, and invest for the long run.

Warren uses a ‘mental checklist’ process”

when analyzing a company, stop and confirm that you’ve asked yourself whether the revenues might be overstated or understated due to boom or bust conditions.

“It’s easy to hide in a statement. It’s hard to hide between statements,”

One check, for example, requires the members of the team to verify that they’ve read the footnotes on the cash flow statements. Another has them confirm they’ve reviewed the statement of key management risks. A third asks them to make sure they’ve looked to see whether cash flow and costs match the reported revenue growth.

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.

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.

But to his surprise, he found they were able to evaluate many more investments in far less time overall.

Finding an entrepreneur who can execute a good idea is a different matter entirely. 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.

He called one type of investor the “Art Critics.”

“Sponges” took more time gathering information about their targets, soaking up whatever they could from interviews, on-site visits, references, and the like.

The “Prosecutors” interrogated entrepreneurs aggressively, testing them with challenging questions about their knowledge and how they would handle random hypothetical situations. “Suitors” focused more on wooing people than on evaluating them. “Terminators” saw the whole effort as doomed to failure and skipped the evaluation part.

Then there were the investors Smart called the “Airline Captains.” They took a methodical, checklist-driven approach to their task.

The most interesting discovery was that, despite the disadvantages, most investors were either Art Critics or Sponges—intuitive decision makers instead of systematic analysts.

We don’t like checklists. They can be painstaking. They’re not much fun.

Maybe our idea of heroism needs updating.

The fear people have about the idea of adherence to protocol is rigidity.

But step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE.

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.

Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness.

To be sure, checklists must not become ossified mandates that hinder rather than help. Even the simplest requires frequent revisitation and ongoing refinement.

In the end, a checklist is only an aid. If it doesn’t aid, it’s not right. But if it does, we must be ready to embrace the possibility.

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

We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”

We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.

We know the patterns. We see the costs. It’s time to try something else. Try a checklist.