Book Cover

In week 8 of re-read of The Checklist Manifesto by Atul Gawande (use the link and buy a copy so you can read along) we read about building a usable checklist. In this chapter, Dr. Gawande puts all of the lessons learned in chapter 6 into action and tests the result.

The chapter begins with Gawande and his team applying what they learned in Chapter 6 (The Checklist Factory) to the surgery checklist developed in Chapter 5.  The major shift the team adopted was to simplify the list and to adopt to a “do confirm” approach. Originally the checklist reflected a “read do” approach which takes more time and effort.

As part of the revamping of the surgery checklist, the team TESTED their changes. In this case, the author and his team performed a low tech simulation by using people in the hall to walk through the checklist. Low-tech, low-fidelity prototyping can be extremely effective as a testing tool to identify the rough spots in a process. The testing that Gawande did in the hall is very much akin to conference room pilots. Testing early in process development without huge investments of time, effort and resources will reduce risk.

Two of the major ideas in this chapter were the ideas of whether the goal was to improve surgical safety or recordkeeping and the tension between brevity and effectiveness.  Formating checklists for record keeping requires them to be more formal and packaged. The are tools for conveying evidence. I have used several appraisal techniques over the years that used checklists to collect performance evidence (CMMI and TMMi are two examples). Those checklists were always less effective at changing the culture and therefore process effectiveness. The goal of the surgery checklist was to ensure that the team talked about what might happen and go wrong during the surgery. The conversation and pre-planning improved the outcome, not the collection of evidence.  Secondly, teams developing checklists need to determine the line between the keeping the checklist simple (brevity) and making sure the checklist includes every possible step imaginable. Re-read Chapter 5 and then make sure the checklist is as simple as it needs to be. After simplification, the surgical checklist that is the prime example in this chapter included 19 steps and took only two minutes to execute.

The majority of the chapter dives into the pilot process for the checklist. Eight hospitals were identified that cut across a wide range of environments (posh to very not posh). The author includes a great list of ideas for implementation of checklists (and any other processes) on page 145. The third takeaway in this chapter is that sheep dipping is never an effective implementation technique. Sheep dipping is the scenario that begins by training everyone, whether they need to use the technique in the near future or not, and then holding them accountable for using the process or technique. Sheep dipping almost never works for implementing major cultural changes, for example the surgical checklist, because training never changes how people perceive positional power.

The result of the pilot process was incredible (if they were not, the book probably would not have been written). What I found interesting was despite the great results, there was still skepticism about what was the cause of the the impact. Was the effectiveness an artifact of of team communication and team satisfaction as the report stated, or some other unmeasured attribute? In process improvement, questions like this can often lead to paralysis, which will cause the change to fail. However, the skepticism was somewhat shallow, even though 20% of a post-pilot survey were skeptics, 93% would want the checklist used if they were to have surgery done on them.


We have three or four more weeks left in this re-read, which means it is time to start soliciting ideas for the next book. To date, Sandeep Koorse has suggested Charles Duhigg’s The Power of Habit and Steven Adams has suggested Bad Blood – SECRETS AND LIES IN A SILICON VALLEY STARTUP. What are your suggestions? I will run the poll in two weeks!

Remember to buy a copy of The Checklist Manifesto and READ along!

Previous Installments:

Week 7 – The Checklist Factory

Week 6 – The First Try

Week 5 – The Idea

Week 4 – The End Of The Master Builder

Week 3 – The Checklist

Week 2 – The Problem With Extreme Complexity

Week 1 – Approach and Introduction