- Progress in human understanding has become increasingly complex and overwhelming.
- Checklists help prevent serious but easily avoidable mistakes.
- Checklists should be as short as possible, include all essential steps and leave no room for misunderstandings.
- Today’s complex tasks can no longer be left to a lone hero’s expertise; we need teams.
- Team communication is vital in complex situations and can be greatly enhanced by a checklist.
- Medical checklists have already saved many lives.
- Checklists can be effective in diverse settings.
Much of the The Checklist Manifesto is flow curation describing how various industries (medicine, construction, food service, aviation, …) use checklists. A shared practice is the checklisting of communication tasks. The construction industry calls this communication check listing a submittal schedule. Submittal schedules document flow between teams.
Another shared practice is using checklists to distribute power. “Cleared for takeoff” culture gives anyone on any of the teams that are constantly communicating per the submittal schedule the power to say, whoah. Further, the checklists make the minimum necessary steps explicit while giving room to adapt. Make checklists that are a cognitive net, not a wagging finger.
Checklists document and shape flow. They inspire flow in emergencies and sustain it through the quotidian. The virtues that come with the lightweight discipline of checklists are many and emergent. They relieve anxiety, make process transparent, and help teams flow during stress.
Checklist cool tricks
- distribute power.
- push power of decision making to the periphery.
- provide a cognitive net.
- make the minimum necessary steps explicit.
- make sure simple steps are not missed.
- make sure people talk.
- capture and shape real flow.
- inspire flow in emergencies and sustain it through the quotidian.
- capture flow between teams.
- encourage a shared culture around flow.
- accessibly capture institutional memory in the context of flow.
Attributes of a good checklist
What makes a good checklist? Checklist shouldn’t be about just checking boxes. Instead of being a chore, checklists should fit and assist real flow. The Checklist Manifesto offers these suggestions.
- are not lengthy.
- have clear, concise objectives.
- define a clear pause point at which the checklist is supposed to be used.
- have fewer than ten items per pause point.
- fit the flow of the work.
- continually update as living documents.
- Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.
- Make the minimum necessary steps explicit
- Provide a cognitive net
- Establish a higher standard of baseline performance
- “forcing functions”: relatively straightforward solutions that force the necessary behavior—solutions like checklists.
- We are besieged by simple problems.
- Submittal schedule – checklist of communication tasks
- Submittal schedules make people talk
- We can build complex things because of tracking and communication
- A checklist to make sure simple steps are not missed. A checklist to make sure people talk.
- Push power of decision making to the periphery. Give people room to adapt. Make sure they talk and take responsibility.
- In a complex situation, don’t issue instructions, make sure people talk.
- Following the recipe is essential to making food of consistent quality over time.
- behavior-change delivery vehicle
- bring gifts rather than wag fingers
- simple, cheap, effective, and transmissible
- Cleared for takeoff culture.
- Pre-launch team briefing. Team huddle.
- Pause points.
- Simple interventions. Leverage.
- Checklists distribute power.
- An inherent tension exists between brevity and effectiveness.
- Part of every expert’s job should be finding a way to ensure that the group lets nothing fall between the cracks. Systems require experts to tend flow to be healthy.
- Getting people to offer their names and concerns during the pre-launch briefing makes them more likely to speak up later. “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.”
- “That’s not my problem” is possibly the worst thing people can think
- You must define a clear pause point at which the checklist is supposed to be used
- You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist.
- The checklist cannot be lengthy.
- Ideally, the person driving isn’t the person working though the checklist. Copilots are good. The driver is less distracted and power is distributed.
- “Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.”
Checklists 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.
In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.
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.
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.
Checklists, he found, established a higher standard of baseline performance.
Four generations after the first aviation checklists went into use, a lesson is emerging: 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.
All were amenable, as a result, to what engineers call “forcing functions”: relatively straightforward solutions that force the necessary behavior—solutions like checklists.
We are besieged by simple problems.
And the question of when to follow one’s judgment and when to follow protocol is central to doing the job well—or to doing anything else that is hard.
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 assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted. So the submittal schedule made them talk.
the major advance in the science of construction over the last few decades has been the perfection of tracking and communication.
They trust instead in one set of checklists to make sure that simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems.
There is a particularly tantalizing aspect to the building industry’s strategy for getting things right in complex situations: it’s that it gives people power. In response to risk, most authorities tend to centralize power and decision making.
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.
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.
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.
More remarkably, they had learned to codify that understanding into simple checklists. They had made the reliable management of complexity a routine. 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.
“David Lee Roth had a checklist!” I yelled at the radio.
“following the recipe is essential to making food of consistent quality over time.”
All the examples, I noticed, had a few attributes in common: They involved simple interventions—a vaccine, the removal of a pump handle. The effects were carefully measured. And the interventions proved to have widely transmissible benefits—what business types would term a large ROI (return on investment) or what Archimedes would have called, merely, leverage.
Plain soap was leverage.
The secret, he pointed out to me, was that the soap was more than soap. It was a behavior-change delivery vehicle.
“Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not.”
bringing them a gift rather than wagging a finger.
Could a checklist be our soap for surgical care—simple, cheap, effective, and transmissible?
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.
He explained that his hospital had completed a feasibility trial using a much broader, twenty-one-item surgical checklist. They had tried to design it, he said, to catch a whole span of potential errors in surgical care. Their checklist had staff verbally confirm with one another that antibiotics had been given, that blood was available if required, that critical scans and test results needed for the operation were on hand, that any special instruments required were ready, and so on.
The checklist also included what they called a “team briefing.” The team members were supposed to stop and take a moment simply to talk with one another before proceeding—about how long the surgeon expected the operation to take, how much blood loss everyone should be prepared for, whether the patient had any risks or concerns the team should know about.
But however embarrassing it may be for us to admit, researchers have observed that team members are commonly not all aware of a given patient’s risks, or the problems they need to be ready for, or why the surgeon is doing the operation. In one survey of three hundred staff members as they exited the operating room following a case, one out of eight reported that they were not even sure about where the incision would be until the operation started.
“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. But in medicine, we see it all the time. I’ve seen it in my own operating room.
They can each be technical masters at what they do. That’s what we train them to be, and that alone can take years. But the evidence suggests we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to whatever problems might arise.
Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork—a kind of team huddle, as it were. So was another step that these checklists employed, one that was quite unusual in my experience: surgical staff members were expected to stop and make sure that everyone knew one another’s names.
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.
You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). 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 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.
However 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.
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.
In aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process.
An inherent tension exists between brevity and effectiveness.
We surmised that improved communication was the key. Spot surveys of random staff members coming out of surgery after the checklist was in effect did indeed report a significant increase in the level of communication. There was also a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications.
Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place. But will we do it?
Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.
Yet we should also be ready to accept the virtues of regimentation.
“When surgeons make sure to wash their hands or to talk to everyone on the team”—he’d seen the surgery checklist—“they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.”
The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).
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. This isn’t rigidity. This is making sure everyone has their best shot at survival.
All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. The codes are sometimes stated, sometimes just understood. But they all have at least three common elements. First is an expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own. Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise. Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges. Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own. In medicine, we hold up “autonomy” as a professional lodestar, a principle that stands in direct opposition to discipline. But in a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for. It has the ring more of protectionism than of excellence. The closest our professional codes come to articulating the goal is an occasional plea for “collegiality.” What is needed, however, isn’t just that people working together be nice to each other. It is discipline.
Airline manufacturers put a publication date on all their checklists, and there is a reason why—they are expected to change with time.
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.
“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,”
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.
In the spring of 2007, as soon as our surgery checklist began taking form, I began using it in my own operations. I did so not because I thought it was needed but because I wanted to make sure it was really usable. Also, I did not want to be a hypocrite.
Just as powerful, though, was the effect that the routine of the checklist—the discipline—had on us. Of all the people in the room as we started that operation—the anesthesiologist, the nurse anesthetist, the surgery resident, the scrub nurse, the circulating nurse, the medical student—I had worked with only two before, and I knew only the resident well. But as we went around the room introducing ourselves—“Atul Gawande, surgeon.” “Rich Bafford, surgery resident.” “Sue Marchand, nurse”—you could feel the room snapping to attention.
It turns out that the key to Apple’s creativity, speed, and adaptability is, on its surface, the exact opposite of the kind of free-wheeling creativity one might expect. It’s a checklist. A really long one.
Whereas Apple relies on detailed, internally documented processes, many other tech companies rely on “tribal knowledge” haphazardly passed from one employee to another. Kahney continues:
“‘It was a very rude awakening for me to go a different company like Excite or Yahoo because they had none of that!’ [said Sally Grisedale, former manager of Apple’s advanced technology group.] ‘Nothing written down. Like, Process? Are you kidding? Just ship it and get it out there!’”
The utility of checklists for accomplishing complex tasks has long been known. They were championed and refined by the US Air Force (which also pioneered, during WWII, the research that became industrial and organizational psychology) and are used by surgeons to cut fatalities by one-third, according to Atul Gawande’s excellent The Checklist Manifesto: How to Get Things Right.
One of the central tenets of The Checklist Manifesto is that even when tasks are simple—and Apple’s ANPP definitely is not—it’s human nature to forget critical steps. In design, perhaps the right people weren’t consulted in the correct order, or a critical supplier was left out of the decision-making process, leading to delays and compromise.
While Gawande’s checklists for pre-surgical prep are relatively simple, what the ANPP illustrates is an additional kind of value the checklist can add for large organizations: As a living document, it becomes a public store of all that is known about how to best accomplish the main business of an organization. At Apple, that’s making hardware. Every business is different, but, argues Kahney throughout his book on Apple, selectively imposing seemingly rigid structures on even the most creative enterprise frees employees from having to worry about whether they’re getting all those little steps right, so they can concentrate on being creative with the parts of their work that are different from all the other times they’ve done it before.
Perhaps Dr. Gawande believes that the point he made in his original article bears repeating, since it’s been hard for people to accept its central tenet: that the complexities of technology in the 21st century may be best handled by the simplest solution. “We may admit that errors and oversights occur — even devastating ones,” he writes, referring here primarily to his fellow surgeons, a group not known for modesty. “But we believe our jobs are too complicated to reduce to a checklist.”
The study began in the spring of 2008, and the results were startling. Without adding a single piece of equipment or spending an extra dollar, all eight hospitals saw the rate of major postsurgical complications drop by 36 percent in the six months after the checklist was introduced; deaths fell by 47 percent. “In every site, introduction of the checklist had been accompanied by a substantial reduction in complications,” he writes. “In seven out of eight, it was a double-digit percentage drop. This thing was real.”
And few can make it as clear as he can what exactly is at stake in the effort to minimize calamities. If something as simple as a list that reminds medical personnel to wash their hands and introduce themselves by name and job to everyone in the operating room can improve care, that’s reason enough to take the checklist concept seriously.
What a powerful insight this is: In an age of unremitting technological complexity, where the most basic steps are too easy to overlook and where overlooking even one step can have irremediable consequences, something as primitive as writing down a to-do list to “get the stupid stuff right” can make a profound difference.
Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking, but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But this new plane was too complicated to be left to the memory of any pilot, however expert.
With the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The Army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the Army gained a decisive air advantage in the Second World War which enabled its devastating bombing campaign across Nazi Germany.
In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.
The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.
I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).
“At the current rate, it will never happen,” he said, as monitors beeped in the background. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.