The Checklist Manifesto By- Atul Gawande

Atul Gawande has a startling idea: that many of the problems that we face today can be solved by the simple, humble checklist.

As a surgeon, he realized that many people were contracting serious illnesses – thousands of them dying from them – while they were in the hospital getting treatment for other things. In other words, hospitals were killing people.

His book outlines the solutions he helped implement across surgery sites worldwide, which dramatically improved outcomes for the better.

His book outlines his remarkable story, but also how checklists are solving problems in other industries too – like construction and aviation.

Why Humans Fail
As human beings, we fail for many reasons. Some things are just outside of our control and understanding. Even with the amazing technological advances we’ve seen in the past 100 years, our physical and mental powers are limited.

However, as Gawande points out, many things are in our control, and we can put them into two buckets.

The first bucket is ignorance. There are areas in which science has only given us a partial understanding of an issue. Try as they might, there are some snowstorms that the weather people just can’t predict.

The second bucket is ineptitude. These are areas in which the knowledge exists, but we fail to apply it correctly. These are the buildings that get built incorrectly and collapse, the snowstorms that could have been predicted, and the steps before a surgery that should be followed to prevent infections from developing in a patient.

That last example is the one where Gawande has direct experience. In the US alone, 150,000 deaths occur in hospitals after surgeries each year, and experts predict that at least 75,000 of them are avoidable.

As Gawande says in the book:

“Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.”

The solution in these situations, he says, is the humble checklist.

Checklists that save lives
One of the things that checklists overcome is the failure of human memory and attention. We know this intuitively – anybody who has forgotten where they put their keys knows how poor our memory and attention can be at times.

In particular, Gawande saw this play out time and time again in operating rooms around the world. Ask any surgeon whether or not they consistently take all of the steps necessary to prevent central line infections (caused bacteria or viruses entering the body when an IV is inserted), and they’ll say “yes, of course I do – we learned that on the first day of medical school.”

Just to bring this example to life, here are the 5 steps doctors are required to take in order to prevent these infections.

Wash their hands with soap.
Clean the patient’s skin with antiseptic.
Put sterile drapes over the entire patient.
Wear a mask, hat, sterile gown, and gloves.
Put a sterile dressing over the insertion site once the line is in.
That’s it!

If every surgeon followed those 5 steps in every single surgery, there would be no central line infections. Except every surgeon will tell you that they follow the steps all the time, and the data shows that thousands of people get central line infections every single year at hospitals.

Peter Pronovost, M.D., Ph.D. – a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine – decided to give a checklist for these steps a try. First, he asked his nurses to watch the surgeons before the surgery and record whether or not they followed the steps.

After a month, the data was clear. In more than a third of the cases, the surgeons skipped at least one of the critical steps.

He instituted the checklist at the hospital, and found that the ten-day-line-infection rate went from 11 percent to zero. Over the next 15 months, in this single hospital, that checklist prevented forty-three infections, eight deaths, and saved two million dollars in extra costs (central line infections need to be treated).

The state of Michigan decided to implement this remarkable tool state wide, and found that over a period of eighteen months, they saved more than fifteen hundred lives and $175 million in extra costs.

Checklists that make money
As it turns out, checklists can be used for all sorts of things. One of the more exciting findings for entrepreneurs is that they can be used to make more money.

Gawande interviewed three different professional investors who used checklists in their business. One of them was Guy Spier, who runs a company called Aquamarine Capital Management, where he is in charge of a $70 million fund. The second investor didn’t want to be identified, but is a director at one of the largest funds in the world that is worth billions of dollars. The third investor is Mohnish Pabrai.

Pabrai is an investor and the managing partner of Pabrai Investment Funds. He has a $50 million portfolio, and uses checklists to determine whether or not to make an investment in a company.

He is a follower of the value investing model (the patron saint of which is Warren Buffet) and over the course of his career has studied every single deal Berkshire Hathaway has done – good and bad. That, along with his own successes and failures, lead him to create a list of dozens of mistakes that they could make in the investment process.

Then, he systematically created a checklist to guard against them all. They ensure that at every step of the investing process they have the critical information they need in order to make the best possible decision.

All three of the investors that Gawande interviewed found that their returns were higher and they made fewer mistakes because of those checklists.

So why don’t more investors take this kind of approach?

Psychologist Geoff Smart conducted a revealing research project. He studied and tracked fifty-one venture capitalists over time. For those of you who are unfamiliar, VCs make multi-million-dollar investments in risky, unproven start-up companies.

He studied how those people make their investment decisions, and identified six different approaches.

1. Art Critics are people who assess entrepreneurs almost at a glance, the way an art critic assesses the quality of a painting.

2. Sponges take their time gathering information about their targets, soaking up whatever they could and then making a gut call.

3. Prosecutors interrogated entrepreneurs aggressively testing them with challenging questions about their knowledge and how they would handle different situations.

4. Suitors were more focussed on wooing people rather than evaluating them.

5. Terminators see the entire effort as doomed to failure and skip the evaluation all together.

6. Airline Captains took a methodical checklist-driven approach, studying past mistakes and lessons and then built checklists into their process.

Then Smart tracked the VCs success over time. Not surprisingly, the Airline Captain approach was the clear winner. They had a median 80 percent return on their investments, and the other groups had a median of 35% or less.

The most interesting discovery from his study was that only one in eight VCs used the Airline Captain approach, in spite of its obvious advantages. All of this in spite of Smart publishing his findings in the best-selling book Who.

Let’s move on to explore why checklists work, and why most of us refuse to use them in spite of their effectiveness.

Why Checklists Work
Checklists offer solutions for two problems.

First, as we’ve already discussed, it helps us remember the right sequence of steps to perform an important action. It is particularly helpful in what engineers call “all-or-nothing” processes – where missing one of the steps means you might as well not made any effort at all. The steps for central line infections and the pre-flight checklist for an airline pilot fall into this category.

Second, it prevents us from lulling ourselves into skipping steps even if we remember them.

Checklists remind us of the minimum necessary steps and make them explicit. They not only give us the opportunity to verify we’ve done things correctly, but also instill a discipline of higher performance.

One industry where checklists are used for pretty much everything is the airline industry. As Gawande points out, Dan Boorman has more experience translating theory into practice than pretty much everybody on the planet. He is a veteran pilot who has spent the past couple decades developing checklist and flight deck controls for Boeing.

The pilot handbook for each Boeing plane is about two hundred pages long and contains scores of checklists.

There are “normal” checklists for things they do every day – how they check the engines, what they do before taxiing to the runway, etc.

Then there are the non-normal checklists, which cover every conceivable emergency situation a pilot might run into – from a dead radio to a copilot becoming disabled.

Boeing issues more than one hundred checklists every single year – either new or revised – and over the years they have learned a thing or two about what makes a good checklist.

Here’s how Boorman explains the difference:

Bad checklists are:

Vague and imprecise.
Long, hard to use and impractical.
Made by people with no awareness of the situations they are to be deployed in.
Treat people using the tools as dumb and try to spell out every single step.
Turn people’s brains off instead of turning them on.
Good checklists are:

Precise.
Efficient, to the point and easy to use in the most difficult situations.
Do not try to spell out everything.
Provide reminders of only the most critical and important steps – the ones that even highly skilled professionals using them could miss.
Why we don’t use them
It’s now clear that checklists work, and we have a process for creating good ones. The biggest issue with them is compliance – people don’t use them even though they know they work.

A potential reason is that our culture celebrates “heroes”. The people who seem to have superpowers to produce results that most of us can only dream of.

One of those heroes in recent memory is Captain Chelsey Sullenberger III, who landed a passenger airplane in the Hudson River in New York City after being hit by a flock of geese shortly after takeoff.

Although the press heralded Sully as a hero (he was), the reality was that he was able to save all of the passengers aboard that flight by relying on his training to go through the checklists.

Maybe if we focused more of our attention on exactly why our heroes are able to create remarkable results, we’ll place less emphasis on their personal skills and abilities and more emphasis on the systems and procedures they use to produce remarkable results.

Conclusion
It’s exquisitely clear that using checklists will produce better results in almost any area of your business. In fact, the more important the task, the more effective a checklist will be.

The ball is in your court.