The Checklist Manifesto

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What makes this recovery astounding isn’t just the idea that someone could be brought back after two hours in a state that would once have been considered death. It’s also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated.

Medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.

it’s tempting to believe that no one else’s job could be as complex as mine. But extreme complexity is the rule for almost everyone.

But it’s not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution—the practical matter of what knowledge requires clinicians to do.

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.

What do you do when expertise is not enough? What do you do when even the superspecialists fail? We’ve begun to see an answer, but it has come from an unexpected source—

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But flying this new plane was too complicated to be left to the memory of any one person, however expert.

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.

Much of our work today has entered its own B-17 phase. Substantial parts of what software designers, financial managers, firefighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from memory alone.

Yet it is far from obvious that something as simple as a checklist could be of substantial help. We may admit that errors and oversights occur—even devastating ones. But we believe our jobs are too complicated to reduce to a checklist.

Mapping out the proper steps for every case is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters.

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. Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.

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. Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients. “This has never been a problem before,” people say. Until one day it is.

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.

And nurses have developed yet further such bedside innovations—for example, medication timing charts and brief written care plans for every patient.

Charts and checklists, that’s nursing stuff—boring stuff. They are nothing that we doctors, with our extra years of training and specialization, would ever need or use.

The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.

These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. He was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of ICU staff taken before introducing the ventilator checklists, he found that half hadn’t realized that evidence strongly supported giving ventilated patients antacid medication. Checklists, he found, established a higher standard of baseline performance.

few adopted the idea. There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence.

It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.

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.

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checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities. But they presumably have limits, as well. So a key step is to identify which kinds of situations checklists can help with and which ones they can’t.

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Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex. Simple problems, they note, are ones like baking a cake from a mix. There is a recipe. Sometimes there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success. Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. Success frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent. Timing and coordination become serious concerns. Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all.

We are besieged by simple problems.

Checklists can provide protection against such elementary errors.

the question of when to follow one’s judgment and when to follow protocol is central to doing the job well—or to doing anything else that is hard. You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way. The value of checklists for simple problems seems self-evident. But can they help avert failure when the problems combine everything from the simple to the complex?

So as I looked up at this whole building that had to stand up straight even in an earthquake, puzzling over how the workers could be sure they were constructing it properly, I realized the question had two components. First, how could they be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly?

Along the right wall as we walked in was, O’Sullivan explained, the construction schedule. As I peered in close, I saw a line-by-line, day-by-day listing of every building task that needed to be accomplished, in what order, and when—

The schedule spread over multiple sheets. There was special color coding, with red items highlighting critical steps that had to be done before other steps could proceed. As each task was accomplished, a job supervisor reported to O’Sullivan, who then put a check mark in his computer scheduling program. He posted a new printout showing the next phase of work each week, sometimes more frequently if things were moving along. The construction schedule was essentially one long checklist.

In the absence of a true Master Builder—a supreme, all-knowing expert with command of all existing knowledge—autonomy is a disaster. It produces only a cacophony of incompatible decisions and overlooked errors.

a “submittal schedule.” It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another—on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction—who had to share (or “submit”) particular kinds of information before the next steps could proceed.

It is unnerving to think that we allow buildings this difficult to design and construct to go up in the midst of our major cities, with thousands of people inside and tens of thousands more living and working nearby. Doing so seems risky and unwise. But we allow it based on trust in the ability of the experts to manage the complexities. They in turn know better than to rely on their individual abilities to get everything right. They trust instead in one set of checklists to make sure that simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems. “The biggest cause of serious error in this business is a failure of communication,” O’Sullivan told me.

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But the list on O’Sullivan’s other wall revealed an entirely different philosophy about power and what should happen to it when you’re confronted with complex, nonroutine problems—such as what to do when a difficult, potentially dangerous, and unanticipated anomaly suddenly appears on the fourteenth floor of a thirty-two-story skyscraper under construction. The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.

The trouble wasn’t a lack of sympathy among top officials. It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.

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