The Checklist Manifesto by Atul Gawande

Atul Gawande is a surgeon, writer, and public health researcher. He directs the World Health Organizations Global Patient Safety Challenge, has published three books, and his Ted Talk has been viewed over one million times.

The Checklist Manifesto is Dr. Gawande’s third book and discusses the importance of organization and pre-planning; both in medicine and in life.  When taking over the Safety Challenge for the WHO implementing simple checklists were the key to massive improvements.  But creating these checklists was no simple task.  The book documents his journey as he learns checklist theory from professionals not only in the medical community, but from aviation and construction as well.

In the age of the super-specialist our tasks have become too complex to work from memory alone.  And many of these task are all-or-nothing, where if you miss a single step you might as well not have done any of them.  It is here that the simple checklist has been proven time and again as a powerful tool.

Checklist Culture

  • Tasks can be simple, complicated, or complex.  The value of checklists on simple tasks is self evident, but takes more care and organization for complex tasks.
  • Silent disengagement of super-specialists is a danger to consider, with “Not my Job” mentality being pervasive.  This is the worst thing people can think.
  • The biggest cause of serious errors in complex undertakings is lack of communication.  In the construction industry they use communication checklists to combat this; specifying who, when, with a check in the box once the communication is completed.
  • Decentralize control.  Give the checklists to those people with the least power.  The nurses in the ER hold the Doctors accountable.
  • Activation Phenomenon – giving people a chance to say something at the beginning will improve the chances that they actually say something.
  • Daniel Boorman from Boeing is one of the keepers of Boeings “Flight Philosophy”.  When you step foot on their aircraft there is an expectation that it is flown in the same way, no matter who the pilot is.  Boeing issues over one hundred checklists a year.  They are key to their operations.
  • All professionals have a code of conduct with these common elements:
  1. An expectation of selflessness
  2. An expectation of skill
  3. An expectation of trustworthiness
  • In aviation there is a fourth; discipline in following procedures and working with others.

Checklists

  • Checklists  help with memory recall and clearly set out the minimum number of necessary steps in a process.
  • Pause points are built in to the process, at which the teams must stop and run through a checklist.
  • Pilots use checklists for two reasons:
  1. They are trained to do so
  2. They have been proven effective
  • Pilots typically work off an electronic checklist system, but have a paper copy in a spiral bound binder as back up.
  • Checklists are not comprehensive “How-To” guides.  They are a quick and simple tool to assist professionals performing complex tasks.
  • A checklist is only an aid.  If it doesn’t aid, then it isn’t right.

Bad Checklists

  • Vague
  • Imprecise
  • Too long
  • Hard to use – impractical
  • Made by desk jockeys with no experience in the situations during which they will be used
  • Treat people as dumb tools and try to spell out every step

Good Checklists

  • Precise, efficient, to the point
  • Easy to use, even in difficult situations
  • Provides reminders only of the most critical and important steps
  • Above all, they are practical

Making a Good Checklist

  • A clear Pause-Point must be defined, where the checklist will be used
  • Decide what type of checklist; DO-CONFIRM or READ-DO
    • DO-CONFIRM means that team members perform their tasks from memory and experience, often separately.  Then they stop and confirm, via the checklist, that everything that was supposed to be done was done.
    • READ-DO means that people carry out the tasks as they check them off.  Like a recipe.
  • A good checklist cannot be lengthy.
    • A good rule of thumb is to limit it to between five and nine items, which is the average limit of working memory.
    • Keep it short by focusing on the “Killer Items”, the most important steps that are still somehow overlooked.
  • Wording must be simple and exact, using the familiar language of the profession.
  • It should fit on one page.
  • The page should be free of clutter and unnecessary colors.  Do not use all capitals.
  • IT HAS TO BE FIRST TESTED IN THE REAL WORLD.

DO-CONFIRM checklists give the professional more flexibility when performing tasks and is the type most used at Boeing.

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