10 Lessons From ‘The Checklist Manifesto’

Failure isn’t due to ignorance. According to best-selling author Atul Gawande, it’s because we haven’t properly applied what we already know.

Read more from our #LISTS primer here.

We humans are highly skilled, expertly trained, and hardworking. We have a tremendous amount of know-how at our fingertips, and we use that knowledge to do remarkable things. We construct buildings that reach ever-increasing heights, we use complex robotic arms to surgically repair damaged hearts and other organs, and we defy gravity with aeronautical precision. We do all this, and more, with a level of expertise and technology that is increasingly advanced and sophisticated—and would have been hard to imagine a century ago.

checklist-2Yet our failures remain frequent. Actually, it’s hard to believe that we still screw up as often as we do. Simple mistakes (either the result of unforeseen complications or failure to follow through on a task) cost corporations hundreds of thousands of dollars a year. Sometimes, they even cause planes to fall out of the sky. The truth is, our overloaded brains can only hold on to so much information. The volume and complexity of what we know has exceeded our ability to consistently and correctly put it to use. That knowledge we have worked so hard to attain? It both saves us and burdens us. At least that’s the theory put forth by The New York Times bestseller, The Checklist Manifesto: How To Get Things Right, by renowned author and surgeon Atul Gawande.

Gawande believes that in an age of relentless technological complexity, where the most basic steps can easily be overlooked, a humble technique—making a process list to follow when completing a given task—can serve as a revolutionary tool to help us avoid error and get things right.

In 2008, the World Health Organization agreed to work with Gawande’s thesis, bringing the checklist concept to eight hospitals around the world. During the next six months, deaths fell by 47 percent and post surgical complications dropped by 36 percent. “In medicine,” Gawande writes, the issue is “making sure we apply the knowledge we have consistently and correctly.” Failure isn’t from ignorance, it’s from not properly applying what we know.

Maybe you’re not sure that a checklist would be useful in your work environment. Fair enough. However one thing Gawande’s research makes abundantly clear: From medicine to homeland security to investment banking to building construction, checklists can be a game changer.

After reading, re-reading, highlighting, underlining, and dog-earing lots of pages, we came up with 10 takeaways from Gawande’s book.

  1. A checklist is not a how-to guide or a to-do list. Rather, it’s a tool that aids memory recall. It simply outlines the minimum number of steps required to complete a task, which, in turn, frees up extra bandwidth for whatever you’re working on. When you consider how your own job responsibilities might benefit from a checklist, think about this: A simple checklist implemented by Johns Hopkins Hospital led to a drop in central line infections from 11 percent to zero and saved the hospital $2 million. What was on the checklist? Just five steps, including “wash hands” and “wear a mask”—crucial steps that were frequently skipped by even the most experienced surgeons.
  1. Often, our memory and judgment are unreliable, and a checklist is a ridiculously simple way to make up for that. Doctors forget to wash their hands, fund managers neglect to properly vet investment opportunities, and pilots faced with a crisis in the air forget protocol that can cost lives. Gawande makes this point over and over: Relying on memory or instinct alone is a fool’s game. When a single-engine Cessna airplane loses power in flight, there are six key steps the pilot needs to follow to restart the engine. “It is the first step that is the most fascinating,” writes Gawande. It is simply: FLY THE AIRPLANE. Because pilots—just like the rest of us—can become so crushed by the cognitive overload of thinking through an emergency, they forget the primary task. Fly the damn plane. If you forget that, nothing else follows.
  1. A checklist can shield you from failure. That’s because it functions as that cognitive safety net we just mentioned. Four generations after the first aviation checklists were introduced, Gawande writes, a lesson is emerging. “Checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realize. They catch flaws of memory and attention and thoroughness.” So it not only can help save a plane full of passengers when the cockpit equivalent of your car’s “check engine” light starts flashing, it can keep you from making needless mistakes in everything from market research to staffing.
  1. There are good checklists and bad checklists. A good checklist is precise, efficient, and to the point; easy to use even during the most trying circumstances. A good checklist is a reminder of only the most critical and important steps. And it is, above all, practical. A bad checklist is everything else: vague, imprecise, too long, and wordy, and hard to use.
  1. Even the unlikeliest professions can benefit from a checklist. Consider David Lee Roth and the brown M&Ms. Roth’s performance contract notoriously stipulates that every single brown candy be removed from the bowls of M&Ms provided backstage. If Roth finds a single offending chocolate, the contract gives him the option to cancel the show. But what most of us don’t know and what Gawande points out is this: Roth’s M&M obsession is simply a safety net, or a checklist of sorts. In his memoir, Crazy from the Heat, the former Van Halen frontman points out that if a venue can’t follow simple instructions on a bowl of M&Ms, chances are they’re skipping more important steps as well.
  1. No job is too complicated to reduce to a checklist. Gawande, a renowned surgeon and head of the World Health Organization’s Safe Surgery Saves Lives Program, readily admits that doctors believe their jobs are too complex to reduce to a checklist. “Sick people,” he writes, “are phenomenally more various than airplanes” (or rock concert arenas, for that matter). But think about it: The recording of vital signs, for example, is nothing more than a checklist. So is a patient chart. Gawande doesn’t expect doctors – or anyone – to reduce every task to its components, but when applied correctly, a checklist can lead to better outcomes. (Not convinced? See #1.)
  1. For projects of complexity, checklists are not only helpful, but are required for success. Nowhere is this point better illustrated than in the field of modern building construction. Over the decades construction work has grown infinitely more intricate, and today the division of labor is so specialized (siloed) that no one person can oversee all of it. Which is why builders use checklists to break the build down into manageable tasks. “They supply a set of checks to ensure the stupid but critical stuff is not overlooked,” Gawande writes. Which brings us to the next lesson.
  1. A checklist fosters teamwork and communication. Must we really be reminded to talk to each other? Often, yes. It’s interesting to note that builders use checklists to specify communication tasks. It’s one way project managers make sure the experts speak to each other to discuss unplanned developments and map the way forward. It’s good business, regardless of the field. When surgical staff—prompted by their checklist—introduce themselves to one another before reaching for a 10-blade, their ability to problem-solve as a team increases. “People who don’t know one another’s names don’t work together nearly as well as those who do,” Gawande writes.
  1. A checklist both promotes discipline and encourages creativity. This may sound surprising because a checklist is rigid, inflexible; a statement that leaves no room for improvising. But so often costly mistakes are the result of lax discipline. When a doctor forgets to wash his hands, for instance, the results can be devastating. “We are not built for discipline,” writes Gawande. “It is something we have to work at.” But when a course of action is set and we adhere to the discipline instilled by the checklist, our minds (no longer grasping for correct computer codes or bank routing numbers) are freed up and have more room to stretch creatively.
  1. A checklist isn’t a magic bullet. It has its limits, of course. In the end, a checklist is only an aid. “If it doesn’t aid, it’s not right,” writes Gawande. “But if it does, we must be ready to embrace the possibility.”