The Checklist Manifesto

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Atul Gawande’s The Checklist Manifesto: How To Get Things Right comes close on the heels of Umberto Eco’s The Infinity of Lists. Both books are about lists and both emphasise the ability of lists to bring about order and control. Both books attracted me because I am a consummate list-maker. More “practical” than “poetic”, a taxonomical distinction that Eco proposes in his book, I write my lists in blue, striking out the “done” items in red, thus also making it a motivational tool. It is therefore safe to say that the title of Gawande’s book was immediately attractive.

Despite my prejudicial preference for lists and reading about lists, it is a credit to the engaging quality of Atul Gawande’s writing that the book kept me absorbed for the 3 hours it took to read all 193 pages of it.

The author proposes “checklists” as a functional tool to deal with the limitations of human knowledge and the possibility of making mistakes in the face of complex problems. Using stories from construction management, airline piloting and disaster management, and surgery, he shows how checklists can be used to break down complex tasks into simpler steps, thus helping prevent expensive mistakes. The author delves further into two kinds of lists (Do-Confirm or Read-Do) using a story from how the airline manufacturing industry writes their “user manuals”.

Early on, he points out that checklists are not some silver bullet, and that there is judgement involved. Some situations may benefit from checklists, while others may not need any. Later in the book, he also admits that to many, lists are protocols and embody rigidity. He then proceeds to illustrate why this needn’t be so and to demonstrate the importance of team work and how checklists enable that discipline, especially in disasters.

I found Chapters 7 and 8 most interesting. The stories told so far describe the complexity of the work/ task itself but these two chapters introduce another layer, that of institutional complexity.

Chapter 7 details the WHO sponsored study to examine if checklists made any difference to safety, infections, post-surgery deaths in 8 quite disparate hospitals around the world. The settings varied from a hospital in Tanzania where 4 surgeons, aided by 5 untrained anaesthesia staff, work on thousands of surgeries; to one in New Zealand that has 92 anaesthetists for some 20,000 surgeries per year, a number also dealt with in an Indian hospital using just 7 anaesthetists. The settings were also culturally diverse adding a layer of complexity not foreseen in the design of the checklist. For instance, the author mentions a different kind of English being spoken in an English NHS hospital, and observes the interplay of gender segregation and professional responsibility in a Jordanian surgery theatre. The results – from using the checklist – regarding reduction in technical problems, complications, infections and deaths were encouraging, for all cultural settings and even allowing for the Hawthorne Effect.

In Chapter 8, much mainstream media coverage of Jan 2009’s “Miracle on the Hudson River” is debunked while the author tells the story of the pilots Sullenberger and Stiles and their calm use of appropriate procedures, while their cabin crew prepared passengers for and then monitored safe evacuation, to strengthen his thesis. The other half of Chapter 8 particularly resonated with me because I work with investors and entrepreneurs. I was fascinated by the stories of the 3 investors who have incorporated checklists into their investment decisions, favouring dispassionate analysis over irrational exuberance, so to speak.

The title is deceptively simple for this is a profound book, written accessibly and clearly. It is a defence of rational, systems-thinking approach to solving complex problems, to creating team work and collegiality amongst narrow specialists while ensuring desirable outcomes, no matter what the setting.

Managers, entrepreneurs, investors as well as professional project managers such as event planners would do well to read, ponder, internalise and practise the idea proposed in the book.

Star rating: 5 out of 5

Usefulness note: The varied examples from learned professions such as surgery, airline piloting, construction management and investing should make the book broadly readable.


3 thoughts on “The Checklist Manifesto

  1. Thanks for the review. I also love checklists and crossing things out, so I think I’ll like this book. I enjoyed one of his other books, Complications, about being a surgeon and was constantly amazed at how he found time to both be a surgeon and write about the grueling environment. That book really gives a good and scary behind-the-scenes view of healthcare.

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