Checklist Manifesto

January 5, 2012

I’ve been on a non-fiction kick lately. The past four books I read were  non-fiction and I recently finished The Checklist Manifesto by Atul Gawande.

Gawande has a long list of credentials, including: general and endocrine surgeon at Brigham and Women’s Hospital in Boston, MA; staff member at the Dana Farber Cancer Institute; staff member at the New Yorker magazine; Associate Professor of Surgery at Harvard Medical School; Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health; and, he’s the director of the World Health Organization’s Global Challenge for Safer Surgical Care. It is a unique characteristic to be both brilliant and an engaging writer.

Gawande’s challenged is to create a global approach to safer surgical care. With such an overarching task, spanning small rural African hospitals to the largest, most well-funded hospitals in the USA, he struggles with where to begin for an initiative that will actually make surgeries safer. His beautifully simple and cheap solution…checklists. He talks with people in all sorts of industries that effectively use checklists, such as pilots, construction crews, rock stars and fund managers. We as humans can only retain so much information. When complex situations arise, our capability to remember all the details flies out the window. Even the most basic, common-sense steps can be forgotten. Partly because the steps are so standard, we assume they have been done. Take the checklist in the cafe. Closers close every night, yet if they don’t follow the checklist, inevitably something is forgotten.

The problem with checklists is they can become too long, too complicated, and in the end, make everyone frustrated and ready to chuck the whole darn thing. The aviation industry has spent years honing checklists. One key factor is to make sure the crew introduces themselves. Airplane crews, as with doctors, may have never worked together. When everyone has a chance to at least introduce themselves, they feel more like a team. When crisis arise, teams work better than individuals. Second, the checklist does not state every single step, but the most important steps, the “killer items.”

Gawande defines killer items as “the steps that are the most dangerous to skip and sometimes overlooked nonetheless.” If it is too long, people will look for shortcuts and end up skipping steps. Finally, there are built in pauses to communicate with your team. You can check out a selection of check lists from a variety of industries on Gawande’s website:

Checklists have proven to be very effective in all walks of life. However, we don’t like them very much. We tend to feel like checklists are inferior to our innate and trained abilities. Plus, they tend to be issued from the top, so we feel forced to use them. It takes discipline to go through the same routine time and time again, when we think we already know the routine. In fact, Gawande says “all learned occupations have a definition of professionalism” which include three common things: selflessness, expectation of skill, and expectation of trustworthiness. He adds a fourth: discipline. “This is a concept almost entirely outside the lexicon of most professionals, including my own,” he says. “In medicine, we hold up “autonomy” as a professional lodestar, a principle that stands in direct opposition to discipline. Individual Autonomy hardly seems the ideal we should aim for. It has the ring more of protectionism than of excellence. What is needed is discipline. We are flawed by nature and inconsistent creatures. We are built for novelty and excitement, not careful attention to detail.”

It takes careful adherence to check lists to level out our innate humanness. Even in my non-life-threatening daily grind, I find that if I don’t write down my tasks, I don’t get them done. I will even forget the thing that was too important to forget! As for the cafe, we have re-implemented our opening, shift change, and closing task lists. We have lists for inventory, packaging supplies and staff communication. I could certainly use more discipline in my life, both professional and personal. This is a very interesting read, and I highly recommend it.

What about you? Do you use checklists to manage your life? Do they work? Do you have the discipline to adhere to them? I’d love to hear your thoughts – and hopefully learn a thing or two from you!

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