The Checklist Manifesto.

I learned of Atul Gawande’s brief business book The Checklist Manifesto: How to Get Things Right through a positive mention of it in Daniel Kahneman’s fantastic book on cognitive psychology, Thinking, Fast and Slow. Gawande, a successful surgeon in Boston, wrote two books on improving medical care through optimizing processes (rather than throwing money at new equipment or drugs). His third book is aimed at a more general audience, extolling the virtues of the checklist as a simple, effective way to reduce the frequency of the most avoidable errors in any complex system, even eliminating them entirely, saving money and even lives at a near-zero upfront cost.

When Gawande discusses checklists, he’s using the term in the sense of a back-check, a list that ensures that all essential steps have been taken before the main event – a surgery, a plane’s takeoff, a large investment – occurs. This isn’t a to-do list to get you through the day, the type of checklist I make every morning or the night before to make sure I don’t forget any critical tasks, work or personal, from paying bills to making phone calls to writing a dish post. Gawande instead argues for better planning before that first incision, saying that key steps are often overlooked due to a lack of communication, excessive centralization in a single authority (the surgeon, the pilot, etc.), or focus on more urgent steps that detracts from routine ones.

Gawande illustrates his points about the design and use of checklists primarily through his own experiences in surgery and through his work with the WHO on a project to reduce complication rates from surgery in both developed and developing countries – a mandate that included the requirement that any recommendations involve little or no costs to the hospitals. That all but assured that Gawande’s group would only be able to recommend process changes rather than equipment or hiring requirements, which led to a focus on what steps were often skipped in the operating room, deliberately or inadvertently. Several common points emerged. For example, other medical personnel in the room saw surgeons as authoritarian figures and wouldn’t speak up to enforce key steps like ensuring antibiotics were being delivered prior to incision, or critical information wasn’t passed between team members before the operation began. To solve these issues, Gawande needed to devise a way to increase communication among team members despite superficial differences in rank.

The group took a cue from aviation, with Gawande walking the reader back to the creation of preflight checklists and visiting Boeing to understand the method of developing checklists that work. (There’s been some backlash to Gawande’s recommendations, such as the fact that surgeons can “game” a checklist in various ways, detailed in this NEJM subscriber-only piece.) A checklist must be concise and clear, and must grab the lowest-hanging fruit – the most commonly-missed steps and/or the steps with the greatest potential payoff. The checklist also has a secondary purpose – perhaps even more important than making sure the steps on the list have been followed – which is increasing communication. Gawande fills in the blanks with examples from medicine, aviation, and finance of how simple and perhaps “stupid” errors have helped avoid massive mistakes – or how skipping steps or hewing to old hierarchies of command have led to great tragedies, including the worst aviation disaster in history, the 1977 runway crash of two Boeing 747s at Tenerife North Airport in the Canary Islands, killing 583 people. (This isn’t a great book to read if you’re afraid of flying or of surgery.)

Gawande reports positive results from the implementation of pre-surgery checklists in both developed and developing countries, even in highly challenging conditions in Tanzania, Jordan, and India. Yet he also discusses difficulties with buy-in due to surgeons being unwilling to cede any authority in the operating room or to divert attention from what they see as more critical tasks. Acceptance of checklists appears to have been easier in aircraft cockpits, while in the investment world, Gawande presents a little evidence that checklists have made virtually no inroads despite a few investors finding great success in using them to override their emotional (“fast thinking”) instincts.

Even if you’re in an industry where checklists don’t have this kind of immediate value, it’s easy to see how they might apply to other fields with sufficiently positive ROIs to make their implementation worth considering. A major league team might have a checklist to use before acquiring any player in trade, for example – looking at recent reports and game logs to make sure he’s not injured, talking to a former coach or teammate to ensure there’s no character issues, etc. A well-designed blank scouting report is itself a checklist, a way of organizating information to also force the scout to answer the most important questions on each player. (Of course, having pro scouts write up all 25 players on each minor league team they scout runs counter to that purpose, because they’re devoting observation time to players who are completely irrelevant to the scout’s employers.) The checklist is more than just a set of tasks; it’s a mindset, a way of forcing communication on group tasks while also attempting to avoid high-cost mistakes with a tiny investment of time and attention. If the worst thing you can say about an idea is that people need to be convinced to use it, that’s probably a backhanded way of saying it’s worth implementing.

Next up: I’m about halfway through Ursula K. Le Guin’s utopian/dystopian novel The Dispossessed.