The Checklist Manifesto: How to Get Things Right, Gawande, Atul

The idea of a simple checklist to raise the quality of a routine practice seems innocuous enough. It also seems to rankle those with lots of education and experience as an unnecessary intrusion on their autonomy.

The canonical example is the story of the effort at Johns Hopkins Hospital to reduce central line infections in critical care settings. A central line is a catheter inserted into someone’s jugular vein in order to deliver medications. It’s a routine step for many patients in a critical care unit. It’s also a primary source of infection for patients in hospitals. While inserting a central line is straightforward for someone with the proper training, medical professionals will skip steps in the hustle and bustle. Peter Pronovost, a critical care specialist at Hopkins, developed a five-point checklist of the steps necessary to avoid central-line infections.

There’s absolutely nothing on the list that practitioners aren’t already trained to do and absolutely nothing controversial about the steps called for. Many of those professionals considered it an insult to have the obvious pointed out to them in written form. Yet when this checklist was deployed at Hopkins, central line infections dropped from 11% of patients to zero. Comparable results have been routinely achieved elsewhere.

Gawande reported these results first in an article in The New Yorker. In this book he expands on that story to look at

• the origins of the modern checklist in WWII aviation
• multiple examples of checklists deployed in other health care settings
• the challenges inherent in developing checklists that work well in complicated environments
• the difficulties in gaining meaningful acceptance of checklists among highly autonomous professionals

We live in an increasingly complicated and faster-paced world. But our memories are limited and fallible. The right piece of paper in the right place can compensate for those limitations and increase our capacity to deal with that world. The first balancing act is to design a checklist that increases our capacity to handle a situation significantly more than it increases the load on our limited memories. Pronovost’s checklist only touched on the five items most critical to preventing infections. It made no attempt to spell out every possible step in the process.

A checklist shouldn’t be confused with a procedure manual. Avoiding that confusion is an essential element in making organizational acceptance of checklists possible. Checklists are intended to improve and systematize the performance of those who are already proficient. In themselves, they are poor tools for developing proficiency in those still learning their craft.

This confusion between checklist and procedure is at the root of most resistance to efforts to deploy checklists in suitable settings.  Unfortunately, Gawande contributes to this confusion himself when he conflates checklists with project plans. Both are useful documents  but they serve different purposes and are constructed differently. I’d suggest that you skip the chapter on "The End of the Master Builder" on first reading. It makes the core argument clearer.

Even when properly designed and targeted as relevant aids for the proficient, there is still a change management and leadership challenge to address in deploying a checklist to support more effective practice. While Gawande offers a number of excellent stories and examples of implementing checklists in various settings, he isn’t looking for or tuned into the relevant details of organizational change.  This book provides excellent insight into why checklists work and what to think about when constructing them. Expect to look elsewhere for comparable advice on managing the associated change. Expect to need to do so as well.

As compelling as the rational evidence for checklists may be, orchestrating their adoption into the work practices of professionals presents a large hurdle. The hurdle, of course, is emotional. A checklist can be viewed as diminishing one’s expertise rather than as reinforcing it. Reversing that perception for both the expert and the rest of the organization is the key.