The Checklist Manifesto
- Author: Atul Gawande
- Full Title: The Checklist Manifesto
The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. ( Location 116)
Careful studies have shown, for example, that heart attack patients undergoing cardiac balloon therapy should have it done within ninety minutes of arrival at a hospital. After that, survival falls off sharply. ( Location 140)
- Note: This must be why Carlee is required to be back to the office so quickly when on call
the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. ( Location 181)
The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to do. ( Location 422)
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. ( Location 447)
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. ( Location 453)
These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. He was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. ( Location 493)
We are besieged by simple problems. In medicine, these are the failures to don a mask when putting in a central line or to recall that one of the ten causes of a flat-line cardiac arrest is a potassium overdose. ( Location 611)
You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way. ( Location 627)
“If engineers were in charge, every building would be a rectangular box,” Salvia said. Instead, every building is new and individual in ways both small and large—they are complex—and as a result there is often no textbook formula for the problems that come up. ( Location 704)
There was special color coding, with red items highlighting critical steps that had to be done before other steps could proceed. ( Location 768)
- Note: Shoukd gateway steps in Dorsata Careplan have special handling
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. ( Location 827)
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. ( Location 910)
Can be boiled down to a good tweet:
Make checklists for all the “simple stuff” you have to do so as an expert so it gets done every time. So that you can focus on the things that actually require your expertise.
Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.
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.
You must decide whether you want a DOCONFIRM 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.
- Note: Dorsata should aim to be a Do Confirm Checklist
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. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)
- Note: We’re checking out so far.
Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork, discipline, and a shared standard is.
- Note: We enable discipline & teamwork and a shared intention.
Checklists not only ensure disciplined completion of essential steps in any process, no matter how complicated, they can efficiently guide you through those steps.
Checklists establish a higher standard of baseline performance.
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 seem able to defend anyone, even the experienced, against failure in many more tasks than we realized.