The Checklist Manifesto
How to Get Things Right
Atul Gawande is a surgeon, writer, and public health researcher. He’s also an extraordinary, best-selling author of a number of books. Short story: Want to get things right? Use a checklist. Sounds too silly to work but… It does. Period. Big Ideas we explore include two reasons we err (ignorance + ineptitude), what to do about it (checklists!), how to reduce your Masterpiece Day mortality rate by at least 47% (checklists!), why Van Halen doesn’t like brown M&M’s (checklists!), and your Big 3 Keystone Initiative (checklist!).
Big Ideas
- Why We ErrIgnorance + ineptitude.
- Flying and Unflyable PlaneThat is our lives.
- Reducing MortalityBy 47%.
- Brown M&M’sWhy Van Halen doesn’t like them.
- Your Keystone InitiativeYour Big 3 Checklist.
- Our Code of Conduct1 + 2 + 3 +4.
“Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.
That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.
It is a checklist.”
~ Atul Gawande from The Checklist Manifesto
Atul Gawande is a surgeon, writer, and public health researcher. He’s also an extraordinary, best-selling author of a number of books.
We ended our last Note on The Progress Principle by Teresa Amabile with a Big Idea featuring wisdom from this book. The basic idea of that idea and of this book?
Simple surgical checklists—of the most mundane, “stupid” things like confirming the side of the body on which the surgery will be performed and having the surgical team introduce themselves to one another—can reduce the mortality rates of surgeries by 47%.
After finishing that last Note, I immediately found this book on a bookshelf in my office (we’ve had a bunch of people request a Note on it) and started reading it.
It’s really good. Well written, very compelling. I highly recommend it. (Get a copy here.)
It is also, of course, packed with Big Ideas. Gawande walks us through the power of checklists on “How to Get Things Right.” His emphasis is on his field of medicine/surgery but he highlights the parallels between his world and that of aviation, building, finance and even running a world-class restaurant. The bottom line? Checklists improve performance everywhere they are applied. Yet, for some wacky reason, they are rarely applied.
Of course, I’m all about seeing how simple checklists can Optimize our lives—reducing the mortality rates of our Masterpiece Days. So, that’s where we’ll focus our energy. Let’s jump in!
Download MP3
Download PDFChecklists 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.
Get the Book
Listen to the PodcastWhy we err: Ignorance + Ineptitude
“In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed, is ‘necessary fallibility’—some things we want to do are simply beyond our capacity. We are not omniscient or all powerful. Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is—and will remain—outside of our understanding and control.
There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snowstorms, save people from heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre point out, we have just two reasons that we nonetheless fail.
The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.”
That’s from the Introduction where Gawande walks us through the philosophical underpinnings of why we err.
Quick recap: First, we have “necessary fallibility” in which we fail because we are operating in the sphere of our mysterious universe that is simply out of our control. Then we have failures within domains that *are* within our control.
There are two reasons we fail in these situations according to Gorovitz and MacIntyre: Ignorance and Ineptitude.
Sometimes the knowledge isn’t there on how to succeed. That’s ignorance. On the other hand, if we *know* what we could do to succeed but don’t do it, that’s ineptitude.
We can apply that wisdom to surgery, meteorology, construction and, of course, to our own lives.
In fact, this really gets at the heart of all of our work together.
Optimizing our lives is rarely about IGNORANCE per se and more about INEPTITUDE. If we simply more consistently applied even a fraction of the stuff we already know, we’d be doing pretty darn well, eh?
We need to move from theory to PRACTICE. From knowing to DOING.
One of the best ways to do that?
Checklists.
Flying an Unflyable Plane (that is our lives!)
“What they decided not to do was almost as interesting as what they actually did. They did not require Model 299 pilots to undergo longer training. It was hard to imagine having more experience and expertise than Major Hill, who had been the air corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach, they created a pilot’s checklist. …
The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, landing and taxiing. It had the kind of stuff that all pilots know how to do. They check that their brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked—dumb stuff. You wouldn’t think it would make that much difference. But with the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the army gained a decisive advantage in the Second World War, enabling its devastating bombing campaign across Nazi Germany.”
That’s from the second chapter where we’re introduced to The Checklist.
Gawande is a great storyteller. In fact, one of the testimonials in the book describes him as “the Malcolm Gladwell of medical and ethical writing” while Gladwell himself says, “It has been years since I read a book so powerful and so thought-provoking. Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious.”
So… The story he tells here is set in October, 1935. Boeing Corporation is showcasing their new plane for the army. It carried five times as many bombs as the army had requested and it could fly both faster and farther than any bomber before—with a wingspan of 103 feet and four engines rather than the normal two. It was amazing and supposed to be a lock to win the army’s contract.
The plane cruised down the runway, lifted up 300 feet then crashed, killing the pilot in the process. Boeing nearly went bankrupt as a result.
Investigations revealed no mechanical failure and, although the report said the tragedy was due to “pilot error,” the plane was deemed “too much airplane for one man to fly.”
Then the Boeing team got to work to figure out how to MAKE it flyable. The answer wasn’t more training. The pilot, Major Hill, was ALREADY the most competent, well-trained pilot out there. The answer was a checklist. Super simple stuff that any pilot could do. Index cards with the basic what-to-do stuff for three major phases of flying that beast: Takeoff + Landing + Taxiing.
The unflyable plane was now flyable. And it became a decisive factor in the outcome of WWII.
Fantastic. So, how do we apply that to our lives?
Well, Gawande talks a lot about inserting checklists at “pause points.” For aviation that includes things like the takeoff, landing and taxiing. For surgery, it’s before anesthetics, before incision and before leaving the OR.
For our lives? Well, let’s think about our Masterpiece Days. How about these three primary chunks: 1. Our AM Bookend; 2. Our PM Bookend; and, 3. Our Work Cycles.
As per Masterpiece Days 101 and our Notes on The Compound Effect, etc., we know that we have more control over the BEGINNING of our days and the END of our days than the middle, so we’d be wise to start there.
What would a checklist look like for our AM and PM Bookends? We’ll get into details on how to create them in a moment, but think about the few very simple core things you already do when you have GREAT days. As Josh Waitzkin says, you want to make your prior peak moments your new baseline. And, the best way to do that is to systematize the mundane via checklists!
Mine? PM: Digital sunset/shut-down complete. Fam time. Read with Emerson. Sleep. AM: Meditate (20 min) + Move (5 min) + Deep Work (90 min Creative before Reactive).
(Note: It’s REALLY hard to have a bad day (aka crash!) when I do that.)
Then we have our Work Cycles. (I just came up with that. Hah.) This is how we oscillate our deep focus with our deep recovery a la the Notes on The Power of Full Engagement and Peak Performance. You’re INTENSELY ON and then equally INTENSELY OFF. 50-90 minutes of Deep Work then 7-20 minutes of Deep Recovery. Repeat.
What would a checklist look like for that?
For me: Phone in airplane mode, powered off, in closet. Deep Work on the next most important thing. Max 90 minutes. Recovery can be anything as long as it’s away from the computer.
Checklists of the mundane. That’s how we fly the unflyable plane that is our lives.
Reducing Mortality by 47%
“‘You’ve got to see this,’ Alex said.
He laid a sheaf of statistical printouts in front of me and walked me through the tables. 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 by 47 percent. The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observational data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.”
This is the passage that Teresa Amabile references in The Progress Principle that got me to read the book.
She says: “The results are astonishing. In a three-month experiment in eight different hospitals around the world, the rate of serious complications for surgical patients fell by 36 percent after introduction of the checklist, and deaths fell by 47 percent. Even Gawande himself, a highly trained surgeon with years of operating experience, found that his own performance improved notably after he started using the checklist. His point is that surgery, like any complex task, requires a regular check of all the fundamentals—to liberate the team to focus on the work and any unexpected circumstances that may arise.”
Again… Want astonishing results?
Regularly check your fundamentals—for Masterpiece Days and for whatever you do in your life.
Gawande walks us through similar jaw-dropping results in finance and spends a bunch of time reviewing the power of checklists in aviation. And, he makes the point that, even with the data, most people and organizations *still* don’t use checklists. We’re wired to be inspired by the novel and it takes discipline to remember the basic fundamentals. More on that in a moment…
Van Halen Doesn’t Like Brown M&M’s
“As Roth explained in his memoir, Crazy from the Heat, ‘Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors—whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.’ So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. ‘When I would walk backstage, if I saw a brown M&M in that bowl,’ he wrote, ‘well, we’d line check the entire production. Guaranteed you’re going to arrive at a technical error. … Guaranteed you’d run into a problem.’ These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.
‘David Lee Roth had a checklist!’ I yelled at the radio.”
That story is epic.
Imagine that for a moment. You’re the first band in history to take your huge production into smaller markets. Your nine eighteen-wheelers roll up to do the show. You cruise back stage before go time and take a glance at your jar of M&M’s. Brown ones? Show’s off.
WHY? Because if the local promoters couldn’t pay attention to THAT detail, they probably missed a ton of other details—some of which might be life-threatening.
Guess what? We need Article 126, aka “The No-Brown-M&M’s Clause’ in YOUR life—the seemingly trivial thing you make yourself do just to flex your “I’m on top of my life” muscle.
This is where my 1 + 10 + 100 + 1,000 + 10,000 tracking comes in. Long after I “need” to track it to stay plugged in, I keep on tracking it. No brown M&M’s over here. I know that if I’m careless with those simple practices, I’ll be careless with others.
And I don’t want to kill my Masterpiece Days.
You?
Your Keystone Checklist Initiative
“The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with … and lets it rise above to focus on the hard stuff.”
One of the reasons people don’t like checklists (or discipline on the fundamentals in general) is that they think it will stifle their freedom and creativity.
But guess what? The exact opposite happens. As Gustav Flaubert says so perfectly: “Be regular and orderly in your life so that you may be violent and original in your work.”
When we can systematize/routinize/checklist the basics, we free ourselves up to do the work that matters. (Austin Kleon echoes this in Steal Like an Artist as does Scott Adams in How to Fail at Almost Everything and Still Win Big.) And, when our checklist includes our Masterpiece Day fundamentals, we also ensure we’re plugged in and energized to jumbo crush it. Consistently.
Now, let’s look at what a good check list looks like and then create your Keystone Checklist.
Short story on a good checklist: It’s short. Precise. And, most importantly, SUPER PRACTICAL.
OK. Time to create your Keystone Checklist. First, aside: Gawande tells us about an early study that demonstrated the power of checklists. It was called the “Keystone Initiative.” I knew when I read it that we’d use that phrase. “The Keystone Initiative.” ← Brilliant.
So… Let’s create a super simple v1 Keystone Checklist. Short. Precise. Practical.
What THREE things do you do when you have your best days?
Think about that for a moment. What are they?
- __________________
- __________________
- __________________
Mine? Digital sunset. AM1 Deep Work. And my 1 + 10 + 100 + 1,000 +10,000 sequence.
Your Keystone Initiative. Spending some time creating and testing this and then executing it consistently would DRAMATICALLY improve your life. I’d be willing to bet (a lot!) that your Masterpiece Day mortality rate would drop AT LEAST 47%.
Our Optimizer Code of Conduct
“All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. The codes are sometimes stated, sometimes just understood. But they all have at least three common elements.
First is an expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own. Second is the expectation of skill: that we will aim for excellence in our knowledge and expertise. Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges. Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own… Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”
That’s from the penultimate chapter “The Hero in the Age of the Checklists.”
And what a great checklist for our code of conduct as humans: Selflessness + Excellence + Trustworthiness + Discipline.
Our modern hero has discipline—the humility to focus on mastery of the mundane. And you know what? That goes perfectly with the ancient idea of a hero who was, as we know, “a protector”—selflessly using love as their fuel as they cultivated the strength for two.
Here’s to embracing the simple fundamentals that lead to Masterpiece Lives.
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