Book Summary: The Checklist Manifesto by Atul Gawande

The Book in Three Sentences

Checklists are required for success.
When doctors and nurses in the ICU create their own checklists for what they think should be done each day, the consistency of care improves to the point where the average length of patient stay in intensive care dropped by half.
The three different kinds of problem in the world are the simple, the complicated, and the complex.
Checklists can either be DO-CONFIRM or READ-DO (see below for a description) and must be kept between 5-9 items.
The wording of should be simple and exact and fit on one page.

“The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.”

“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.

“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 instill a kind of discipline of higher performance.”

“The researchers found that simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.”

Pronovost found checklists established a higher standard of baseline performance.

“Checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized.”

“Three different kinds of problems in the world: the simple, the complicated, and the complex.”

“The philosophy is that you push the power of decision-making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.”

“Under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided—and even enhanced—by procedure.”

“The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an ‘activation phenomenon.’ Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.”

“When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.”

“The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.”

“The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)”

“It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals.”

“Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.”

“In the end, a checklist is only an aid. If it doesn’t aid, it’s not right. But if it does, we must be ready to embrace the possibility.”