The Checklist Manifesto

Introduction

p.10

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. Furthermore, whatever the chosen treatment, each involves abundant complexities and pitfalls.

p.14

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.

The Checklist

p.36

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 .

…

Checklists seem to provide protection against such failures . They remind us of the minimum necessary steps and make them explicit .

The End of the Master Builder

p.48

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 .

p.50

We are besieged by simple problems .

p.51

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 .

p.68

Joe Salvia had earlier told me that the major advance in the science of construction over the last few decades has been the perfection of tracking and communication .

The Idea

p.73

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 .

p.79

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 .

…

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 .

…

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 .

The First Try

p.93

Snow persuaded the local council to remove the water well’s pump handle . This disabled the well , ended the spread of the disease , and also established the essential methods of outbreak investigation that infectious disease specialists follow to this day .

p.108

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 .

The Checklist Factory

p.120

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 .

p.122

So what did they do ? They grabbed their checklist book : CAPTAIN : You want me to read a checklist ? FLIGHT ENGINEER : Yeah , I got it out . When you’re ready . CAPTAIN : Ready .

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When you’re making a checklist , Boorman explained , you have a number of key decisions . You must define a clear pause point

p. 123

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 .

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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 . Boorman didn’t think one had to be religious on this point .

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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 .

p. 128

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 .

The Hero in the Age of Checklists

p.167

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

p.177

But step one on the list is the most fascinating . It is simply : FLY THE AIRPLANE . Because pilots sometimes become so desperate trying to restart their engine , so crushed by the cognitive overload of thinking through what could have gone wrong , they forget this most basic task . FLY THE AIRPLANE .

p.184

We’re 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 .