The Checklist Manifesto added January 22, 2011

Humans are forgetful. We need constant reminders of what must be done, as we are easily distracted. The problem necessitating the use of memory aids is well described by Atul Gawande:

We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is—and will remain—outside our understanding and control.

Some areas are well within reach of human mastery, however, such as the construction of skyscrapers. Gawande discusses two primary causes for shortcomings even in areas that are well defined and feature significant achievement: ignorance and ineptitude. With the growth of monumental scientific and technological advancement, ineptitude has become as significant as (if not more instrumental than) ignorance. Resolving ineptitude is the topic of the book.

For nearly all of history, people's lives have been governed primarily by ignorance. This was nowhere more clear than with the illnesses that befell us. We knew little about what caused them or what could be done to remedy them. But sometime over the last several decades—and it is only over the last several decades—science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.

Gawande discusses the need for significant and thorough training (particularly from the perspective of one involved with the medical profession), but also observes that learning theory is insufficient and must be accompanied by relevant and meaningful experience. Experience is still insufficient for ensuring competence in complex matters; sometimes simple habits (such as employing checklists) can yield unparalleled benefits.

Gawande first discusses the problem of extreme complexity. While the scenarios described are taken from the field of medicine, the observation that bodies of knowledge are increasing and becoming more unwieldy holds true for almost all realms of knowledge work.

Next comes a discussion of the checklist itself:

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-nothing 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.

A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don't always matter. Perhaps the elevator controls on airplanes are usually unblocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only about one of fifty patients. "This has never been a problem before," people say. Until one day it is.

Checklists seem to provide protection against such failures. They 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. Which is precisely what happened with the vital signs—though it was not doctors who deserve the credit.

Compelling accounts of significant benefits being realized through the employment of checklists for critical hospital functions are provided.

In the end of the master builder, Gawande turns to the field of architecture for examples of complexity managed by detailed checklist-style enumeration of tasks and responsibilities. Buildings are subject to many variables, and high-quality architecture requires an astounding level of precision. Reliable systems are now central to important architectural projects.

In the idea, the author postulates that checklists may be essential for all complex situations, regardless of profession. This chapter draws from the realm of food preparation for inspiration. Even artistic endeavors, Gawande muses, could benefit tremendously from the structure and reliability fostered by checklists.

The first try describes a failed attempt at incorporating checklists into a medical practice. Checklists involving needless and excessive levels of detail, lacking clarity, or distracting from completing the tasks they are designed to improve, will bring frustration rather than accomplishment. New practices must be made clearly necessary and beneficial if they are to be in fact embraced.

The checklist factory discusses Atul Gawande's research of checklists following the disastrous incident of the prior chapter. He describes his interaction with David Boorman from The Boeing Company in Seattle, Washington. The aviation checklist stories are interesting, though the conclusions are simple and seem rather obvious: clarity, brevity, urgency, and familiarity are among the critical matters. Any process requires periodic revision; checklists should (obviously) be revised as appropriately.

The test describes the corrective efforts taken to revise the initial checklist experiment undertaken by Atul Gawande to more effectively address the issues it was intended to solve. The surgery checklist was made more usable, focusing more on conversation among relevant personnel than on writing check marks. All of the items were revised, and numerous iterations were developed. Various medical institutions adopted the checklists developed by Gawande and his team, to significant improvement in overall quality, substantial reduction in complications.

The hero in the age of checklists describes the difficulty of identifying patterns and making applicable deductions and inferences from exposure to limited data items. It is easy to observe a systematic explanation of a mistake and acknowledge its implications, but it is much more challenging to independently produce the intelligence to correctly ascertain a situation. Examples from investing, medicine, and aviation are cited. Does increasing formalization through checklist systems eliminate creativity? No! It requires immense creativity to see the connections that permit effective process design, and responding to unexpected contingencies is always a distinguishing property.

The save is a powerful story from the medical practice of Atul Gawande and provides a persuasive conclusion to an enlightening book. The story involves a life-threatening situation that was resolved by the preparation of a blood bank because of the direction of a checklist, although that step was typically not necessary for the type of case being addressed. Lives are saved every day through the use of checklists; perhaps less significant things in your own life would also benefit from them.

The book features this short bio of Atul Gawande:

Atul Gawande is the author of Better and Complications. A MacArthur Fellow, a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and an associate professor at Harvard Medical School and the Harvard School of Public Health, he also leads the World Health Organization's Save Surgery Saves Lives program. He lives with his wife and three children in Newton, Massachusetts.