Book notes: The Checklist Manifesto by Atul Gawande

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

Synopsis: We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies‚ and neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third.

In riveting stories, Gawande explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from homeland security to investment banking, skyscraper construction, and businesses of all kinds.

Initial thoughts:

I put this book on my Audible wish-list primarily because I heard Ramit Sethi, author of I Will Teach You To Be Rich, recommend the book on a podcast with Tim Ferriss, author of The Four Hour Workweek. I follow and look up to both of them, so it was one of those easy decisions to read.

While the title and main idea seems pretty straightforward, I figured if these two authors recommended it, I knew it would have more nuggets than its face value.

Key ideas:

• Things are not always under our control even though we sometimes think they are
• Two sources of failure: ignorance and ineptitude
• The issue with ineptitude is making sure we apply the knowledge we have consistently and correctly
• Defeat under conditions of complexity occur quite often in many fields like medicine
• One needs practice to achieve mastery, a body of experience that creates real success
• In many fields like medicine where managing extreme complexity has become an art, knowledge has both saved us an burdened us
• Because of the increase complexity, we rely heavily on specialists and super-specialists
• In fields like aviation and building building, fields have become too complex to rely on single individuals as there is a fallability in human memory and attention
• All-or-none processes: cannot miss a single key step. Either you do it all or you might as well not have done any
• No more master builders, instead there are 16 specialists, master schedules, and meetings to communicate and discuss problems
• One checklist to make sure important steps aren’t missed, another to ensure hard problems are communicated and solutions are signed off on, no longer relying on one person
• The 2nd checklist revealed a different philosophy about power, and how to confront difficult, complex, and unexpected anomalies
• Philosophy: push the power of decision making to the periphery and away from the center, and allow them to adapt
• Hurricane Katrina & FEMA: to many decisions to be made, too little precise information, and lack of understanding the need to push power to the periphery and allow front lines to adapt
• Walmart CEO: “a lot of you will make decisions above your level. Make the best decision you can with the information you have. Above all, do the right thing”
• Efforts to dictate every step from the center will fail on emergency situations like this
• People need room to adapt, though not as isolated individuals. They require a seemingly contradictory mix of freedom and expectation to coordinate and manage toward common goals
• Making complexity a routine. Balancing the virtues of: freedom and discipline, craft and protocol, specialization and group collaboration
• In conditions of crisis and complexity, checklists are not only helpful but required for success. There needs to be room for judgement, but aided and enhanced by procedure
• Example: brown m&ms in contract as test to make sure key details weren’t missed
• Even in the kitchen where culinary artistry is hailed and considered more art than science, checklists were used to maintain consistency and standards of excellence
• Seeking simple interventions that made a huge difference, like checklists or introducing the habit of using soap in slum villages as behavior change delivery vehicles
• The most dangerous issue in an operating room is the “silent disengagement” as a consequence of specialized technicians sticking narrowly to their domains; “not my problem”
• Their job isn’t just performing their task well, but also helping the group get the best possible result, making sure nothing falls through the cracks, and adapting as a team to tackle any surprise issues (working as one unit instead of a group of specialists)
• Good checklists are concise, precise, and easy to use, especially in difficult situations
• Checklists aren’t how-to guides, but quick and powerful tools
• 80/20 split for and against using checklists in operating rooms, but 93% said they would want it to be used in their operations (participants of study said)
• It’s not about checking boxes, but embracing a culture of teamwork and discipline
• We must be ready to accept the virtues of regimentation
• For value investors, a huge opportunity can create “cocaine brain” in which the same receptors get triggered on the brain when money is involved
• Mistakes come from emotion, greed, and handling complexity; becoming systematic is necessary to avoid mistakes
• Checklists help improve outcome without  and increase an skill
• Captain Sully: most successful ditching in aviation history
• The success was a testament to teamwork and adherence to protocol above any amount of skill he may have had
• The fear people have of adherence to protocol is rigidity
• The checklist gets the dumb, but important, stuff out of the way that your brain doesn’t need to occupy itself with
• Preparation and discipline long before the situation is what it means to be a hero
• Technology can and does aid, but it also adds layers of complexity
• We all depend on systems, and one of the most profound difficulties is making them work
• In healthcare and other industries, its not about having great components and spending time trying to optimize the parts

Closing thoughts:

I know it always seems like I say this but this book was fantastic. So many brilliant nuggets in this book, great for understanding how a simple intervention like a checklist can have a huge impact on industries with increasing complexity. I love the simple but powerful themes mentioned like artistry vs protocol, teamwork, adaptability, pushing power to the periphery, the value of discipline, and taking a hard look at the systems we use and how we can improve them. Definitely a book worth rereading.

Nutshell: The power and simplicity of a checklist can help facilitate discipline, foster better teamwork, improve communication, and enhance systems overall.

Rating: 5/5

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