# The Checklist Manifesto  ## Metadata - Author: [[Atul Gawande]] - Full Title: The Checklist Manifesto - Category: #books ## Highlights - There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snowstorms, save people from heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre point out, we have just two reasons that we may nonetheless fail. The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about. ([Location 115](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=115)) - Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: 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. ([Location 179](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=179)) - What they decided not to do was almost as interesting as what they actually did. They did not require Model 299 pilots to undergo longer training. It was hard to imagine having more experience and expertise than Major Hill, who had been the air corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. ([Location 418](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=418)) - 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. (When you’ve got a patient throwing up and an upset family member asking you what’s going on, it can be easy to forget that you have not checked her pulse.) Faulty memory and distraction are a particular danger in what engineers call all-or-none 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 unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients. “This has never been a problem before,” people say. Until one day it is. ([Location 446](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=446)) - 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. ([Location 455](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=455)) - 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. ([Location 492](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=492)) - These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. ([Location 494](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=494)) - Checklists, he found, established a higher standard of baseline performance. ([Location 497](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=497)) - In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. Most ICUs—including the ones at Sinai-Grace Hospital—cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now—all because of a stupid little checklist. ([Location 551](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=551)) - checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities. ([Location 593](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=593)) - We are besieged by simple problems. In medicine, these are the failures to don a mask when putting in a central line or to recall that one of the ten causes of a flat-line cardiac arrest is a potassium overdose. In legal practice, these are the failures to remember all the critical avenues of defense in a tax fraud case or simply the various court deadlines. In police work, these are the failures to conduct an eyewitness lineup properly, forgetting to tell the witness that the perpetrator of the crime may not be in the lineup, for instance, or having someone present who knows which one the suspect is. Checklists can provide protection against such elementary errors. ([Location 613](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=613)) - 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. ([Location 909](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=909)) - Tags: [[blue]] - The trouble wasn’t a lack of sympathy among top officials. It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible. Asked afterward to explain the disastrous failures, Michael Chertoff, secretary of Homeland Security, said that it had been an “ultra-catastrophe,” a “perfect storm” that “exceeded the foresight of the planners, and maybe anybody’s foresight.” But that’s not an explanation. It’s simply the definition of a complex situation. And such a situation requires a different kind of solution from the command-and-control paradigm officials relied on. ([Location 942](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=942)) - Tags: [[blue]] - No, the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals. ([Location 986](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=986)) - Tags: [[blue]] - That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how. ([Location 991](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=991)) - Tags: [[blue]] - I came away from Katrina and the builders with a kind of theory: 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. ([Location 995](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=995)) - Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. ([Location 1509](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=1509)) - 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. ([Location 1541](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=1541)) - Tags: [[blue]] - 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. ([Location 1547](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=1547)) - Tags: [[blue]] - after about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things. People start “shortcutting.” Steps get missed. So you want to keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless. ([Location 1549](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=1549)) - Tags: [[blue]] - 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.) ([Location 1553](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=1553)) - Tags: [[blue]] - 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. ([Location 1615](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=1615)) - Tags: [[blue]] - “Warren,” Pabrai said—and after a $650,000 lunch, I guess first names are in order—“Warren uses a ‘mental checklist’ process” when looking at potential investments. So that’s more or less what Pabrai did from his fund’s inception. He was disciplined. He made sure to take his time when studying a company. The process could require weeks. ([Location 2049](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2049)) - Tags: [[blue]] - His mental checklist wasn’t good enough. “I am not Warren,” he said. “I don’t have a 300 IQ.” He needed an approach that could work for someone with an ordinary IQ. So he devised a written checklist. Apparently, Buffett himself could have used one. Pabrai noticed that even he made certain repeated mistakes. “That’s when I knew he wasn’t really using a checklist,” Pabrai said. So Pabrai made a list of mistakes he’d seen—ones Buffett and other investors had made as well as his own. It soon contained dozens of different mistakes, he said. Then, to help him guard against them, he devised a matching list of checks—about seventy in all. ([Location 2067](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2067)) - Tags: [[blue]] - So Pabrai added the following checkpoint to his list: when analyzing a company, stop and confirm that you’ve asked yourself whether the revenues might be overstated or understated due to boom or bust conditions. ([Location 2083](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2083)) - Tags: [[blue]] - the anonymous investor I spoke to—I’ll call him Cook—made a checklist. But he was even more methodical: he enumerated the errors known to occur at any point in the investment process—during the research phase, during decision making, during execution of the decision, and even in the period after making an investment when one should be monitoring for problems. He then designed detailed checklists to avoid the errors, complete with clearly identified pause points at which he and his investment team would run through the items. ([Location 2085](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2085)) - Tags: [[blue]] - The checklist doesn’t tell him what to do, he explained. It is not a formula. But the checklist helps him be as smart as possible every step of the way, ensuring that he’s got the critical information he needs when he needs it, that he’s systematic about decision making, that he’s talked to everyone he should. With a good checklist in hand, he was convinced he and his partners could make decisions as well as human beings are able. And as a result, he was also convinced they could reliably beat the market. ([Location 2102](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2102)) - Tags: [[blue]] - “When surgeons make sure to wash their hands or to talk to everyone on the team”—he’d seen the surgery checklist—“they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.” ([Location 2107](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2107)) - Tags: [[blue]] - With the checklist in place, however, he observed that he could move through investment decisions far faster and more methodically. As the markets plunged through late 2008 and stockholders dumped shares in panic, there were numerous deals to be had. And in a single quarter he was able to investigate more than a hundred companies and add ten to his fund’s portfolios. ([Location 2124](https://readwise.io/to_kindle?action=open&asin=B0030V0PEW&location=2124)) - Tags: [[blue]]