Gawande’s “Checklist Manifesto”

By  |  February 8, 2010 | 

Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.

Atul Gawande, by Fred FieldIn this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.

Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.

I won’t focus this post on the Hopkins-Michigan central line and the WHO surgery stories, which are both well known to readers of this blog. Nor will I concentrate on the book’s recitation of the history of checklists in fields as diverse as building construction, investing, and aviation (while illuminating and often fascinating, some of the examples, particularly the investment analogies, are a bit thin, a point made elsewhere). Finally, I won’t cover what Atul learns about how to create a great checklist from his field trip to Boeing’s “Checklist Factory,” beyond saying that this part of the book is actually a useful primer for those getting into the checklist business.

Instead, I’d like to focus on the subjects that don’t come through in reviews and interviews (such as Atul’s charming appearance on The Daily Show) but, I believe, are much deeper and more valuable.

“For nearly all of history, people’s lives have been governed primarily by ignorance,” Gawande writes. But in healthcare, he points out, we now know so much about so many things (and can treat so many maladies with our arsenal of thousands of medications and procedures) that when we don’t get it right, “the problem we face is ineptitude… making sure we apply the knowledge we have consistently and correctly.”

This, of course, helps explain why the public is so unsettled by our patient safety and quality flaws. Patients no longer give us the benefit of the doubt, attributing our failures to ignorance. Instead, they assume that we do know the right thing to do, but simply screwed it up. “The public was spoiled by the discovery of penicillin,” Atul said at a recent lecture at UCSF, since it gave people the illusion that curing illness was pretty easy.

In observing that medicine has problems that range from simple (getting the dumb stuff right) to the profoundly complex, he notes that,

… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail.  People need room to act and adapt.

Is he arguing against his central premise, the value of checklists in healthcare? Well, no. He continues,

Yet they cannot succeed as isolated individuals, either – that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation – expectation to coordinate, for example, and also to measure progress toward common goals.

This is one of the book’s epiphanies: checklists can not only ensure that people perform multi-step processes correctly, but can also remind us to talk to each other and coordinate our activities at particularly crucial junctures. Atul learned that the value of the preoperative checklist, coupled with the Time Out, was not simply in ensuring that the team gave the preop antibiotics or had units of blood on hand, but in forcing all the team members to introduce themselves to each other. It was as much a culture-changing intervention as a cookbook.

In fact, the most interesting parts of the book are ones in which Atul describes our culture; it is this culture that explains why checklists rub so many caregivers the wrong way.

In medicine, he writes,

we have the means to make some of the most complex and dangerous work we do… more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity… Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

In broadening this point, he plumbs an even deeper truth: “All learned occupations have a definition of professionalism, a code of conduct… [with] at least three common elements,” he observes: selflessness, an expectation of skill, and an expectation of trustworthiness.

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. In medicine, we hold up ‘autonomy’ as a professional lodestar, a principle that stands in direct opposition to discipline…. The closest our professional codes come to articulating the goal [of discipline] is an occasional plea for ‘collegiality.’ What is needed, however, isn’t just that people working together be nice to each other. It is discipline.

These insights about medicine, and particularly the physician psyche, are not only profoundly interesting; they are vital to understand if we are to make healthcare better. Checklists can’t solve all our problems, but they – and other safety-oriented activities like standardization, simplification, forcing functions, and double-checks – can help us deliver healthcare that is far safer and more reliable. In applying these solutions, though, we need to understand that they challenge some of our most deeply held beliefs about the nature of medical practice and what it means to be a good doctor.

We have met the enemy, and it is us.


  1. menoalittle February 9, 2010 at 5:41 am - Reply


    At a time when ill-designed not fit for purpose electronic records and CPOE systems have coalesced to encroach on health care professionals’ time and create a toxic communication drought, along comes Gawande with a book on how a checklist becomes an oasis in the electronic communication desert, one in which no one knows whether a communication was received or executed.

    As you keenly observe, “…is one of the book’s epiphanies: checklists can not only ensure that people perform multi-step processes correctly, but can also remind us to talk to each other and coordinate our activities at particularly crucial junctures…” Checklists are needed to replace inferior medical education in which the focus now is on the computer rather than the patient and its hand-off. We need a lot more than checklists to cure a medical care environment that is being polluted by computerized care administration systems designed by folks who know little to nothing about medical care. These are the same folk who rid their HIT companies of any one who complains about the dangers of the devices and associated systems they are creating.

    Best regards,


  2. KevinStokuvich February 12, 2010 at 7:03 am - Reply

    great articles

  3. PatriceSpath February 16, 2010 at 6:14 pm - Reply

    I too have read this book and found it quite insightful. The title is deceptive … I wondered how (and why) an entire book would be written about checklists.

    As I pondered Gawande’s observations, I was reminded of the quote attributed to John F. Kennedy: “The greater our knowledge increases, the greater our ignorance unfolds.”

    — Patrice Spath

  4. chris johnson February 19, 2010 at 1:32 am - Reply

    I do critical care, and, without patting ourselves on the back too much, I think we’ve done better at the checklist approach than some other specialties. Perhaps this is because resuscitation skills are central to what we do. And when we teach resuscitation, a situation where stress runs high, the concept of a team approach in which at least one team member is ticking off, out loud, items to do or consider doing is extremely helpful and reassuring, especially to trainees.

  5. gene spiritus March 1, 2010 at 5:32 am - Reply

    As I read the book I was most taken by the fact that we in Medicine will never reach our potential without changing the dynamics of the health care team. It is impossible in this day and age to manage patients without the support of knowledgeable nurses, pharmacists, dietiicians, therapists, technicians and the myriad staff that clean, cook and insure that the hospital functions. The surgeons have moved much further than we in the cognitive fields such as Medicine. We need to adopt team training for our residents and faculty before we develop our check lists. I have found that unless we get the staff to work with the doctors to develop our check lists we are not successful In addition we need to move to team training to the Medical Schools, Nursing School and most professional health care disciplines

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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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