# The Checklist Manifesto ## Metadata * Author: [Atul Gawande](https://www.amazon.comundefined) * ASIN: B0030V0PEW * Reference: https://www.amazon.com/dp/B0030V0PEW * [Kindle link](kindle://book?action=open&asin=B0030V0PEW) ## Highlights The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors 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 measure 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, the nurses would have backup from the administration to intervene. For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. — location: [476](kindle://book?action=open&asin=B0030V0PEW&location=476) ^ref-63919 --- 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. — location: [485](kindle://book?action=open&asin=B0030V0PEW&location=485) ^ref-13978 --- M.D. and — location: [499](kindle://book?action=open&asin=B0030V0PEW&location=499) ^ref-54658 --- December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. Most ICUs—including the ones at Sinai-Grace Hospital—cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now—all because of a stupid little checklist. — location: [551](kindle://book?action=open&asin=B0030V0PEW&location=551) ^ref-31834 --- Two professors who study the science of complexity—Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex. — location: [597](kindle://book?action=open&asin=B0030V0PEW&location=597) ^ref-53340 --- All were amenable, as a result, to what engineers call “forcing functions”: relatively straightforward solutions that force the necessary behavior—solutions like checklists. — location: [611](kindle://book?action=open&asin=B0030V0PEW&location=611) ^ref-24494 Only for simple problem. Innovation is not formulaic - no simple check list or process --- Senior Wal-Mart officials concentrated on setting goals, measuring progress, and maintaining communication lines with employees at the front lines and with official agencies when they could. 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. Wal-Mart’s emergency operations team even included a member of the Red Cross. — location: [964](kindle://book?action=open&asin=B0030V0PEW&location=964) ^ref-6871 --- 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. — location: [986](kindle://book?action=open&asin=B0030V0PEW&location=986) ^ref-42499 --- 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. — location: [991](kindle://book?action=open&asin=B0030V0PEW&location=991) ^ref-13724 --- most common complications of surgery in children. And the most effective way to prevent it, aside from using proper antiseptic technique, is to make sure you give an appropriate antibiotic during the sixty-minute window before the incision is made. The timing is key. Once the incision is made, it is too late for the antibiotic. Give it more than sixty minutes before the procedure, and the antibiotic has worn off. But give it on time and studies show this single step reduces the infection risk by up to half. Even if the antibiotic is squeezed into the bloodstream only thirty seconds before the incision is made, researchers have found, the circulation time is fast enough for the drug to reach the tissue before the knife breaches the skin. Yet the step is commonly missed. In 2005, Columbus Children’s Hospital examined its records and found that more than one-third of its appendectomy patients failed to get the right antibiotic at the right time. Some got it too soon. Some got it too late. Some did not receive an antibiotic at all. — location: [1227](kindle://book?action=open&asin=B0030V0PEW&location=1227) ^ref-13142 --- 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. — location: [1248](kindle://book?action=open&asin=B0030V0PEW&location=1248) ^ref-34930 --- 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. — location: [1261](kindle://book?action=open&asin=B0030V0PEW&location=1261) ^ref-32671 --- First came what pilots call their “normal” checklists—the routine lists they use for everyday aircraft operations. There were the checks they do before starting the engines, before pulling away from the gate, before taxiing to the runway, and so on. In all, these took up just three pages. The rest of the handbook consisted of the “non-normal” checklists covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled, and engine failure, to name just a few. They addressed situations most pilots never encounter in their entire careers. But the checklists were there should they need them. — location: [1449](kindle://book?action=open&asin=B0030V0PEW&location=1449) ^ref-45157 --- Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. — location: [1509](kindle://book?action=open&asin=B0030V0PEW&location=1509) ^ref-51236 --- When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used — location: [1541](kindle://book?action=open&asin=B0030V0PEW&location=1541) ^ref-42776 --- 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. — location: [1542](kindle://book?action=open&asin=B0030V0PEW&location=1542) ^ref-15404 --- 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. — location: [1547](kindle://book?action=open&asin=B0030V0PEW&location=1547) ^ref-38110 --- But after about sixty to ninety seconds at a — location: [1549](kindle://book?action=open&asin=B0030V0PEW&location=1549) ^ref-30568 --- given pause point, the checklist often becomes a distraction from other things. — location: [1550](kindle://book?action=open&asin=B0030V0PEW&location=1550) ^ref-41621 --- The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. — location: [1553](kindle://book?action=open&asin=B0030V0PEW&location=1553) ^ref-37642 --- checklist has to be tested in the real world, which is inevitably more complicated than expected. — location: [1558](kindle://book?action=open&asin=B0030V0PEW&location=1558) ^ref-8133 --- First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently. This is not easy — location: [1559](kindle://book?action=open&asin=B0030V0PEW&location=1559) ^ref-29463 --- to do in surgery, I pointed out. Not in aviation, either, he countered. You can’t unlatch a cargo door in midflight and observe how a crew handles the consequences. But that’s why they have flight simulators, and he offered to show me one. — location: [1560](kindle://book?action=open&asin=B0030V0PEW&location=1560) ^ref-5571 --- Although these are critical steps, experience had shown that professional pilots virtually never fail to perform them when necessary. So they didn’t need to be on the checklist—and in fact, he argued, shouldn’t be there. — location: [1613](kindle://book?action=open&asin=B0030V0PEW&location=1613) ^ref-49195 --- 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 — location: [1615](kindle://book?action=open&asin=B0030V0PEW&location=1615) ^ref-31093 --- the skills of expert professionals. — location: [1616](kindle://book?action=open&asin=B0030V0PEW&location=1616) ^ref-42627 --- How this happened—it involved a checklist, of course—is instructive. But first think about what happens in most lines of professional work when a major failure occurs. To begin with, we rarely investigate our failures. Not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any other kind of work where the mistakes do not turn up on cable news. A single type of error can affect thousands, but because it usually touches only one person at a time, we tend not to search as hard for explanations. Sometimes, though, failures are investigated. We learn better ways of doing things. And then what happens? Well, the findings might turn up in a course or a seminar, or they might make it into a professional journal or a textbook. In ideal circumstances, we issue some inch-thick set of guidelines or a declaration of standards. But getting the word out is far from assured, and incorporating the changes often takes years. One study in medicine, for example, examined the aftermath of nine different major treatment discoveries such as the finding that the pneumococcus vaccine protects not only children but also adults from respiratory infections, one of our most common killers. On average, the study reported, it took doctors seventeen years to adopt the new treatments for at least half of American patients. — location: [1671](kindle://book?action=open&asin=B0030V0PEW&location=1671) ^ref-18454 --- the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form. If the only thing people did in aviation was issue dense, pages-long bulletins for every new finding that might affect the safe operation of airplanes—well, it would be like subjecting pilots to the same deluge of almost 700,000 medical journal articles per year that clinicians must contend with. The information would be unmanageable. — location: [1682](kindle://book?action=open&asin=B0030V0PEW&location=1682) ^ref-62132 Goes into fail efficiently- have actionable learning --- Usual procedure was to infuse the presurgery antibiotic into patients in the preoperative waiting area before wheeling them in. But the checklist brought the clinicians to realize that frequent delays in the operating schedule meant the antibiotic had usually worn off hours before incision. — location: [1920](kindle://book?action=open&asin=B0030V0PEW&location=1920) ^ref-50092 --- The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. — location: [1933](kindle://book?action=open&asin=B0030V0PEW&location=1933) ^ref-58237 --- The checklist doesn’t tell him what to do, he explained. It is not a formula. But the checklist helps him be as smart as possible every step of the way, ensuring that he’s got the critical information — location: [2102](kindle://book?action=open&asin=B0030V0PEW&location=2102) ^ref-25595 --- Geoff Smart, a Ph.D. psychologist who was then at Claremont Graduate University, conducted a revealing research project. He studied fifty-one venture capitalists, — location: [2140](kindle://book?action=open&asin=B0030V0PEW&location=2140) ^ref-34947 Add to book --- venture capitalists he studied decided whether they’d found such a person. These were styles of thinking, really. He called one type of investor the “Art Critics.” They assessed entrepreneurs almost at a glance, the way an art critic can assess the quality of a painting—intuitively and based on long experience. “Sponges” took more time gathering information about their targets, soaking up whatever they could from interviews, on-site visits, references, and the like. Then they went with whatever their guts told them. As one such investor told Smart, he did “due diligence by mucking around.” The “Prosecutors” interrogated entrepreneurs aggressively, testing them with challenging questions about their knowledge and how they would handle random hypothetical situations. “Suitors” focused more on wooing people than on evaluating them. “Terminators” saw the whole effort as doomed to failure and skipped the evaluation part. They simply bought what they thought were the best ideas, fired entrepreneurs they found to be incompetent, and hired replacements. Then there were the investors Smart called the “Airline Captains.” They took a methodical, checklist-driven approach to their task. Studying past mistakes and lessons from others in the field, they built formal checks into their process. They forced themselves to be disciplined and not to skip steps, even when they found someone they “knew” intuitively was a real prospect. — location: [2150](kindle://book?action=open&asin=B0030V0PEW&location=2150) ^ref-18495 --- Airline Captain, hands down. Those taking the checklist-driven approach had a 10 percent likelihood of later having to fire senior management for incompetence or concluding that their original evaluation was inaccurate. The others had at least a 50 percent likelihood. — location: [2163](kindle://book?action=open&asin=B0030V0PEW&location=2163) ^ref-56221 --- The Airline Captains had a median 80 percent return on — location: [2165](kindle://book?action=open&asin=B0030V0PEW&location=2165) ^ref-27517 --- the investments studied, the others 35 percent or less. Those — location: [2166](kindle://book?action=open&asin=B0030V0PEW&location=2166) ^ref-10093 --- best-selling business book on hiring called Who. But when — location: [2170](kindle://book?action=open&asin=B0030V0PEW&location=2170) ^ref-54065 --- Both were tremendously experienced. Skiles had nearly as many flight hours as Sullenberger and had been a longtime Boeing 737 captain until downsizing had forced him into the right-hand seat and retraining to fly A320s. This much experience may sound like a good thing, but it isn’t necessarily. Imagine two experienced but unacquainted lawyers meeting to handle your case on your opening day in court. Or imagine two top basketball coaches who are complete strangers stepping onto the parquet to lead a team in a championship game. Things could go fine, but it is more likely that they will go badly. Before the pilots started the plane’s engines at the gate, however, they adhered to a strict discipline—the kind most other professions avoid. They ran through their checklists. They made sure they’d introduced themselves to each other and the cabin crew. They did a short briefing, discussing the plan for the flight, potential concerns, and how they’d handle troubles if they ran into them. And by adhering to this discipline—by taking just those few short minutes—they not only made sure the plane was fit to travel but also transformed themselves from individuals into a team, one systematically prepared to handle whatever came their way. — location: [2202](kindle://book?action=open&asin=B0030V0PEW&location=2202) ^ref-7186 Researchera from different areas --- 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. Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. — location: [2298](kindle://book?action=open&asin=B0030V0PEW&location=2298) ^ref-40454 --- “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment of trying to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” — location: [2331](kindle://book?action=open&asin=B0030V0PEW&location=2331) ^ref-22042 In tracser bullet as of why ---