• T. Kearny Vertner, III

Observations: The Checklist Manifesto

Even experts skip or forget important steps.


I recently finished reading Atul Gawande's The Checklist Manifesto and thoroughly enjoyed it. Having worked professionally in a field where checklists are a fundamental concept, it was good to have it validated by someone outside of my expertise. He starts by assuming that there are two general types of errors: 1) errors of ignorance, where we make mistakes because we don't know enough, and 2) errors of ineptitude, where we make mistakes because we don't correctly use what we know. His thesis is that many of our errors are due to the latter. We have so many experts with so much information at their fingertips that it's easy for those experts to forget a step or skip a detail.


Synopsis


Gawande spends much of his time speaking from personal experience. As a general and endocrine surgeon, he observed countless situations where a step or two would go missing from a routine medical procedure (such as intubation). These missing steps added up, creating a significant number of complications that well-educated doctors wrote off as part of the procedure's reasonable risk. After conducting exhaustive (though surprisingly controversial) research, Gawande found that while surgeons may have felt second-guessed, it was often quite appropriate, and the results were dramatic reductions in procedural complications. Applying the same rigor to other areas of medicine, such as diagnosis, yielded similar results. Brilliant doctors simply forgot to ask specific critical questions. It wasn't that they weren't educated and capable, but they were still entirely too human.


The Checklist Manifesto gets fun when Gawande branches off into non-medical examples, such as skyscraper construction or David Lee Roth's infamous touring contracts when he was the Van Halen frontman. While some like to point out his contract rider requiring a bowl of M&M candies in his dressing room with all of the brown candy removed as an example of fame and excess, the truth was far more interesting. Roth purposefully buried that rider deep within the contract, surrounded by other careful details regarding stage and crew safety requirements. Any violation would result in immediate cancellation and a massive bill for the venue. If he walked into his dressing room and saw a brown M&M, the show was immediately canceled at the venue's expense, because it was quite clear that the contract had not been read and followed to the level of detail necessary to ensure the safety of the performers and stage crew. All of this was accomplished by building a detailed checklist.


One area that hit close to home was aviation. In aviation, crews take checklist discipline almost completely for granted. The wisdom seems clear to all involved and the checklists are (usually) closely followed by folks regardless of their competence and experience with the aircraft. The development of these checklists is a rigorous process, involving extensive testing and analysis, with almost every line of each procedure written in the blood of another aviator's mishap.


Why Checklists Matter to You

Checklists have been useful for more than just aviation in my life. I have also found them handy for organizing several routine processes. One of the best checklists I routinely employ is my packing list. I have several pre-planned packing lists depending on where I am going and how long I will be there. Additionally, I have addendums for travel with the U.S. Air Force, with lists of necessary uniform items and professional equipment, depending on the type of trip. While packing, I make sure I have each of the lists in hand and lay everything out, checking it against my list before placing it in the appropriate suitcase.


Speaking of travel, another checklist I love is when the whole family is vacating the house for a bit. We all worry if we brought in the garbage cans, held the mail, or emptied that last load of dishes; creating a checklist can help save us from that worry. All the better, it's a checklist you can bring the whole family into!


Once at the workplace, I've found that the Air Force benefits from using checklists outside of the aircraft, too. I've frequently built office checklists of daily tasks, weekly tasks, and monthly tasks. It makes it easy to divide routine work while applying a healthy measure of careful diligence. Likewise, I almost always carry a bullet journal with me, where many days will be filled with to-do lists... which are little more than a checklist for your day.


Critique

Gawande's field of expertise is clearly medicine, and it shows as most of his examples require a considerable medical background for the layman to understand. He does a delightful job of bringing you into his world and helping you comprehend many of the pertinent details, but it can be occasionally hard to follow. As mentioned above, his writing truly shines when he discusses examples in other fields that he's less familiar with. He's still diligent about explaining necessary technical details, but he's got fewer blindspots and assumptions about his reader's knowledge; he was clearly in the same place when researching his book.


There are a lot of books on management out there that focus on the why or the bigger how. This one is nice because it narrowly focuses on one specific how. The checklist becomes a relatively simple and achievable means to countless ends, and the reader is left pondering how something so simple might create dramatic and tangible results in their home and work. More importantly, another book on the subject might have been needlessly dry and prescriptive, but Gawande's skill at storytelling is delightfully entertaining.


Conclusion


The Checklist Manifesto, by Atul Gawande, is an engaging book that can either ignite or reinforce your passion for the humble checklist. If you have never used one, you'll be sorely tempted to try. If you already use one regularly, this book will validate its use to you. Fundamentally, it recognizes a simple truth: experts need help. No amount of expertise will consistently overcome human error through distraction, exhaustion, or indifference. Checklists can often help us all overcome these challenges and ensure that our experts diligently consider each step at the right time. Let me know the creative ways you have made checklists work in your home or workplace!


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