Review: The Checklist Manifesto by Atul Gawande

An useful read on the incredible power and effectiveness of the simple, humble checklist.

A few of the key takeaways:

• When you fail at a task, the cause of that failure is either ignorance, where you don’t know how to succeed, or ineptitude, where you know how, but you’re unable to apply that knowledge. In the modern world, and more of our errors are due to the second cause. For example, in the world of medicine, we know how to cure more and more diseases and ailments, but despite that knowledge, still fail at a high rate due to simple mistakes.

• Note that the failure rate in medicine is not high due to a lack of training. The amount of training and specialization in medicine is extraordinary: whereas in the pasts, you could be a doctor with just a couple years of training, nowadays you need 4 years of undergrad, 4 years of med school, 3-7 years of residency, and potentially even more for certain specialties. So we’re talking 11 - 15 years or more. Training is not the issue. The error rate amongst trained medical professionals is very low: less than 1% or less. But even this error rate is too high when it comes to medicine. For example, on average, medical professionals must take 175+ actions per day for each patient in the ICU, and each of those actions involves complicated decisions and processes. Even with an error rate of less than 1%, that’s still 1-2 errors per day for every single patient.

• So the real problem is complexity. Many disciplines in the modern world have become so developed, that one of the main challenges is managing extreme complexity. For example, in medicine, the typical doctor has to be aware of thousands of diseases, drugs, patient details, and the interactions between all of them. The same sort of complexity arises in constructions, software engineering, aviation, and many other disciplines.

• In other industries that face extreme complexity, the checklist is a central tool in helping to manage that complexity. In aviation, checklists are used extensively for every aspect of flight: pre-flight checklists, take-off checklists, landing checklists, and checklists for each type of emergency and problem. These checklists have been a critical ingredient in the remarkable safety record of the aviation industry.

• Construction projects also make extensive use¬†of checklists, assembled from the huge number of experts that are involved (e.g., architectures, electricians, plumbers, etc). But construction and other major projects that involve hundreds or thousands of individuals also use distributed decision making. In situations where the complexity goes beyond what any one person can handle, central command-and-control does not work. Instead, you set clear expectations, distribute the decision making, and define regular check ins to make sure everyone is working towards a common set of goals. When issues come up, all the relevant experts are expected to look into them and make local decisions about them, and even sign affidavits so they are legally liable for those decisions. The use of checklists and distributed decision making are key ingredients in the remarkable safety record of construction projects.

• In the world of medicine, Gawande explains the impact checklists have had. In a world-wide study, across hospitals of every imaginable kind, the introduction of a single, extremely basic general-purpose checklist for surgery led to double digit drops, from 25-50%, in complications and death. It’s remarkable to think how many extra people might have died or suffered if not for a simple, silly checklist.

• Checklists must be designed, thoroughly tested, and iteratively refined over time. They are not something you just throw together in a few minutes. The aviation industry has experts dedicated to this process, who have spent years honing the craft of effective checklists, so you’ll have to invest some time to get it right. Some of the key ingredients to a successful checklist are that (a) it’s short, ideally fitting on a single page, (b) there are no distractions or other noise on that page beyond the core items in the list, (c) the items in the checklist are not a comprehensive list of every possible thing that must be done, but instead, focused specifically on the items people tend to miss, or the ones that are the most costly if you get them wrong.

Rating: 4 stars