The Checklist Manifesto Summary: 8 Lessons by Atul Gawande

To focus on the big picture, we need to remember small things in life. The summary of The Checklist Manifesto by Atul Gawande will help you get it right.
Natalia Rossingol
August 16, 2022

You’re a cook at a popular restaurant, and you’re desperately trying to finish cooking by 5 pm when the guests arrive. Suddenly, the chef gives you a sheet of paper with a list of items you need to check. You get annoyed; you’re already in a hurry. But the chef insists – he says you’re stressed, and may forget to put salt in the soup; the checklist will help. And you know… he’s not wrong.

“The Checklist Manifesto: How to Get Things Right” by Atul Gawande is not a typical self-help book. The author, a surgeon by profession, describes the concept of checklists through the prism of a long personal journey: not only did he research the impact of checklists on work in different fields, but also implemented the practice of using them at hospitals. Failing and getting frustrated, he was able to prove that this technique works – even though the whole world seemed to resist.   

In our summary of “The Checklist Manifesto” we tried to embrace the most vivid ideas about checklists – or rather, the lessons Atul Gawande learned about the concept.

Lesson #1: Science complexity makes us fail – but there is a way out

In their essay about human fallibility, the philosophers Gorovitz and MacIntyre tried to explain why people make mistakes. They discussed two reasons. The first one, they explained, is that human beings are not all-powerful. Our physical and mental capabilities are limited, and many things still remain beyond our understanding (like the secrets of the universe).

The second reason concerns realms that we can control, to a certain extent. Here we fail either because we are ignorant, having only a partial understanding of things, or because we don’t apply the knowledge correctly (the authors call it “ineptitude”). In the first case, we, for example, don’t know how to build a certain type of skyscraper, while in the second case we build skyscrapers that collapse.

What’s interesting, for nearly all of history, ignorance has been the main source of human mistakes – but over the last decades, due to the rapid development of science, we’ve been failing mostly because of ineptitude.  

Gawande provides the following example: back in the 1950-s, people didn’t know much about heart attacks: when that happened to someone, they would be given some morphine and oxygen, and then “everyone would pray and cross their fingers.” Today we know about many ways of treatment and even preventing heart attacks yet we face a different challenge: what treatment is the most appropriate in this particular situation? More than that, each type of treatment involves further choices to make (testing, diagnosis, and so on), which makes the situation more complicated.

While it’s easy to forgive failures of ignorance, failures of ineptitude cause disappointment and anger. If a person gets sentenced to death – and killed – because of a human error, that is a big deal.

However, we should remember there are two sides of a coin: those on the receiving end take it as negligence, while those who actually made the mistake get frustrated because the volume and complexity of knowledge are overwhelming, and they simply cannot handle it.

The truth is, many mistakes are avoidable – in the fields of medicine and business, finances and government, etc. According to Gawande, there is a strategy “for overcoming failure, one that builds on the experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies.” This strategy is a checklist.

Lesson #2. A checklist is an instrument of protection against failures

The story of checklists

In 1935, the U.S. Army Air Corps held a competition for airplane manufacturers to build a next-generation bomber. Boeing presented a plane with amazing capabilities: it could fly faster, almost twice as far as other bombers, and could carry five times as many bombs as requested. It was very promising.

However, soon after the aircraft lifted off, it exploded. An investigation revealed that the cause of the accident was “pilot error”. The army decided to give the aircraft a chance, and bought a few of them as test planes. A group of pilots started figuring out what can be done to prevent the accidents in the future.

The first thought was to make pilots undergo longer training. But this was not logical: the pilots who got in the accident were experienced. So instead, they took a different approach and created a pilot’s checklist.

This checklist was very simple and concise. It covered the most basic stuff: checks for takeoff, flight, landing, and taxing. Flying a new aircraft was complicated, and following the steps, one by one, made it easier for pilots.

As it appeared later, the checklist helped to fly the aircraft for 1.8 million miles without a single accident. The army bought many planes, and they played a decisive role in gaining an air advantage in WW2.

Faulty memory vs. algorithm to follow

Despite the fact that multiple fields like software design, law enforcement, firefighting, etc “have become too much airplane for one person to fly”, people resist the idea of adopting them as a part of their job – it’s hard to believe our complicated work can be reduced to a checklist. But we have to admit that environments can be too complex for us, and sometimes – or rather, often – we struggle and even fail.

Firstly, human memory is not perfect, especially when it comes to routine tasks: it’s easy to forget to do something you normally do if an unusual event occurs. If you run to a store to buy ingredients for a cake, and your boss calls you, you forget to buy flour – you simply won’t be able to make a cake.     

Secondly, we tend to skip unimportant steps – unimportant because nothing happened when we missed them the last time. You can say, “this has never been a problem” – but where is the guarantee this will not be a problem next time?

Gawande says we can fight this – with such a simple instrument as checklists:

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.

Lesson #3. Some checklists require a special component for a problem to be solved

According to Gawande, checklists “provide a cognitive net” – they defend us from mental flaws, and this way, raise unexpected capabilities. Yet we have to realize that situations can be different, and sometimes a checklist can simply not fit a specific one. This is why it’s important to identify what kind of situation you’re in – in other words, what degree of complexity you face in a particular situation.

Types of problems

So what are these degrees? Brenda Zimmerman and Sholom Glouberman, two professors who study the science of complexity, say that there are three types of problems in the world:   

  1. Simple problems. These are problems that require a set of skills and techniques to be solved – but once you’ve acquired those skills and techniques, the process becomes automatic. A great example is any cooking recipe.
  2. Complicated problems. There is no clear instruction to solve these; usually, they require a group of people. However, once you’ve figured a complicated problem out,  you can use the algorithm again. Example – sending a rocket to the moon.
  3. Complex problems. These include problems the outcomes of which are very uncertain because there are too many factors you cannot control. Example – raising a child.

Problems like stopping infections and rescuing drowning victims of shipwrecks are simple ones. But many other critical things people have to deal with - like treating pneumonia patients – are very unpredictable: the same antibiotic can help one person, but will not necessarily help the other one. 

Very often, tasks like this one are simple, complicated, and complex at the same time. So even though a checklist is a helpful thing, will it help in a situation that involves all three types of problems?

Special component

To explain how it works in such a confusing environment, the author tells the story of Joe Salvia, the structural engineer for one of the wings of the hospital where Gawande worked. The construction projects he had been working on put much responsibility on Salvia: one wrong step could lead to the death of a large number of people, as well as to a huge amount of money lost in lawsuits. The fact that he was in charge of many workers didn’t make it any easier.

Salvia found a solution – he used checklists. The daily schedule he developed included a list of tasks to be accomplished, in what order, and when; after the tasks were accomplished, a job supervisor reported to the “project executive” – the boss.

But there is a catch. Let’s look back at history: centuries ago, buildings were put up by Master Builders who designed and engineered them, and then controlled the whole construction process. Later things changed: “The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them” (again, the complexity of science in its brightest expression.)

Now there are architects, engineers, and builders, each with their level of expertise, and each working in their division. And the worst that can happen at the construction is autonomy, says the author:

In the absence of a true Master Builder—a supreme, all-knowing expert with command of all existing knowledge— autonomy is a disaster. It produces only a cacophony of incompatible decisions and overlooked errors. You get a building that doesn’t stand up straight.  

This is why the construction workers Gawande talked to also used another checklist – the one that specified communication tasks. They detailed who had to talk to whom, by which date, and about what aspect of construction; individuals could make their decisions and judgments, but they had to be discussed with other team members.

So when something unexpected happened, the builders would rely on the power of communication. And the instrument of communication was a checklist, the instrument that literally wasn’t letting buildings fall apart.

Lesson #4. Checklists can be different – so make sure you prepare the right one

So what a perfect checklist must look like?

Trying to find a formula for a working checklist, the author contacted Daniel Boorman – a veteran pilot who had been developing checklists for years. Meeting Boorman and seeing his checklists, he realized that over the years, a pilot checklist evolved, and wasn’t just a universal single card – it was a whole handbook that comprised different scenarios.

First of all, there were “normal” and “non-normal” checklists. The normal ones included checks about routine operations (like checks before starting engines), while non-normal checklists covered emergency information. As Gawande pointed out, “They addressed situations most pilots never encounter in their entire careers. But the checklists were there should they need them.”

Secondly, Boorman explained the difference between “good” and “bad” checklists:

Good checklists are:

  1. Precise.
  2. Easy to use even in the most difficult situations.
  3. Provide only the most important steps.

As for bad checklists, they are:

  1. Vague and imprecise.
  2. Too long.
  3. Too hard to use.
  4. They treat the people who use them as dumb as they provide each and every step.

At the same time, recognizing the power of checklists, Boorman also emphasized that it’s limited – after all, it’s not a checklist that saves a situation but a person who uses them:

They [checklists] can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them.

Lesson #5. To make a perfect checklist, follow the rules

According to Boorman, there are specific things you must necessarily consider while making a checklist. These are as follows:

  1. You must define a pause point at which a checklist is supposed to be used (unless it’s obvious – for example, when a warming light goes on).
  2. Decide whether you want a DO-CONFIRM or READ-DO checklist. A DO-CONFIRM LIST means that you have to pause and check if what’s on the list has been done; a READ-DO list means you carry out the task as if you are following the recipe. Naturally, you pick the type of the list according to the situation.
  3. A checklist cannot be too long. Try to keep it between five and nine items.
  4. Focus on “the killer items”, which are items most dangerous to skip (and yet often overlooked).
  5. Keep the wording simple and exact. Use the language of the profession.
  6. Make the checklist look simple: fit it on one page; avoid unnecessary colors; use both uppercase and lowercase.
  7. Test a checklist in the real world before using it on a regular basis. The first drafts tend to fall apart. No matter how much effort you put into developing it, your checklist can fail a real-world test. So keep improving it.

This last point is particularly important. Having learned about checklists, Gawande tried to implement them in the hospital and see if it’s worth implementing in all walks of life. Even though the steps were crystal clear and encompassed everything from equipment inspection to discussions they needed to have, something went wrong.

First of all, the nurse checked the boxes off on the sheet – but he wanted her to do it verbally. It appeared that this requirement wasn’t written anywhere. Some checks were ambiguous – for example, she didn’t know if she was supposed to state allergies or confirm everyone knew about the patient’s allergies.

As a result, the team had to stop using this checklist – it didn’t work.

Lesson #6. The value of checklists is evident – yet we don’t like them

Checklists are not fun – checking everything you do is pretty boring. The one reason why we avoid them is simple laziness. The second one, obviously, is the urgency: sometimes you literally have no time for checklists. As some doctors Gawande worked with would say, “Forget the checklist – treat the patient.”

However, the author thinks that these are not the main reasons. Think about this – checklists can be used not only to do a job, but to make money (a lot of money) through investing, yet people don’t follow them. There must be something besides laziness.

According to Gawande, what stops us from using checklists is an embarrassment, a feeling that comes from deep inside. We believe that those whom we call heroes, those who’ve achieved a lot, don’t follow the rules – instead, they improvise. While people who use checklists are perceived as machines not capable of dealing with the real world by themselves. However, a well-made checklist does completely the opposite, says the author:

The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Did the patient get her antibiotics on time?..), and lets it rise above to focus on the hard stuff (Where should we land?).

Gawande is convinced that we need to reconsider the concept of checklists – and explains that this concept has a lot to do with one of professionalism and, logically, success.

Lesson #7. Checklists provide discipline, and discipline makes success possible

All occupations, explains Gawande, have a definition of professionalism – the code of conduct that involves the nuts and bolts of each profession. These codes have three elements, common to each of them, regardless of the profession:

  1. The expectation of selflessness. No matter who we are – teachers, police officers, soldiers, etc – we take responsibility for others, which means we place their needs above ours.
  2. The expectation of skill. Professionalism means we strive for excellence.    
  3. The expectation of trustworthiness. We are responsible for our behavior.

There is the fourth category though, the one added by aviators – discipline. Gawande underlies that working in teams and with high-risk technologies, we need it more than skills, and even more than trustworthiness:

We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

Checklists can help develop discipline – more than that, they can help maintain it. We cannot change much just working harder and harder. We can do our work better, and even save lives, just by following a boring list that doesn’t let us divert our attention from the really important stuff.

Lesson #8. Checklists give power to those who usually don’t have it

Working in a team, some people may feel less important than others – just because they don’t have that much power. The use of checklists, however, can change it – they can make a serious shift in authority.

This was especially noticeable in the world of medicine: in Johns Hopkins Hospital, a care specialist Peter Pronovost gave a doctor a checklist to try – the initial goal was to decrease the infection rate. The steps were super traditional – wash hands with soap and wear a mask – but they decided to try and see what happens.

Interestingly, the checklist made a “revolutionary” change – it authorized nurses to stop doctors if they saw the doctors were missing something on the list.  The results were impressive – the infection rate fell from 11 percent to zero in ten days.

A team is more than a sum of individuals - that’s a well-known fact. And when teams work under a situation of high complexity – or a situation that demands a lot of responsibility – it makes sense to stop dictating every step from above. Yet, total autonomy, as we mentioned before, is a way to nowhere. What is needed is a “seemingly contradictory mix of freedom and expectation”, and this can be achieved by checklists:

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.

In Gawande’s experiment on implementing checklists, where 8 hospitals throughout the world, from Dehlhi to Seattle, participated, the final results were incredible: due to the use of checklists, the rate of major complications fell by 36 percent, and deaths fell by 47 percent. In the anonymous survey filled out by more than 250 members, 80 percent reported the checklist was easy to use – and 78 reported the checklist prevented an error.

Checklists are not how-to guides – they are rather simple tools that help professionals make most of their skills, not spreading themselves too thin. They seem to make things more complicated – but in fact, they save your time. But we have to understand that checklists are not just about ticking boxes – they are about creating a culture of teamwork and discipline, where everyone takes responsibility for what they do.

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