The Checklist Manifesto
Ridiculously simple. Crazily inexpensive. A solution that helps you get the stupid stuff right. And provides the discipline to communicate and collaborate on complicated and complex problems. A checklist.
“The Checklist Manifesto” by Atul Gawande is about why checklists work, how to build a good one and why their implementation encounters so much resistance.
A summary:
Human Fallibility
Why do we fail at what we set out to do in the world? Three reasons:
Necessary fallibility: some things are simply beyond our capacity.
Ignorance: science has given us only a partial understanding of how the world worksIneptitude: the knowledge exists, yet we fail to apply it correctly.
The balance between ignorance and ineptitude has greatly shifted towards the latter in recent decades.The volume and complexity of what we know have exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.
We need a different strategy for overcoming failure, one that builds on the experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.
2. The Problem of Extreme Complexity
A common answer to extreme complexity: extreme specialization
What do you do when expertise is not enough? What do you do when even the super-specialists fail?
3. The Checklist
Boeing’s creation of pilot’s checklist literally saved the company from bankruptcy.
It is far from obvious that something as simple as a checklist could be of substantial help. We may admit that errors and oversights occur - even devastating ones. But we believe our jobs are too complicated to reduce to a checklist.
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. Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.
The second difficulty is the flaw of thoroughness. People can lull themselves into skipping steps even when they remember them. In complex processes steps don’t always matter. Checklists remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also install a kind of discipline of higher performance.
Checklists establish higher standards of baseline performance. They provide a kind of cognitive net. They catch mental flaws inherent in all of us - flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.
4. The End of the Master Builder
Three different kinds of problems in the world:
the simple: ‘Baking a cake’. For them, there is a recipe; following it brings a high likelihood of success.
the complicated: ‘Sending a rocket to the moon.’ They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. Timing and coordination are serious concerns.
the complex: ‘Raising a child'.’ Expertise is valuable but most certainly not sufficient. Every child is unique. The outcomes of complex problems remain highly uncertain.
We are besieged by simple problems. Checklists can provide protection against such elementary errors.
The question of when to follow one’s judgment and when to follow protocol is central to doing the job well. You want people to make sure to get 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. But can they help avert failure when the problems combine everything from the simple to the complex?
Take construction. for most of modern history, going back to medieval times, the dominant way people put up buildings was by going out and hiring Master Builders. But by the middle of the twentieth century, the Master Builders were dead and gone, replaced by the division of labor. To coordinate between all the specialists, the construction schedule is essentially one long checklist. However, the construction schedule does not only specify construction tasks; it specifies communication tasks, making sure that the experts talk to one another. Man is fallible, but maybe men are less so. The biggest source of serious error in the construction business is a failure of communication.
5. The Idea
When faced with complex problems, the traditional control and command system rapidly become overwhelmed; it can end up in a combination of anarchy and Orwellian bureaucracy. In the face of extraordinary complex problems, power needs to be pushed out of the center as far as possible.
Under the 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 and measure progress toward common goals.
This 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 almost opposite 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.
6. The First Try
The most common obstacle to effective teams is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think. The evidence suggests we need people 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.
People who don’t know one another’s names don’t work together nearly as well as those who do. Giving people a chance to say something at the start seems to activate their sense of participation and responsibility and their willingness to speak up.
7. The Checklist Factory
Good checklists 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 the 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: the members perform their jobs from memory and experience, often separately. Then they stop and pause to run the checklist and confirm that everything that was supposed to be done was done.
READ-DO checklist: people carry out the tasks as they check them off.
A checklist cannot be lengthy. Keep it between five and nine items, which is the limit of working memory.
We rarely investigate our failures. not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any kind of work where the mistakes do not turn up on cable news. A single type of error can affect thousands, but because it usually touches only one person at a time, we tend not to search as hard for explanations.
8. The Test
However straightforward the checklist might appear, if you are used to getting along without one, incorporating it into the routine is not always a smooth process. Sometimes, the difficulties of adhering to a checklist can be social.
9. The Hero in the Age of Checklists
We have an opportunity before us, not just in medicine but in virtually every endeavor. Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place. But will we do it?
Just ticking the boxes is not the ultimate goal of the checklist. Embracing a culture of teamwork and discipline is.
The opportunity is evident in many fields - and so also is resistance.
The checklist does not tell you what to do. It is not a formula. But it helps you be as smart as possible every step of the way. They improve the outcomes with no increase in skill.
Studies by Geoff Smart of how venture capitalists made their investment decisions. He distinguished styles of thinking:
Art Critics. Assess at a glance, intuitively, and based on long experience.
Sponges. Take time gathering information, soaking up whatever they could. Then go with their guts.
Prosecutors. Interrogate aggressively.
Suitors. Focus on wooing people not on evaluating them.
Terminators. Skip evaluation part. Buy what they think are the best ideas, fire entrepreneurs they think are incompetent, hire replacements.
Airline Captains. Take a methodical, checklist-driven approach to their tasks.
Smart tracked their success over time - Airline Captain style turned out to be the most effective.
It sometimes feels beneath us to use the checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us - those we aspire to be - handle situations of high stakes and complexity. The truly great are daring, they improved. They do not have protocols and checklists. Maybe our idea of heroism needs updating.
The fear people have about the idea of adhering to the protocol is rigidity. They imagine mindless automations. But a well-made checklist is exactly the opposite. The checklist gets the dumb stuff out of the way.
The first item on the checklist for an engine failure during a flight in a single-engine Cessna airplane: FLY THE AIRPLANE. This isn’t rigidity. This is making sure everyone has their best shot at survival.
Discipline is hard. Harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconsistent creatures. We can’t even keep from snacking between meals. 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.
Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence. If you connect an engine of Ferrari, the brakes of Porsche, the suspension of a BMW, and the body of a Volvo, you get a pile of very expensive junk, but nothing close to a great car.
