The Checklist Manifesto: How to Get Things Right

by Mary Jo

Lists.  Shopping lists, laundry list, to do lists.  They’re some of the most boring things in the world.  But lists are also one of the most powerful tools we have for dealing with the ever multiplying complexities of modern life.

I didn’t realize that latter fact until reading The Checklist Manifesto  by Atul Gawande, a doctor and writer whose resume is enough to make strong women reach for their smelling salts.

The Brooklyn born son of two Indian American physicians, Gawande is a surgeon at a top Boston hospital, an associate professor at Harvard in both medicine and public health, a Rhodes Scholar, a MacArthur fellow, director of a World Health Organization medical program, and somewhere in there he found time to get married and have children. <g>

TCM belongs to the fairly new non-fiction subgenre that uses science and really good writing to examine a narrow topic and give readers interesting new insights.  The books tend to be quite short, so you can read them quickly and come away feeling virtuous, entertained, and better informed.  While such books may be criticized for being simplistic, they’re still fun to read.

Godfather of this mini-genre is Malcolm Gladwell, author of the bestselling books The Tipping Point,  (about the “social epidemics” that create sudden change, Blink (the complex judgments that go into quick decisions), and Outliers, (about factors that help people really excel.)

Gawande’s thesis is that some errors stem from ignorance—we simply don’t know enough about a particular topic.  But many others stem from not properly using what we do know because the sheer volume of information is so overwhelming.  The subtitle of The Checklist Manifesto is How To Get Things Right.

Hence, checklists to ensure that all the critical steps are taken, and in the right order.  In hospitals and surgery, one of the top items is washing hands to prevent the spread of infection.  Everyone knows this needs to be done, but far too often, busyness or inconvenience interfere with basic hygiene, hands don’t get washed, and potentially lethal diseases are spread.
 
Gawande’s writing really reeled me in.  It’s witty, accessible, and full of human stories.  (It's that staff writer for The New Yorker thing.) 

As a doctor and surgeon, he deals with complicated medical procedures all the time, and knows how easily critical steps can be missed.  He starts with the gripping story of a little girl who spent half an hour in an icy pond in Austria.  She was pulled out pulseless and essentially dead, yet enormously complicated procedures over several weeks saved her life.  And this was done not at one of the world’s famous medical centers, but an average rural Austrian hospital.

That’s the spring board Gawande uses for a wide ranging discussion that goes from medicine to aviation to building skyscrapers.  The spine of the book is the author's part in developing checklists to improve operating room outcomes all over world.  Think of the challenge to develop checklists that will benefit hospitals from the West’s best to third world institutions that are desperately short of supplies and personnel!  Watching that operating room list being developed was fascinating.

Gawande's research into improving outcomes takes him to one area where checklists are really well established: aviation.  In 1935, the prototype of the B-17 Flying Fortress bomber crashed during a competition for the army because the highly experienced pilot had so many things to remember that he forgot to release the lock on the elevator and rudder controls. 

Two men died, including the pilot.  It was thought that the aircraft might too complicated to be flown, even with experienced pilots.

But the military wasn’t about to give up a great airplane without trying to solve the complexity problem.  The solution was a checklist, and they’ve become mainstays of aviation at all levels.  (I think that even Han Solo and Chewbacca used checklists when flying the Millennium Falcon.)

TCM has a whole riveting chapter on the “miracle on the Hudson,” when a USAirways jet was landed on the Hudson River with no casualties after the engines were knocked out by a flock of geese.  The pilot, “Sully” Sullenberger was considered merely modest when he said that that the fortunate outcome was a result of teamwork, but as Gawande shows, it truly was a team effort—and checklists had a lot to do with the miraculous results. 

Effective checklists have to be short enough that they won’t be ignored, and they have to hit the salient points, which means a lot of experimentation.  I loved reading about how Gawande and his team devised checklists for operating theaters and the adjustments that were made after testing.

The bottom line on The Checklist Manifest is that A) checklists can be incredibly valuable, and B) people often hate to use them.  A successful investor on Wall Street uses a checklist when evaluating potential buys, and does very well. He’s made his list widely available, but virtually no one else uses it.  There is something about the boring routine of checklists that makes it easy for attention to wander.  Some people feel checklists crush creativity and intuition, and they’re boring. 

Plus, experts who have spent years developing their skills don’t like to be told that they might miss a crucial step.  That’s why implementing the surgical checklists had to be a team effort.  Some of the surgeons surveyed sneered at the idea that checklists were needed in THEIR operating rooms.

Yet tellingly, when the same surgeons were asked if they would want checklists used if they themselves were being operated on, 93% said yes.  Because the checklists work. 

Gawande ends the book with an example of an operation he performed when he knows with absolute certainty that the checklist saved the life of one of his patients.  The point involved seemed so unnecessary that it was almost skipped, but Gawande and his team followed their own rules, and a life was saved.

If this is the sort of book you like, you’ll like this book. <g>  I have a fondness for well written essays whether they’re Atul Gawande, Barbara Kingsolver, or John Scalzi. 

The book got me thinking about checklists in daily life.  When I was the art editor of a small magazine in England in the old-fashioned days of paste-ups, every page had a checklist of items that must be looked at—headers, page numbers, photographs, etc.  A friend of mine always uses checklists when evaluating autistic children. 

Heck, a recipe is a form of checklist. Checklists can be really useful when packing for a journey so you don’t end up in Moscow with no winter coat.  (And yes, I know an absent-minded professor who did this because it wasn’t cold at home when he left. <G>)

So how do you feel about checklists as a tool of managing life’s complications?  Do you work in a field that uses them?  Do you think you might profitably apply them in some area of private life? 

And do you feel a deep sense of satisfaction when another item is ticked off on your to do list?  I certainly do!

Mary Jo

 

Comments

[Laura Resnick]

I enjoy this sort of book, too, and I'm personally a big believer in lists, so I must look for this. I don't store information well in my head, so I tend to make lists for everything, from the things I need to do today, to the subjects I need to raise in a discussion with my editor, to what to pack for an 8-month journey across Africa.

On a less world-saving note than surgery or aviation, but one which is very practical, I also read somewhere that people who make shopping lists before they go to the store waste less time and money, because they (a) don't buy things that they've already got and don't need, (b) they're less likely to make impulse buys, and (c) they don't have to make extra trips to the store because they keep not getting what they DO need.

[Laura Resnick]

P.S. Hey, in addition to all thos accomplishments--he's also cute, isn't he!

[Sherrie Holmes]

Laura, you took the words right out of my mouth! That is one seriously cute dude! He reminds me a little of Gina Davis's ex-husband, whose name just flew out of my mind.

Mary Jo, I may as well hand you all my money and tell you to go out and buy books for me. Your judgment is unerring. I still bless the day you blogged about Barbara Kingsolver's ANIMAL, VEGETABLE, MIRACLE. That book made a big change in my life, and I even learned how to make cheese as a result of that book! Now you've recommended another book that I must absolutely add to my list.

I am a huge list maker, partly because of my abominable memory (see above reference to Gina Davis's ex), but also because I'm very goal oriented. Every January I sit down and make a list of things I want to accomplish "in the future."

I've done this since 1977, and still have those lists. To see how much I've accomplished in the past 30+ years makes me feel proud of myself. And some of the things on those old lists just make me laugh.

Like an entry for 1977: buy a typewriter. *g* Then in 1995 another entry: get a modem and sign up for the Internet. And I have to chuckle because some of the things on these lists were there for 20-30 years before they got crossed off. But I live by my lists. They're my paper brains.

[Sherrie Holmes]

Goldblum! Jeff Goldblum! And it's Geena, not Gina. I can go to bed a happy woman, now.

[Maggie Robinson/Margaret Rowe]

We just got a new software program for the library this year (our 3rd in the 5 years I've worked there) and I knew at once I was in trouble (I keep hearing you can't teach an old dog new tricks). So I made a list and taped it next to the computer...x+enter clears account, y+enter means in-library use, etc. There are days I still have to look at it, and I'm not ashamed, LOL.

I'm going through a list now, getting myself ready (?) for publication. I've always got a notebook handy to write down stuff when I think of it, whether it's to remind myself to buy milk, change a word in a chapter or return books to the library. Sometimes the front seat of my car is a list, with a pile of things that must be attended to---if I remember to carry them out to the car!

[Linda Banche]

While I have no problem making checklists for myself, at work I have to use them all the time, and I HATE them! There has to be some happy medium where the checklist helps, rather than hinders. Maybe the secret is making your own checklists, rather than having them imposed on you, like I have at work.

[NinaP]

Check lists, I could not survive w/o them. As Sherrie put it, they are my paper brains.

During my recent surgery, I had an opportunity to see check lists hard at work (on me). From the moment I arrived at York Hospital, doctors and nurses hummed around me with amazing efficiency. As a veteran of the manufacturing world (where checklists are called SOPs) I recognized their cadence and when someone made an If-this-then-that turn. As a patient caught up in a whirlwind of pain and fear, it was a comforting sight to see. I knew I was in good hands no matter the curve balls my system kept throwing their way.

[gretchen fucio]

I like making lists and checking things off. It helps me feel
a. accomplished
b. secure
c. organized.
I am none of these things, but lists make me feel that way!

[Lyn S]

I would lose my head if it wasn't on my list. My family laughs at all the times I drove off to the store then turned around because the grocery list wasn't in my purse.

My husband is learning to become a pilot (fulfilling his mom's dream who is paying for it so he won't regret it like she does). He has a spectacular memory (he has never forgot my bday or anniv), and chafes a little at using the checklist that he has memorized. But he realizes that it is vital, who knows when one day you forget that one little thing.
I have 4 new books to read now. I agree that MJP should be my personal book shopper, as long as hers are always on that list.

[maryjoputney]

From MJP:

Yes, I noticed that Dr. Atul is seriously hunky. *g* The Jeff Goldblum comparison is a pretty good one--I looked at the clip of Gawande on Jon Stewart, and the doc towered over Stewart.

It's fun too see all these takes on checklists! They really do make our lives easier and more manageable, as Maggie proved with her personal one for her computer. Linda, I think you're right that tailoring our own makes them more useful.

Thanks for the nice words on my book tastes! There are plenty of books I read and don't blog about, but every now and then I hit on one that is just so cool I want to share.

I liked THE CHECKLIST MANIFESTO so well that I bought Atul Gawande's two previous books, which are collections of his essays from The New Yorker and Salon.

Some women swoon at muscles. I go for brains--but cute never hurts!

[NinaP]

I don't know, Mary Jo. Muscles are nice, brains are good, but I'll take a romantic bent any day. :-)

(a diversion from checklists, I know, but then again...)

[Susan/DC]

I first read about medical checklists in an article Atul Gawande wrote in the December 2007 New Yorker. The article is well worth reading (it's available on The New Yorker website). Evidently the concept originated with Dr. Peter Pronovost, of Johns Hopkins, who himself sounds like an interesting character: he has a joint MD/PhD and a decidedly scientific but practical mind.

Gawande came to Politics & Prose, our local independent bookstore, to discuss The Checklist Manifesto and was quite charming. However, when I asked my son's surgeon if he used a checklist, he replied "my brain is the checklist". Wrong answer, but it's one of the reasons medicine is difficult to regulate or reform: we are the consumers, but for the most part we don't control the details of the care we consume.

[Hannah Lee]

I revise my packing list for each trip, but for my recent trip, I neglected to consult it as I was packing. It was only to New York City, and I was feeling smug that I could pack for a weekend trip without a list. Alas, it was the only time I forgot my daughter's prescription medication. So, my husband and his father spent several hours driving around that Friday night of New Year's, looking for an open pharmacy. None were available but that's a different tale.

"If this is the sort of book you like, you’ll like this book."
My husband as a boy would conclude each book review with "And I recommend this book to all." You have the more nuanced, mature endorsement, Mary Jo!

[Patricia Rice]

I lack memory, so I have lists everywhere, if only I could find them! I even have a grocery list I keep in the computer, with items I usually buy listed by aisle. I don't think it keeps me from buying the yummy foods just out of the deli or bakery or the specials of the day, but it does keep me from forgetting the milk.

[Anna B]

Checklists are a big part of my professional life. As a medical coding auditor I have to audit the doctors notes to make sure they meet the required guidelines for the charges they have billed. When the doctors use a check list during the patient's visit a couple of things happen. The amount billed is reflected in the documentation, the information is clear to any other medical professional who reads that record and most important, the patient got a complete examination and will get better follow up treatment. And yes, a lot of the doctors didn't want to use them. However, today, most of them ask us to create more checklists geared to specific illness, like diabetes or hypertension.
I knew about the OR checklists of course and this book sounds like an interesting read.

[maryjoputney]

From MJP:

**when I asked my son's surgeon if he used a checklist, he replied "my brain is the checklist". Wrong answer**

So true, Susan/DC! When people have trained for years, they tend to feel insulted if anyone questions their expertise. Sadly, even really bright, well trained people can make simiple mistakes. Luckily, the surgeon didn't for your son, but this illustrates how little control the medical consumer has.

**My husband as a boy would conclude each book review with "And I recommend this book to all." You have the more nuanced, mature endorsement, Mary Jo!**

I'm older and warier, Hannah. *g* It sure sounds like you experienced instant karma when you thought you could get away without a checklist for a short trip! Luckily, it did get sorted out, though obviously a hassle.

Anna B, it sounds as if you're on the front lines of checklist use! What you say about checklists that are tailored to particular conditions affirms what Gawande says in the book. The right, relevant (and SHORT) checklist can be hugely useful. (Not to mention making the billing more accurate...."

[Lyn S]

Coincidentally Capt. Sullenberger announced his retirement today. Since you gave away the secret to his heroism, I guess he had to hang up his hat :)

[Andrea Penrose]

Fascinating post, Mary Jo. I love this sort of essay/book (I am a huge fan of the NYer, where I often find myself engrossed in a subject I know nothing about, simply because the writing is so good.) TCM is now on my ever-growing TBR pile.

I find checklists essential these days. They help me focus on getting tasks done efficiently—and leave me feeling very virtuous when I get to cross them off.

But in all seriousness, the stories he recounts about checklist saving lives makes perfect sense. Information overload is daunting, especially in a pressure situation. So having a guide makes all the difference.

Thanks for sharing! Am now off to make a list of what to do for the rest of the day!

[Anne Gracie]

Wonderful post, Mary Jo. I am a constant list-maker. I started it years ago when I had a very busy and stressful day job with many to-do items each day, all wildly different, and in a largely unpredicitable day. I found that making lists not only helped me get things done, but helped me sleep better at night -- if it was on the list I didn't have to worry about it.

Plus, crossing off something from a list is a great feeling. I've even been known to list something I've done, just so I can have the satisfaction of crossing it off. LOL.

[maryjoputney]

From MJP:

Anne, isn't it lovely for us listmakers to know that we're now on the cutting edge of information management? *g*

Cara, I agree with you that a mark of great writing is when an article sucks you in even though you started with interest in the material. Always a pleasure to find that.

[Mary Gramlich]

I can't imagine a life without lists and the great satisfaction I receive from checking things off of them. Life is complicated and confusing and if you can take one 3x5 index card (as I do) and keep your life in order - so be it. I have a list to remind me to check my lists it is that bad. Now I have to go back to store to pick up something that was on a list but not the list for the store I was just at - yuck!

[Patricia Barraclough]

My husband was in the Air Force in B-52s and FB111s. Thank heavens for check lists for both flight crews and ground crews.
My jobs have not needed checklists other than the reminders of what to do before closing at night.
I make lists all the time. They are a necessity for remembering things and help get things done. And yes, there is a great sense of satisfaction when you can check something off.

[maryjoputney]

From MJP:

Mary--even your lists are better organized than mine. *g* I usually use the back of scrap pages from the printer. If something doesn't get done on that list, I transfer it to the next list.

Library Pat, those aircraft your husband used to fly were the reason checklists were invented! That kind of complexity just can't be managed in a mind, at least not on a regular basis.

But even library closing down lists are valuable. Leaving a coffeemaker on could lead to calamity. And if you check the book drop every night--maybe you'll find a little orange kitten like the famous Dewey of Iowa. *g*

[Mary Gramlich]

I am only a little embarassed to say that I have a small pack of index cards in my wallet. You never know when something will inspire you to start a new list or when an emergency like a song I have to have downloded to my iPod is on my satellite radio. Sad to be this way but if not for my lists I would forget what to bring for lunch!

[maryjoputney]

Mary--one should never apologize for being well organized! I do sort of the same thing, except that it's usually a piece of scrap printer paper. *g*