A fun read. This book is fascinating for all - not just those in medicine. Gawande illustrates the power of checklists in fields including medicine, construction, investing and aviation.
The downside to this book is that it could probably be a long article. That said, the supporting examples are interesting, and the book is an easy read overall.
The main takeaway: make checklists for any complex decisions or processes.
Chapter 1: The Problem of Extreme Complexity
We live in the era of the superspecialist—of clinicians who have taken the time to practice, practice, practice at one narrow thing until they can do it better than anyone else.
They have two advantages over ordinary specialists: greater knowledge of the details that matter and a learned ability to handle the complexities of the particular job.
Chapter 2: The Checklist
In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.
A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter.
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.
In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine.
Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent.
In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now—all because of a stupid little checklist.
Chapter 3: The End of the Master Builder
Complex problems can sometimes be broken down into a series of simple recipes, but there is no straightforward recipe. Their outcomes remain highly uncertain.
In these situations, you need both task and communication checklists.
Chapter 4: The Idea
Under conditions of true complexity - where the knowledge required exceeds that of any individual and unpredictability reigns - efforts to dictate every step from centre will fail. People need room to act and adapt.
Checklists 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.
Chapter 6: The Checklist Factory
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.
When you’re making a checklist, 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, 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.
After about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things. People start "shortcutting." Steps get missed. So you want to keep the list short by focusing on "the killer items"—the steps that are most dangerous to skip and sometimes overlooked nonetheless.
The wording should be simple and exact, and use the familiar language of the profession.
Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading.
One further point: no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart, and one needs to study how, make changes, and keep testing until the checklist works consistently.
It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals.
Chapter 8: The Hero in the Age of Checklists
Smart identified several different types of VC investors:
He called one type of investor the "Art Critics." They assessed entrepreneurs almost at a glance, the way an art critic can assess the quality of a painting—intuitively and based on long experience. “Sponges" took more time gathering information about their targets, soaking up whatever they could from interviews, on-site visits, references, and the like.
The "Prosecutors" interrogated entrepreneurs aggressively, testing them with challenging questions about their knowledge and how they would handle random hypothetical situations.
“Suitors" focused more on wooing people than on evaluating them.
“Terminators" saw the whole effort as doomed to failure and skipped the evaluation part. They simply bought what they thought were the best ideas, fired entrepreneurs they found to be incompetent, and hired replacements.
Then there were the investors Smart called the "Airline Captains." They took a methodical, checklist-driven approach to their task. Studying past mistakes and lessons from others in the field, they built formal checks into their process. They forced themselves to be disciplined and not to skip steps, even when they found someone they “knew” intuitively was a real prospect.
Smart next tracked the venture capitalists’ success over time. There was no question which style was most effective. It was the Airline Captain, hands down. Those taking the checklist-driven approach had a 10 percent likelihood of later having to fire senior management for incompetence or concluding that their original evaluation was inaccurate. The others had at least a 50 percent likelihood.
The results showed up in their bottom lines, too. The Airline Captains had a median 80 percent return on the investments studied, the others 35 percent or less. Those with other styles were not failures by any stretch—experience does count for something. But those who added checklists to their experience proved substantially more successful.
The most interesting discovery was that, despite the disadvantages, most investors were either Art Critics or Sponges—intuitive decision makers instead of systematic analysts. Only one in eight took the Airline Captain approach.
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.
We’re obsessed in medicine with having great components—the best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well.
Berwick notes how wrongheaded this approach is. "Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence," he says. He gives the example of a famous thought experiment of trying to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. "What we get, of course, is nothing close to a great car; we get a pile of very expensive junk."