The Checklist Manifesto: How to Get Things Right

“He was, we liked to imagine, a simple machine in our hands. But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway 18-wheeler hurtling down a mountain.”

Atul Gawande is describing a patient named Anthony DeFilippo who suffered a hemorrhage following a surgery. Gawande’s team worked to stabilize the patient, and the quote highlights Gawande’s ability to use metaphor. The metaphor of an 18-wheeler reinforces the way care providers focus on individual tasks in order to remain calm under pressure.

“We continue to have upwards of 150,000 deaths following surgery every year—more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable.”

Once again, Gawande uses data to provide context for readers. This quote is alarming for both those in his field and those unfamiliar with the subject of surgical complications. It also supports Gawande’s purpose for the book, which is to make a compelling argument in favor of implementing checklists as part of the surgical procedure.

“The question of when to follow one’s judgment and when to follow protocol is central to doing the job well—or to doing anything else that is hard.”

Gawande’s comment underscores his belief that training, experience, and instinct all matter when it comes to complex problems. However, when the unexpected happens, having a protocol to follow can make decision-making more efficient and ultimately more successful.

“You know the geometric theory of what is best, but not the practical theory of what can be done.”

Structural engineer Joe Salvia differentiates between what he learned in college and what he learned when he first entered construction. The quote shows tension between what is learned and what is experienced, a critical observation as Gawande seeks to learn the best methods for developing a safe surgery checklist.

“Man is fallible, but maybe men are less so.”

The quote highlights one of the book’s central arguments: that teamwork is critical for positive outcomes when faced with complex problems. Gawande asserts that the likelihood of mistakes decreases the more a group operates as a unit rather than as detached individuals.

“The trouble wasn’t a lack of sympathy among top officials. It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.”

Gawande is discussing the American government’s response to Hurricane Katrina, which devastated New Orleans and other parts of the gulf coast. The failure of the government, according to Gawande, was not because of apathy. Rather, the response failed because the bureaucracy of the federal government was modeled on a top-down command structure, and when communication from the ground was cut off, the government was unable to adapt quickly.

“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.”

Gawande recognizes that balance needs to be attained between forcing people to become automatons and giving people too much room to improvise. He suggests this is perhaps counterintuitive, but a person’s experience and skills should not be overlooked.

“While incisions have gotten smaller and recoveries have gotten quicker, the risks remain serious. Worldwide, at least seven million people a year are left disabled and at least one million dead—a level of harm that approaches that of malaria, tuberculosis, and other traditional public health concerns.”

Although advancements in training and technology have made surgeries safer than in the past, the amount of complications is still relatively high. The data in this quote is another example of how Gawande appeals to logic to support his argument—that the rise of surgical complications is unacceptable, especially in light of advancements.

“Just as important, it also made clear that the surgeon could not start the operation until the nurse gave the okay and removed the tent, a subtle cultural shift. Even a modest checklist had the effect of distributing power.”

Gawande is describing a procedure in which a nurse placed a small metal tent over a scalpel prior to a surgery at Columbus Children’s Hospital. This addition empowered nurses to ensure that before the tent was lifted off the scalpel, the checklists had been read aloud. The quote highlights the necessity of the decentralization of authority in complex circumstances.

“Traditionally, surgery has been regarded as an individual performance—the surgeon as virtuoso, like a concert pianist. There’s a reason that much of the world uses the phrase operating theater.”

Gawande likens the work of a surgeon to that of a composer or a conductor. This is significant in context, because Gawande suggests that the profession should move away from this perception and adapt to the ways things have changed (i.e., technological advancements and more emphasis on teamwork).

“But I was getting impatient, too. The checklist was too long. It was unclear. And past a certain point, it was starting to feel like a distraction from the person we had on the table. By the end of the day, we had stopped using the checklist. Forget making this work around the world. It wasn’t even working in one operating room.”

After returning from the Geneva conference hosted by the World Health Organization (WHO), Gawande implements the rudimentary checklist he helped design. As the quote suggests, the first results were not promising. Gawande himself, who believed in the potential of checklists for surgical care, became temporarily discouraged.

“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.”

Toward the end of this quote, Gawande identifies the limitations of a poorly designed checklist, something he himself experienced. According to him, the checklist is not meant to replace the expertise and instinct of the professionals who use them.

“First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.”

Gawande is reminded of this quote’s lesson by Dan Boorman, the man in charge of developing flight manuals for aerospace manufacturer Boeing. At the time, Gawande was visiting Boorman in the aftermath of his own checklist failure. Boorman’s advice encourages him to keep pursuing a well-designed checklist by field-testing.

“One study in medicine, for example, examined the aftermath of nine different major treatment discoveries such as the finding that the pneumococcus vaccine protects not only children but also adults from respiratory infections, one of our most common killers. On average, the study reported, it took doctors seventeen years to adopt the new treatments for at least half of American patients.”

One of Gawande’s issues with the medical field is its reluctance to embrace change. This quote highlights how slow the field is to incorporate new data compared to the aviation industry’s practice of incorporating new data and protocols within 30 days.

“An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.”

This quote highlights the complexity of developing a useful checklist. Finding the right balance is difficult, as Gawande himself struggles to do. The process depends on experience, but also a feel for nuance (with often comes with field-testing).

“The final results showed that 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.”

This quote references initial findings from the eight hospitals that participated in the WHO-commissioned study that Gawande led. The checklists that Gawande and his team developed showed immediate results, after Gawande incorporated lessons from the aviation industry.

“If someone discovered a new drug that could cut down surgical complications with anything remotely like the effectiveness of the checklist, we would have television ads with minor celebrities extolling its virtues.”

In this quote, Gawande critiques modern media. The checklist is a mundane thing and is treated as such by the media. Gawande suggests that this superficial understanding of medical advancements shines a light on marvels rather than true success stories.

“But it is regarded as an irritation, as interference on our terrain. This is my patient. This is my operating room. And the way I carry out an operation is my business and my responsibility. So who do these people think they are, telling me what to do?”

Gawande speaks hypothetically in this quote, highlighting how those in his profession have a tendency to be territorial. In other words, a major obstacle to the checklist is ego and vanity.

“Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.”

Throughout his development of an effective checklist, Gawande realizes the ultimate benefit of a checklist is its fostering of communication, which in turn, fosters a healthier team dynamic. He alludes to this dynamic in the quote, mentioning that the checklist is as much a means to develop discipline as it is a practical tool.

“Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does.”

Gawande interviews money managers, and this quote captures how some managers develop checks against impulsive investments. The stimulating effect of money-making highlights the need for strategies to prioritize disciplined investments over rash decisions.

“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.”

This quote provides an outlined position, answering what Gawande believes is the root of resistance to the checklist. The checklist runs contrary to culturally held beliefs that heroic figures are above such guidance. In a way, this comment frames the remainder of the book, as Gawande will directly challenge the cultural perception of what a hero should be.

“The next month, when the whole crew of five—not just Sullenberger—was brought out to receive the keys to New York City, for “exclusive” interviews on every network, and for a standing ovation by an audience of seventy thousand at the Super Bowl in Tampa Bay, you could see the press had already determined how to play this. They didn’t want to talk about teamwork and procedure. They wanted to talk about Sully using his experience flying gliders as an Air Force Academy cadet.”

This quote continues Important Quote #22’s analysis. Here, Gawande explores cultural tropes, including the behavior of a hero, and further criticizes the media as it tends to fashion a narrative based on preestablished tropes. When Chesley “Sully” Sullenberger landed a failing plane, news outlets framed the success as his doing alone, rather than the joined effort of him and his crew.

“The fear people have about the idea of adherence to protocol is rigidity.”

This quote suggests that people are resistant to change. Gawande discussed this idea previously, but this quote is one of his more explicit statements regarding such resistance. While it seems Gawande is critical of those who fear change, he recognizes that sometimes, adherence to protocol feels like a removal of agency.