The Checklist Manifesto: How to Get Things Right 

by Atul Gawande

Routine errors are frequently caused by little things that slip through the cracks due to poor communication and distractions.  A simple checklist can eliminate these oversights.  This book explores how checklists can improve quality and efficiency—and even save lives—in a wide range of industries. Given the crisis with health care affordability in the United States, I am impressed with the dramatic cost savings in the medical examples.

In a hospital, “line infections are so common that they are considered a routine complication.” Dr. Peter Provonost of Johns Hopkins created a checklist to address this problem. “For a year afterward… the ten-day line-infection rate went from 11 percent to zero.” Based on this success, more checklists were created in the Johns Hopkins ICU. “Simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.”

Provonost was asked to implement his checklist in ICUs throughout the state of Michigan, where infection rates were higher than the national average. A senior executive from each hospital was assigned to hear staff complaints and help solve problems. “In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs… Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent… Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide… hospitals saved an estimated $175 million in costs and more than fifteen hundred lives.”

Dr. Atul Gawande (the author) was invited to join a World Health Organization task force to improve the safety of surgery around the world.  As you might guess, the result is the WHO Surgical Safety Checklist.

He visited Boeing to learn how checklists are developed in the aviation industry. “When you’re making a checklist… you must define a clear pause point at which the checklist is supposed to be used… decide whether you want a DO-CONFIRM checklist or a READ-DO checklist… The checklist cannot be lengthy… After about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction… The wording should be simple and exact… and use the familiar language of the profession… 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… They are not comprehensive how-to guides… They are quick and simple tools aimed to buttress the skills of expert professionals.”

The WHO team applied the lessons learned from Boeing. Choosing what to exclude was as important as what to include. “In surgery, minutes matter.” Ultimately, they developed a 19-question, 2-minute checklist. The safe surgery checklist was tested in eight hospitals around the world. “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… Infections fell by almost half.” In the author’s own surgeries, “I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed.”  Increased communication and teamwork was a byproduct of the checklist process.

The book also includes examples of how a financial firm uses checklists for investment due diligence and how a restaurant uses checklists to ensure accuracy and quality of orders.

There is an interesting chapter about how skyscrapers are built, but I think this is a weak example of the book’s thesis. The comprehensive scheduling system used to coordinate all of the tasks to be performed by numerous contractors sounds like a project management system (Gannt charts, critical path, etc.)—not a checklist. Throughout the book we learn that an effective checklist is kept short and includes only the most vital points.

Overall this is an excellent book which shows how simple steps can improve performance in a variety of complex fields.

Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Picador, 2010. Buy from

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