Checklist Manifesto Quotes

Man is fallible, but maybe men are less so.

What is needed, however, isn't just that people working together be nice to each other. It is discipline. Discipline is hard--harder than trustworthiness and skill and perhaps even than selflessness. 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.

the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.

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.

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.

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

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.

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.

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.

Instead they choose to accept their fallibilities. They recognised the simplicity and power of using a checklist.

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

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.

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. 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. The power of

We are all plagued by failures - by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber — a machine so complex no one was sure human beings could try it.

We are besieged by simple problems.... Checklists can provide protection

Atul Gawande’s recent A Checklist Manifesto

Atul Gawande, The Checklist Manifesto

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. *

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.

The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them. I

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. But

So Pabrai added the following checkpoint to his list: when analysing a company, stop and confirm that you’ve asked yourself whether the revenues might be overstated or understated due to boom or bust conditions.

You would think that this would be whether the entrepreneur’s idea is actually a good one. But 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.

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. The

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.

The biggest cause of serious error in this business is a failure of communication,

I tried not to seem like a kid who’d just been offered a chance to go up to the front of the plane and see the cockpit. Sure, I said. That sounds neat.

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. That

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. That

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper.

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.

Self-Management If you can read just one book on motivation—yours and others: Dan Pink, Drive If you can read just one book on building new habits: Charles Duhigg, The Power of Habit If you can read just one book on harnessing neuroscience for personal change: Dan Siegel, Mindsight If you can read just one book on deep personal change: Lisa Lahey and Bob Kegan, Immunity to Change If you can read just one book on resilience: Seth Godin, The Dip Organizational Change If you can read just one book on how organizational change really works: Chip and Dan Heath, Switch If you can read just two books on understanding that change is a complex system: Frederic Laloux, Reinventing Organizations Dan Pontefract, Flat Army Hear interviews with FREDERIC LALOUX, DAN PONTEFRACT, and JERRY STERNIN at the Great Work Podcast. If you can read just one book on using structure to change behaviours: Atul Gawande, The Checklist Manifesto If you can read just one book on how to amplify the good: Richard Pascale, Jerry Sternin and Monique Sternin, The Power of Positive Deviance If you can read just one book on increasing your impact within organizations: Peter Block, Flawless Consulting Other Cool Stuff If you can read just one book on being strategic: Roger Martin and A.G. Lafley, Playing to Win If you can read just one book on scaling up your impact: Bob Sutton and Huggy Rao, Scaling Up Excellence If you can read just one book on being more helpful: Edgar Schein, Helping Hear interviews with ROGER MARTIN, BOB SUTTON, and WARREN BERGER at the Great Work Podcast. If you can read just two books on the great questions: Warren Berger, A More Beautiful Question Dorothy Strachan, Making Questions Work If you can read just one book on creating learning that sticks: Peter Brown, Henry Roediger and Mark McDaniel, Make It Stick If you can read just one book on why you should appreciate and marvel at every day, every moment: Bill Bryson, A Short History of Nearly Everything If you can read just one book that saves lives while increasing impact: Michael Bungay Stanier, ed., End Malaria (All money goes to Malaria No More; about $400,000 has been raised so far.) IF THERE ARE NO STUPID QUESTIONS, THEN WHAT KIND OF QUESTIONS DO STUPID PEOPLE ASK?

Listening to the radio, I heard the story behind rocker David Lee Roth’s notorious insistence that Van Halen’s contracts with concert promoters contain a clause specifying that a bowl of M&M’s has to be provided backstage, but with every single brown candy removed, upon pain of forfeiture of the show, with full compensation to the band. And at least once, Van Halen followed through, peremptorily canceling a show in Colorado when Roth found some brown M&M’s in his dressing room. This turned out to be, however, not another example of the insane demands of power-mad celebrities but an ingenious ruse. As Roth explained in his memoir, Crazy from the Heat, “Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors—whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.” So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. “When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error.… Guaranteed you’d run into a problem.” These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.

He also found he made mistakes in handling complexity. A good decision requires looking at so many different features of companies in so many ways that, even without the cocaine brain, he was missing obvious patterns. 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.

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. These

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. This

Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one-year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice—pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine.

has

Surgeons are so absurdly ultraspecialized that when we joke about right ear surgeons and left ear surgeons, we have to check to be sure they don't exist

Pinned to the left-hand wall opposite the construction schedule was another butcher-block-size sheet almost identical in form, except this one, O’Sullivan said, was called a “submittal schedule.” It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another—on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction—who had to share (or “submit”) particular kinds of information before the next steps could proceed.

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. The strategy is unexpectedly democratic, and it has become standard nowadays, O’Sullivan told me, even in building inspections. The inspectors do not recompute the wind-force calculations or decide whether the joints in a given building should be bolted or welded, he said. Determining whether a structure like Russia Wharf or my hospital’s new wing is built to code and fit for occupancy involves more knowledge and complexity than any one inspector could possibly have.

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.

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. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.

Medicine has become the art of managing extreme complexity.

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.

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. 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.

But 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.

Embracing a culture of teamwork and discipline is.

Just ticking boxes is not the ultimate goal here.

There wasn’t much more to it. But getting teams to stop and use the checklist—to make it their habit—was clearly tricky. A couple of check boxes weren’t going to do much all by themselves. So the surgical director gave some lectures to the nurses, anesthesiologists, and surgeons explaining what this checklist thing was all about. He also did something curious: he designed a little metal tent stenciled with the phrase Cleared for Takeoff and arranged for it to be placed in the surgical instrument kits. The metal tent was six inches long, just long enough to cover a scalpel, and the nurses were asked to set it over the scalpel when laying out the instruments before a case. This served as a reminder to run the checklist before making the incision. Just as important, it also made clear that the surgeon could not start the operation until the nurse gave the okay and removed the tent, a subtle cultural shift. Even a modest checklist had the effect of distributing power. The surgical director measured the effect on care. After three months, 89 percent of appendicitis patients got the right antibiotic at the right time. After ten months, 100 percent did. The checklist had become habitual—and it had also become clear that team members could hold up an operation until the necessary steps were completed.

I’m Jay Powers, the circulating nurse”; “I’m Zhi Xiong, the anesthesiologist”—that sort of thing. It felt kind of hokey to me, and I wondered how much difference this step could really make. But it turned out to have been carefully devised. There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do. And Brian Sexton, the Johns Hopkins psychologist, had done studies showing the same in operating rooms. In one, he and his research team buttonholed surgical staff members outside their operating rooms and asked them two questions: how would they rate the level of communications during the operation they had just finished and what were the names of the other staff members on the team? The researchers learned that about half the time the staff did not know one another’s names. When they did, however, the communications ratings jumped significantly. 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. These were limited studies and hardly definitive. But the initial results were enticing. Nothing had ever been shown to improve the ability of surgeons to broadly reduce harm to patients aside from experience and specialized training. Yet here, in three separate cities, teams had tried out these unusual checklists, and each had found a positive effect. At Johns Hopkins, researchers specifically measured their checklist’s effect on teamwork. Eleven surgeons had agreed to try it in their cases—seven general surgeons, two plastic surgeons, and two neurosurgeons. After three months, the number of team members in their operations reporting that they “functioned as a well-coordinated team” leapt from 68 percent to 92 percent. At the Kaiser hospitals in Southern California, researchers had tested their checklist for six months in thirty-five hundred operations. During that time, they found that their staff’s average rating of the teamwork climate improved from “good” to “outstanding.” Employee satisfaction rose 19 percent. The rate of OR nurse turnover—the proportion leaving their jobs each year—dropped from 23 percent to 7 percent. And the checklist appeared to have caught numerous near errors. In

Fifteen years ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty-four-hour stretches. They found that the average patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures; you have to give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and the care of open wounds, and the difficulties only accumulate.

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection. After ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.

Of all organizations, it was oddly enough Wal-Mart that best recognized the complex nature of the circumstances, according to a case study from Harvard’s Kennedy School of Government. Briefed on what was developing, the giant discount retailer’s chief executive officer, Lee Scott, issued a simple edict. “This company will respond to the level of this disaster,” he was remembered to have said in a meeting with his upper management. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.” As one of the officers at the meeting later recalled, “That was it.” The edict was passed down to store managers and set the tone for how people were expected to react. On the most immediate level, Wal-Mart had 126 stores closed due to damage and power outages. Twenty thousand employees and their family members were displaced. The initial focus was on helping them. And within forty-eight hours, more than half of the damaged stores were up and running again. But according to one executive on the scene, as word of the disaster’s impact on the city’s population began filtering in from Wal-Mart employees on the ground, the priority shifted from reopening stores to “Oh, my God, what can we do to help these people?” Acting on their own authority, Wal-Mart’s store managers began distributing diapers, water, baby formula, and ice to residents. Where FEMA still hadn’t figured out how to requisition supplies, the managers fashioned crude paper-slip credit systems for first responders, providing them with food, sleeping bags, toiletries, and also, where available, rescue equipment like hatchets, ropes, and boots. The assistant manager of a Wal-Mart store engulfed by a thirty-foot storm surge ran a bulldozer through the store, loaded it with any items she could salvage, and gave them all away in the parking lot. When a local hospital told her it was running short of drugs, she went back in and broke into the store’s pharmacy—and was lauded by upper management for it.

Having hit on this “theory,” I began to recognize checklists in odd corners everywhere—in the hands of professional football coordinators, say, or on stage sets. Listening to the radio, I heard the story behind rocker David Lee Roth’s notorious insistence that Van Halen’s contracts with concert promoters contain a clause specifying that a bowl of M&M’s has to be provided backstage, but with every single brown candy removed, upon pain of forfeiture of the show, with full compensation to the band. And at least once, Van Halen followed through, peremptorily canceling a show in Colorado when Roth found some brown M&M’s in his dressing room. This turned out to be, however, not another example of the insane demands of power-mad celebrities but an ingenious ruse. As Roth explained in his memoir, Crazy from the Heat, “Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors—whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.” So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. “When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error.… Guaranteed you’d run into a problem.” These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor. “David Lee Roth had a checklist!” I yelled at the radio.

Senior Wal-Mart officials concentrated on setting goals, measuring progress, and maintaining communication lines with employees at the front lines and with official agencies when they could. In other words, to handle this complex situation, they did not issue instructions. Conditions were too unpredictable and constantly changing. They worked on making sure people talked. Wal-Mart’s emergency operations team even included a member of the Red Cross. (The federal government declined Wal-Mart’s invitation to participate.) The team also opened a twenty-four-hour call center for employees, which started with eight operators but rapidly expanded to eighty to cope with the load. Along the way, the team discovered that, given common goals to do what they could to help and to coordinate with one another, Wal-Mart’s employees were able to fashion some extraordinary solutions. They set up three temporary mobile pharmacies in the city and adopted a plan to provide medications for free at all of their stores for evacuees with emergency needs—even without a prescription. They set up free check cashing for payroll and other checks in disaster-area stores. They opened temporary clinics to provide emergency personnel with inoculations against flood-borne illnesses. And most prominently, within just two days of Katrina’s landfall, the company’s logistics teams managed to contrive ways to get tractor trailers with food, water, and emergency equipment past roadblocks and into the dying city. They were able to supply water and food to refugees and even to the National Guard a day before the government appeared on the scene. By the end Wal-Mart had sent in a total of 2,498 trailer loads of emergency supplies and donated $3.5 million in merchandise to area shelters and command centers. “If the American government had responded like Wal-Mart has responded, we wouldn’t be in this crisis,” Jefferson Parish’s top official, Aaron Broussard, said in a network television interview at the time.

Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations.

In order for a capitalist system to thrive, our false beliefs in productivity and labor must remain. We have internalized its teachings and become zombie-like in Spirit and exhausted in body. So we push ourselves and each other under the guise of being hyperproductive and efficient. From a very young age we begin the slow process of disconnecting from our bodies’ need to rest and are praised when we work ourselves to exhaustion. We tell our children to “stop being lazy” when they aren’t participating in work culture with the same intensity as us. We lose empathy for ourselves first and push excessively. We become managers, teachers, and leaders who fall prey to the allure of a capitalist system and treat those we have the honor of working with as human machines. We become rigid and impatient when our checklist isn’t completed to perfection. We become less human and less secure. We believe we are only meant to survive and not thrive. We see care as unnecessary and unimportant. We believe we don’t really have to rest. We falsely believe hard work guarantees success in a capitalist system.

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

Yet given how much surgery is now done—Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually—the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year

We couldn’t understand what had happened. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source. Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded and went back into rhythm. It took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty-eight hours later, the results returned. All the lines were infected. The infection had probably started in one line, which perhaps was contaminated during insertion, and spread through DeFilippo’s bloodstream to the others. Then they all began spilling bacteria into him, producing the fevers and steep decline.

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.

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.

Suppose this was just a Hawthorne effect.” ——that is to say a byproduct of being observed in a study rather than proof of the checklist’s power. (later ruled out)

Guy Speer called it cocaine brain. Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does…

Almost every term the surgical teams used was unfamiliar. We all supposedly spoke English, but I was often unsure what they were talking about.

For all the differences among the eight hospitals, I was nonetheless surprised by how readily one can feel at home in an operating room, wherever it might be. Once a case was underway, it was still surgery. You still had a human being on the table with his hopes and his fears, and his body opened up to you, trusting you to do right by him. And you still had a group of people striving to work together with enough skill and commitment to warrant that trust.

…the reason for the delay was usually not laziness or unwillingness, the reason is more often that the necessary knowledge has not been translated into a simple, usable and systematic form. (regarding delaying adoption of life-saving treatments for at least half of American patients by a whopping 17 years, according to studies.)

Having great components is not enough. We are obsessed in medicine with having great components, the best drugs, the best devices, the best specialists, but pay little attention to how to make them fit together well. Berwick notes how wrong-headed this approach is. Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence, he says. He gives the example of a famous thought experiment, of trying to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the breaks of a Porsche, the suspension of BMW, the body of a Volvo. What we get, of course, is nothing close to a great car. We get a pile of very expensive junk.

When we look closely, we recognize the same balls being dropped, over and over, even by those of great ability and determination. We know the patterns. We see the costs. It’s time to try something else. Try a checklist.

I was crushed by what I had put him through. Though I apologized to him and carried on with my daily routine, it took me a long time to feel right again in surgery. I can’t do an adrenalectomy without thinking his case. And I suspect that is good.

We know the patterns. We see the costs. It’s time to try something else. Try a checklist.

Of all organizations, it was oddly enough Wal-Mart that best recognized the complex nature of the circumstances, according to a case study from Harvard’s Kennedy School of Government. Briefed on what was developing, the giant discount retailer’s chief executive officer, Lee Scott, issued a simple edict. “This company will respond to the level of this disaster,” he was remembered to have said in a meeting with his upper management. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.” As one of the officers at the meeting later recalled, “That was it.” The edict was passed down to store managers and set the tone for how people were expected to react. On

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 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.

But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly. Just making the right treatment choice among the many options for a heart attack patient can be difficult, even for expert clinicians.

It is not enough for a surgeon to have the textbook knowledge of how to treat trauma victims—to understand the science of penetrating wounds, the damage they cause, the different approaches to diagnosis and treatment, the importance of acting quickly. One must also grasp the clinical reality, with its nuances of timing and sequence. One needs practice to achieve mastery, a body of experience before one achieves real success. And if what we are missing when we fail is individual skill, then what is needed is simply more training and practice.

In the face of the unknown—the always nagging uncertainty about whether, under complex circumstances, things will really be okay—

All involve risk, uncertainty, and complexity — and therefore steps that are worth committing to a checklist and testing in routine care. Good checklists could become as important as doctors and nurses as good stethoscopes (which, unlike checklist, have never been proved to make a difference in patient care). The hard question — still unanswered — is whether medical culture can seize the opportunity.

It’s easy to hide in a statement. It’s hard to hide between statements,” Cook said.

Before taxiing out to the runway, we paused again for five more checks: whether anti-icing was necessary and completed, the autobrakes were set, the flight controls were checked, the ground equipment was cleared, and no warning lights were on. The three checklists

I cannot pretend he escaped unscathed. The extended period of low blood pressure damaged an optic nerve and left him essentially blind in one eye. He didn’t get off the respirator for days. He was out of work for months. I was crushed by what I had put him through. Though I apologized to him and carried on with my daily routine, it took me a long time to feel right again in surgery. I can’t do an adrenalectomy without thinking of his case, and I suspect that is good. I have even tried refining the operative technique

But 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. Smart

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

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.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist.

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

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.

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

Training in most fields is longer and more intense than ever. People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own—whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves. It is not clear how we could produce substantially more expertise than we already have. Yet our failures remain frequent. They persist despite remarkable individual ability. *

Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures—perfect for a classic checklist.

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.

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.

In a fire, the metal can plasticize—lose its stiffness and bend like spaghetti. This was why the World Trade Center buildings collapsed,

Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does.

You see it in the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screwups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge. Such

Two professors who study the science of complexity—Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex.

Thinking about averting plane crashes in 1935, or stopping infections of central lines in 2003, or rescuing drowning victims today, I realized that the key problem in each instance was essentially a simple one, despite the number of contributing factors.

And that summer, as Hurricane Ella made its way toward the city, an emergency crew worked at night under veil of secrecy to weld two-inch-thick steel plates around the two hundred critical bolts, and the building was secured. The Citicorp tower has stood solidly ever since. The

Oh yes, he said. In a fire, the metal can plasticize—lose its stiffness and bend like spaghetti. This was why the World Trade Center buildings collapsed,