Why this book: Selected to be read and reviewed by All American Leadership Faculty Reading Group for our bimonthly reading group session.

Summary in 3 Sentences:  Dr Atul  Gawande shares his research-based “manifesto,” supported by many engaging stories for how following simple checklists can be stunningly effective in reducing errors and improving results in a variety of settings.  Much of the book is based on his experience developing  and using checklists as part of surgery, and he describes his efforts with the World Health Organization to universalize this simple process for saving lives and preventing errors.  He also explores with more fascinating examples how checklists have  revolutionized safety in aviation and engineering, and are increasingly used by the most successful chefs in high-end cooking, and by venture capitalists in financial investing.

My Impressions:  The author shows us how the seemingly self-evident process of creating simple checklists can make a profound difference in improving how people and organizations function.  In situations where leaders face numerous variables and potential distractions, potentially must make many decisions, large and small, it is easy to get distracted and lose focus.  Checklists ensure that simple and critically important steps are taken, not skipped inadvertently due to distraction,  nor ignored when emotion or other factors may get in the way.

Sounds obvious, right?  The Checklist Manifesto gives many examples of how effective checklists can be, at so little cost in time, effort and attention, to ensure things are done right, and the right things are done. He explores the worlds of surgery, aviation, engineering, cooking in high-end restaurants, and finance.  These very diverse fields show how this simple process can be adapted to any activity which demands discipline and process to ensure the simple but critical functions are taken care of before too much attention is given to the more complex functions.  Checklists have been shown to serve as a “cognitive safety net” to account for the “flaws in memory, attention, and thoroughness.” (p48)

Gawande is a surgeon and much of his book deals with his experience using and promoting checklists in the operating room.  He led the World Health Organizations effort to recommend that checklists become an international standard for surgery, and his description of the research and his  work with the WHO is fascinating and informative.  Research has shown that at least half of the deaths and major complications that follow surgery have been due to avoidable mistakes.   He offers numerous examples of mistakes that surgical teams have made that have cost people their lives or many extra months of recovery –  that could have been avoided had the surgical team gone thru a simple checklist at certain key stages of a surgical procedure.  He includes his own experience in surgery, in which checklists have been critical to saving the lives of his patients.

The checklist made its debut on the large stage of professional activity in aviation, and was so effective, it has become standard practice in commercial aviation the world over, in helping aircrews ensure that key steps and procedures are followed during routine, non-routine or emergency situations.

He also looks at how checklists have transformed the world of complex engineering, where so many different trades and specialties must coordinate and collaborate to create a large and complex structure.  In engineering, he found that checklists often include an unexpected imperative: Simply that people from different disciplines key to building the structure have met and spoken with each other.  In engineering, as in so many other fields, communications gaps and miscommunications are the source of many serious failures.

At the conclusion of the book he introduces us to to three highly successful venture capitalists who have used checklists for making sure that their investments meet rational and agreed upon criteria.  They seek to avoid what they call “cocaine brain” when an investor or an institution falls in love with a company or project for whatever reason, and invests without putting checks in all the key boxes to ensure a dispassionate due-diligence  analysis has been done.  These “cocaine brain” investments that have not been carefully scrutinized can cost a company millions of dollars and immeasurable disruption and distraction.  He shares how the “airline captain” methodical checklist-driven approach to investing has resulted in dramatically fewer firings of senior managers, and significantly higher returns on investments, compared to investors using other styles and approaches to investment decision making.  (p171)

The Checklist Manifesto also shares examples of ineffective and even counter-productive checklists.  These are checklists that try to do too much, are too long, too complicated, are vague or imprecise, hard to use, impractical.   Boeing has a team of people who create checklists for their aircraft – and this team puts enormous energy and research into making sure the checklists are short, clear, precise (without being too detailed,) and easily understood. The checklists Boeing provides are invariably modified by users to better fit the context in which they will be used.   Boeing found that creating a great checklist took multiple iterations, and constant feedback, and some compromise.  But on one thing the Boeing team is  adamant: A checklist must be tested in the real world, which is inevitably more complicated than expected.  (p124)

There is a lot of basic, good leadership advice in this book.  Using the checklist process allows leaders to evaluate team members’ conscientiousness and discipline.  Gawande echoes McChrystal in Team of Teams and Marquet in Turn the Ship Around in pointing out that efforts to dictate every step from the center (or the top) will fail.   But discipline, and well ingrained processes and procedures (checklists) to ensure that fundamentals are covered make it easier for leaders to push decision making down to those closest to emerging problems.  Checklists also have the effect of distributing power; the surgeon cannot begin surgery until the nurse has gone through the checklist and gives the go-ahead.

It was a surprise to read how checklists have been resisted at every turn.   Even after presenting irrefutable data that show how effective checklists have been, many leaders are unwilling to adopt them, and prefer to trust people’s intuition, and trained habitual practice to make sure key steps are taken.  They don’t want to give authority over to the holder and enforcer of a checklist.  There is a sense that checklists add rigidity to a process and reduce the autonomy of the experienced leader.  Gawande makes the case that this prejudice has resulted in great costs.  He argues that checklists add discipline and process, but don’t take away the need for judgment. Judgment is always required he says, but “judgment aided – even enhanced – by procedure.” (p79)

He has a great sentence which summarizes his views on the resistance to checklists:

We don’t like checklists. They can be painstaking. They’re not much fun. But I don’ think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives, but from making money.  It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – those we aspire to be – handle situations of high stakes and complexity. The truly great are daring . They improvise. They do not have protocols and checklists.   Maybe our idea of heroism needs updating. (p173)

Some key points and insights I got from The Checklist Manifesto:

• Checklists can ensure consistency in performing the basics and fundamentals.
• There are three types of problems – each of which requires some consistency in approach and some basics that must be done to ensure a good outcome:
  • Simple problems – Follow a simple procedure and  you get the result  -like a recipe for baking a cake.
  • Complicated problems – A series of predictable processes that require multiple people, multiple teams, specialized expertise, that require timing and coordination. Like sending a rocket to the moon.
  • Complex problems – Every situation is different and even the variables are different or unknown. Each problem requires a new approach. Like raising a child. 49
• Checklists get the dumb stuff out of the way, the routines our brain shouldn’t  have to occupy itself with.  177
• Checklists free up the leaders to consider complexities and contingencies, since they know that the basics will be taken care of. 177
• Amazing how effective it is to include steps to ensure that key people have communicated with each other.  In surgery, this simply includes the requirement that those on the team introduce themselves to each other before surgery begins.
• He refers to the “activation phenomenon,” giving everyone a chance – or even forcing them – to say something and communicate with the others on the team,  which activates their sense of participation in and responsibility for the outcome. 108
• Pilots use their checklists for two reasons: “First they are trained to do so…. Second, the checklists have proved their worth – they work.” (p121)
• You must decide whether you want a DO-CONFIRM checklist, or a READ-DO checklist 123
• A rule of thumb is to keep a checklist to between five and nine items, and should last between 60 and 90 seconds to run through.  After 90 seconds, it becomes a distraction and people start shortcutting.  123
• Points of controversy in implementing a checklist to a procedure:   Who has the authority to start the process – get everyone’s attention to kick off the checklist? Who has the authority to  bring the process to a halt? 137
• A tension exists between brevity and effectiveness. 138
• Using the checklist involved a major cultural change – a shift in authority, responsibility, and expectations about care..146
• One of the key functions of the checklist:  It grabs everyone’s attention and bring focus onto what is important – right now.  153
• The Hawthorne effect – a byproduct of being observed in a study rather than proof of the checklist’s power.
• 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. 157
• Gawande noted that if someone discovered a new drug that could cut down the surgical complications with anything remotely like the effectiveness of the checklist, we would have television and minor celebrities extolling its virtues.  158
• He notes that it DOES matter whether surgeons believe in the process.  “Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.”  160
• The “rock star” status of surgeons and aviators is diminished when processes create a much greater consistency in excellent performance.  As a culture, we value having “the right stuff” and audacity in high risk environments.   Following checklists and Standard Operating Procedures feels like the exact opposite. 161
• One of the venture capitalists found that using the checklist did increase the up-front work load. But eventually they were able to evaluate many more investments in far less time overall, with the benefit of making fewer mistakes. 168
• In the financial markets using a checklist to help make investment decisions created efficiency – one more edge over their competitors. They created a process that was not only more thorough, but also faster.  168-69
• 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.  184
• We don’t study routine failures.. we don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them…When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination.    185-86
• No matter how routine an operation is, the patients never seem to be.  189