The Checklist Manifesto

Before you start reading, just know that there is a picture of surgery below.

As I mentioned in my last post, I try to read a book a day when I can. Last weekend, I read Dr. Atul Gawande’s The Checklist Manifesto. Gawande began by explaining the high incidence of medical errors and went on to describe his search for a better way to care for patients. His writing was so compelling that it made me regret not going to medical school.

The main argument was that we live in an era where extreme complexity is the norm. The volume and nuance of available information is beyond any human capacity to manage. To deal with a constant barrage of information, we tend to super-specialize. While a doctor in 1900 could reasonably attempt to treat all manner of illnesses, today we have specialists like pediatric oncologists (children’s cancer doctors). Similarly, bankers now specialize in things like telecommunications mergers in Latin America. We see this sort of intense specialization in all fields that require handling of complex knowledge; however, this causes the loss of more generalized skills.

Tendon surgery
This surgery is meant to repair a ruptured Achilles tendon.

Super-specialization has another major flaw, as well. As we become well-versed in a given field, we tend to trust ourselves too much. We develop a false sense of security and begin to skip steps in processes. Our egos get in the way of rational decision-making. A neurosurgeon who has studied and practiced for decades won’t necessarily listen to a nurse’s advice.

So we see two major problems: informational complexity is beyond our ability to completely understand and we are hard-pressed to reason without the influence of ego. Since we are fallible in this way, we often succumb to either ignorance (a lack of knowledge) or ineptitude (a misapplication of knowledge). As our memory and attention are prone to failure, we can wind up making dangerous mistakes in all-or-none processes (i.e. those in which the success of the process depends on the success of each individual step). The question, then, is how can we apply knowledge consistently and correctly?

According to Gawande, the answer is making a checklist. It seems impossible that the humble checklist could correct our cognitive weaknesses, but it does. A checklist forces us to lay out the minimum necessary steps in a process explicitly. It makes us verify accurate completion of tasks and create a disciplined approach to task management. It provides a tool to manage complex workflows involving dynamic team actions.

The ideal way to build an effective checklist is to democratize power. The most powerful people in a team need checks on their power in case they succumb to cognitive errors. If, while prepping for surgery, a nurse points out that the doctor’s gloves became contaminated when he adjusted the overhead lamp, the surgeon should be required to listen. By acknowledging the nurse’s comment, the surgeon might then reduce the likelihood of infection by swapping gloves. Team communication and buy-in are necessary in the absence of a single “master builder” who knows everything about every step of a given project.

To build a checklist, the team should demarcate critical steps in concise, simple language. Creating a checklist is like creating a recipe for a restaurant: the team of cooks must set out all of the necessary steps and assign tasks to the relevant people. The checklist might include contingency plans or special options. Ultimately, the key steps and criteria for success should be laid out so that the entire team knows what needs to happen at any given time.

checklist meeting

To ensure success, team cohesion is also necessary. If people begin to say “that’s not my job!”, there’s a problem. Teammates should be willing to absorb each other’s workflow to ensure the success of each step in the all-or-none process. A great way to create team cohesion is to do bonding activities. During his surgeries, Gawande encouraged his team to get in a huddle and introduce themselves to each other. Little things like this help build a culture of teamwork and discipline.

Finally, we must continually revise checklists in order to keep up with new information. To do so, we need to make analytical, rational decisions about processes. It’s unacceptable to continue doing something one way because “that’s how we’ve always done it.” Instead, teams should research the patterns behind success and create post-mortem reports of failures. Then, the team should adjust accordingly.


Also published on Medium.

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