Book Notes: The Checklist Manifesto

Read: January 30, 2011
I should say first that I bring a few prejudices into this that will make me believe this is the greatest book ever written (it isn’t but it’s very good and easy to read and worthwhile): 1) I love checklists! I think everything should have a checklist. 2) I am obsessed with (in that way that bloggers are “obsessed with” things not actually clinically) manifestos. I hope that 2013 is the year when I can write my own. 3) I’ve read many things by Gawande and I’ve always enjoyed them. So… onto my notes!
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 1090)
This isn’t even about checklists – its a good way to think about operating any project: people need room the make the decisions you hired them to make. But you also need to find ways to make expectations clear, provide boundaries and measure progress towards goals.
There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do. (location 1494)
There are good checklists and bad, Boorman explained. 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. (location 1663)
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 (unless the moment is obvious, like when a warning light goes on or an engine fails). 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. 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. Boorman didn’t think one had to be religious on this point. (location 1701)
 I’d never really thought about this distinction before: that there are checklists that walk you through something step-by-step and then there are ones where you use it as a memory aid, confirmation step. I’m not convinced by the small number of items, but I wonder if it’s just that if you need so many you either need to make the whole thing more simple or break it up into separate actions?
We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t 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. (location 2393)
I don’t know if it’s heroism, I think it’s just that checklists look amateur – like if you have to consult the manual maybe you don’t know what you’re doing. Checklists need better PR!
 The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff … (location 2452)
What is this? I read most of my books via Kindle software on my iPad and I like to use the Highlight and Notes functions to mark things I want to remember or come back to. I thought I’d share those highlights and notes here with you. If you’ve also read the book, let me know what stood out for you too!

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