Mastering Complexity with Checklists: Lessons from Atul Gawande’s “The Checklist Manifesto”

Ever feel your work (and your life) is becoming more complicated by the day, or even by the hour? You’re not alone. The dizzying rate of technological change is enough to make even the most hardened techies feeling disoriented. Amidst all the break-neck innovations bombarding our daily feeds, the fundamentals however, seem to be holding…for now. 

Until the robots start doing our dishes, we mortals are still relevant. We’re still responsible for doing stuff, building stuff, creating stuff, fixing stuff, and improving stuff. We’re tasked with meeting our weekly, monthly, and quarterly goals, delivering for our organizations and serving our teams. 

Although the What and How we do things is changing quickly. Our “Why” remains mostly unchanged. Apple still wants us to Think Different and Starbucks still wants to  inspire and nurture the human spirit – one person, one cup and one neighborhood at a time. 

So, as long as we humans continue to do stuff, we can be asking ourselves, how can we leverage more of our time, how can we accomplish our goals in a better way, a faster, more efficient and higher quality way…for our clients, customers, members, employers, constituents, families and communities. How can we deliver consistently…at scale?    

Enter the simple checklist: 

Yes, it’s a painfully obvious solution that’s been around for decades, yet most organizations are either not doing it, or not doing it well. ‘The Checklist Manifesto’ by Atul Gawande has long served as the bedrock resource around the topic of checklists as a means for hacking the human tendency of missing important steps in our work, making the case and paving the roadmap for crafting useful checklists that actually work…and even save lives.

The Problem of Extreme Complexity

Other than maybe defense procurement, it’s hard to imagine a more complex environment than healthcare. Despite years of training, doctors and nurses still struggle with treating us, and most of the time it’s not their fault. They’re human. 

Gawande asks two fundamental questions: “What do you do when expertise is not enough?” and “What do you do when even the super-specialists fail?”

Going back in time, the US Army Air Corps held a flight competition in 1935 for a new long-range bomber. One contender was Boeing’s B-17 ‘Flying Fortress’, a reliable plane, but one that crashed too frequently, often due to pilot error. It was deemed too complicated to fly. A checklist was introduced with simple instructions, like what to do before take off and landing. After building-in standardized checklists for operating the aircraft, tracking became easier, and the plane was suddenly less complicated for pilots. The US military ordered 13,000 B-17s, which flew over one million miles without incident. 

Checklists have a similar effect in every industry from finance to law. 

So, how can we apply checklists to work? The possibilities are really endless, from simple operating processes to more complex technical processes, any series of repetitive steps can leverage a checklist. Eric Larson, founder and CEO of Cloverpop even suggests developing checklists to counteract our human biases to improve decision making. 

Human Nature in Complexity

Gawande identified two reasons why experts sometimes fail: 

1. Fallible memory and retention 
2. A tendency to skip seemingly unimportant steps 

Checklists reduce these two problems by clarifying which steps to take. 

The End of the Master Builder

Another case-study Gawande explored is the construction industry. He looked at how construction companies building skyscrapers essentially ended the Master Builder model of pre-modern times with checklists. A Master Builder completes a construction project on time with minimal mistakes, and at the time, was only one highly skilled human being. Not scalable. 

But the construction industry removed them by introducing two checklists: 

1. The ‘What’ Checklist that details which steps to perform. 
2. The ‘How Checklist’ that instructs workers on how to respond to challenges. 

The First Try

Inspired by the promise of checklists in Healthcare, Gawande built a safe surgery checklist in collaboration with the World Health Organization, specialists, physicians, nurse practitioners and hospital administrators. At first, their checklist faced challenges due to its impracticality. Surgeons found it lengthy and unclear. 

The Checklist Factory

After their first attempt, Gawande visited Danial Boorman at Boeing Aerospace to learn their approach. Boorman explained the difference between good and bad checklists: 

1. Good checklists are precise and encourage communication 
2. Bad checklists treat workers as unintelligent and prevent critical thinking

Boorman also explained that following checklists wasn’t easy. Gawande would have to introduce the right type of checklist for each situation.

Some people would need ‘Do confirm checklists’ that involve team members confirming they’ve performed every step in the right order. 

Others would need ‘Read-do checklists’ where members check off tasks after completing them. 

The Test

Gawande used Boorman’s advice to build a surgery checklist with 3 pause points: 

• 5 checks before anesthesia 
• 7 checks after anesthesia and before incision 
• 5 checks before the patient leaves the operating room

This checklist reduced major surgery-related complications by 36% and deaths by 47%. 

For example, a surgeon accidentally cut a hole in a patient’s major artery and lost blood fast. The checklist ensured the nurse had sufficient blood to offset the emergency. 

Try it yourself

You won’t know the benefits of checklists until you’ve experienced them yourself. Checklists have their limits. You need to recognize when to use them.

Generally, you can categorize problems, projects, and processes as one of the following: 

1. Simple – You can fix simple problems with a routine. For instance, how do you boil an egg? You put it in a pan with hot water on a stove for a couple of minutes. 
2. Complicated – Complicated problems are repeatable and potentially depend on multiple individuals or groups. An example is launching a rocket to the moon. You might break down a complicated problem into multiple simple ones 
3. Complex – Complex problems are difficult and may require unique solutions. The best example is raising a child. Every child has unique problems and needs. So you develop a unique solution for each one. 

Thinking about each challenge in terms of the degree of complexity, influences how we might approach the creation of checklists for teams and organizations in any industry.

Tips for creating useful checklists: 

1. Have clear, concise objectives
2. Keep it simple, document 20% of the process that gets you 80% of the result* 
3. Limit to between 5-10 primary steps with 2-3 sub-steps ea.  
4. Keep the wording simple and concise, include the desired outcome
5. Use language familiar in the profession
6. Whenever possible, fit onto a single page
7. Remove extraneous words and use color coding sparingly 

*Source: Traction, Gino Wickmen.

Guideline: 

As much as practical, define your desired outcome for each of the primary steps, keep the “how” flexible. This prevents over prescribed solutions and fosters creative problem solving, innovation, and better use of technology that drives ongoing efficiencies and continuous improvement. The “how” will always be improving and teams should be provided wide latitude for defining how best to achieve the desired results. 

Gawande’s book reveals how a simple solution can solve profound problems. When done right, checklists make even the most diligent, trained professional’s life easier by simplifying their workflow and providing clear direction.