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The Checklist Manifesto: Summary, Quotes, and Lessons

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I suppose it’s fitting that the first blog post written on Checkli be a tribute to The Checklist Manifesto: How to Get Things Right, by Atul Gawande. After all, this book helped plant the seed, that eventually grew into the globally used free checklist tool, Checkli.

I can remember it like it was yesterday. A coworker, had left the book on a shelf in my office, and for the next few months, there is sat. A brilliant red cover, that demanded your attention every time you walked through the door.

So, eventually I read it.

I must admit, I’m not much of a reader, yet I could not put this book down. In fact, I read it twice. I was truly fascinated and fully emerged within the first few pages.

How could something be so simple, like a checklist, revolutionize the biggest industries in the world? I had to keep reading.

In the book, Gawande provides unbelievable, yet undeniable, case study after case study of how the world’s biggest industries and companies grew, by incorporating simple, and eventually mandatory checklists into processes.

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This was so intriguing to me, because at the time, I was the CEO of The Ocean Agency, a digital marketing agency in Chicago, IL. I had about 30 employees, in a 5,000 square foot office, on Michigan Avenue, and I was eagerly looking for the secret to future success and sustainable growth.

I found exactly what I was looking for in The Checklist Manifesto.

Summary

In summary, The Checklist Manifesto shows that the successful use of complex and advanced technology requires too many simple tasks to remember, and that using a checklist is a simple solution.

In Gawande’s own words, “The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.”

Gawande provides shows how different industries and some of the biggest companies in the world, that require people to use complex technology, have incorporated mandatory checklists, to ensure that all steps and process, no matter how big or small, are properly and successfully completed.

Case Studies

The book is full of remarkable and exciting case studies that expose the wide spectrum of extremities that lie between the before and after use of checklists. Below are two of the most memorable case studies.

Boeing

Gawande describes the incredible importance of checklists in modern aviation, by exploring its early implementation, traced back to October 30, 1935.

It was on that day that The Boeing Company was displaying the new B-17 Bomber, and competing for the business of the United States Military.

Shortly after takeoff, the “Flying Fortress”, as it was commonly referred to, lifted in to the air, in all its glory, only to immediately bank, and nose dive into the ground, killing the pilot and injuring several others on board. Members of the Military could only look on in horror and shock.

The Boeing Company almost goes bankrupt.

The investigation later determined that the globally renowned, expert pilot, simply forgot to release the flight control gust locks. A trivial task, easily accomplish by any pilot.

It was as a result of that day, October 30, 1935, that The Boeing Company began the mandatory implementation and use of checklists by pilots, from takeoff to landing.

Subsequently, October 30, 1935 is known today as Checklist Day.

“Much of our work today has entered its own B-17 phase. Substantial parts of what software designers, financial managers, firefighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from memory alone. Multiple fields, in other words, have become too much airplane for one person to fly. Yet it is far from obvious that something as simple as a checklist could be of substantial help.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

Johns Hopkins Hospital

Line infections are a very common problem in I.C.U.s (Intensive Care Units), at hospitals across the world. To insert a line into a patient, there is usually a five step, simple and standard process. However, these lines commonly become infected 4% of the time, costing hospitals millions in malpractice lawsuits.

Even worse, line infections result in the death of patients, anywhere between 5% and 28% of time (Source: New Yorker) , depending on the sickness of the patient when they entered the I.C.U..

Skeptical doctors at Johns Hopkins Hospital were very apprehensive about implementing a five step mandatory checklist before inserting a line into a patient. After all, it was only five trivial steps that they have performed thousands of times.

After months of observation, it was shockingly determined that at least one step of the five step process was missed 2/3 of the time.  This mind-blowing observation convinced the board at Hopkins that a five step mandatory checklist, for every line inserted in the I.C.U. was a brilliant idea worth trying.

The results were staggering to say the least. Early results showed that implementing the simple checklist, prevented 43 infections, saved eight lives, and saved the hospital millions of dollars lawsuits.

After see these astonishing results, this same mandatory checklist was implemented at Michigan University Hospital. Gawande notes that over a three month period, line infections were reduced by 66%, save the lives of an estimated 1,500 people.

All because of a simple checklist.

“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.” ~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

Quotes

Here are a few more of my favorite quotes from The Checklist Manifesto.

“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.” ~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“We don’t like checklists.  They can be painstaking. They are not fun” ~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“We are not built for discipline, we are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.” ~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“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.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“under conditions of complexity, not only are checklists a help, they are required for success.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“Medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“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.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“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 professional using them could miss. Good checklists are, above all, practical.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“One essential characteristic of modern life is that we all depend on systems—on assemblages of people or technologies or both—and among our most profound difficulties is making them work.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“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.”

“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. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives. *”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“…finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognised the opportunity, the two-minute WHO checklist is just a start.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“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.

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“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.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

“You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.”

~ Atul Gawande, The Checklist Manifesto: How to Get Things Right

 

 

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Author, Atul Gawande

Atul Gawande, MD, MPH is the author of The Checklist Manifesto: How to Get Things Done Right. He is also a Surgeon well respected public health researcher. Currently, he practices general and endocrine surgery at Brigham and Women’s Hospital.

Ted Talks

As of today, Gawande has shared two very popular Ted Talks:

How do we heal medicine?