The Checklist Manifesto book summary by Hue Chen

The Checklist Manifesto is a book written by Atul Gawande, a surgical doctor. A checklist is the simplest, most effective way to improve KPIs. The book starts of a little slow but really picks up steam by chapter 3. I would suggest all managers and directors to read it. The book was suggested to our team by Jennifer Berkowitz, our Scaling Up coach.

Simple Truths

• The human memory is not perfect, especially when it comes to routine tasks; it's easy to forget to do something you normally do if an unusual event occurs (ie: you're grocery shopping, you get an unexpected call, and you forget to purchase an ingredient for a recipe.)
• If you adamantly follow a checklist, recipe, standard operating procedure, set of instructions, etc., you are far less likely to make mistakes.
• "Master Builders" / "Master Craftsmen" are a supreme, all-knowing expert with command of all existing knowledge. They are very rare and extremely hard to replicate efficiently. Antoni Gaudi and the Sagrada Familia is one example. Jean de Chelles who built Notre-Dame Cathedral is another. William Thornton, the first architect of the US Capital Building is yet another example. You can replicate a Master Builder through a series of coordinated checklists done by several experts of more narrow fields (ie: master electrician, master plumber, master concrete, etc.)
• Decentralized decision making, when done right, can be much more effective than the old "Command and Control" model. Pushing power and decision making down to where the actual activity is, results in fast and more relevant decisions.
• We rarely investigate our failures in most Industries

Goals

• Surgeons: Avoid making simple mistakes that may cause severe complications or even death. Save patients with only minutes to live, by having a team of medical professionals all on the same page as to what needs to be done.
• Airplane Pilots: Avoid making simple mistakes that could cause the aircraft to crash. Safely land an aircraft during an emergency when there are only minutes to make a decision.
• Restauranteurs: Insure that consistent, high-quality food and service is being delivered to customers at all times.
• Investment Real Estate: Maximize the chance of a successful investment by removing the emotional decision making any instead relying on an objective comprehensive checklist that insures that all aspects of an investment have been investigated and documented.
• Retail leasing: Increase the time to lease when taking on a new project by insuring that all of the steps in a successful leasing campaign have been executed on a timely basis.
• Property Management: Insure that all tasks and problems are addressed in a consistent manner that adheres to best practices following a process that satisfies the owner.

Checklist Creation

• Determine if you are creating a "read-do" checklist or a "do-confirm" checklist. If the issue is not extremely time sensitive, then a "do-confirm" checklist will likely be used.
• Keep the checklist to 5 to 9 items. If you need many more items, consider breaking up the action items into multiple checklists with a "pause" in-between each to review what had already been done and what needs to be done.
• Use simple wording and try to fit on 1-sheet of paper.
• Good checklists are easy to use and precise.
• List the minimum steps necessary. The ones that must be done 100% of the time.

Examples in from the book

Boeing

• Boeing in 1935 was competing to be one of the US Army's contractor for the next gen long-range bomber.
• Their Model 299 was heavily favored and it was being tested by Major Hill, a very experienced test pilot.
• This plane was much more complex that prior models. During take-off, the pilot forgot to release a new locking mechanism on the rudder controls. This caused the plan to stall at 300 feet turn on 1 wing and crash.
• The US Army ordered their planes from Douglas, however, they knew that the Boeing plane had superior engineering and ordered a few of their planes to see if the issue was "operator error."
• The US Army created a checklist for the Model299's more advance operating system, after which a total of 1.8 million miles were flown without an incident and subsequently 13,000 planes were ordered.

World Health Organization's Surgical Safety Checklist

• Before this checklist was created the global rate of major complications from surgeries was estimated to be between 3% and 16%. Postoperative infection rates as high as 20% in some hospitals. There was a wide variation between safety standards.
• 8 hospitals participated in a study in order to help create and determine the effectiveness of the checklists. St. Mary's Hospital (London), Toronto General, University of Washington Medical (Seattle), Prince Hamzah (Jordan), Auckland City Hospital (New Zealand), Philippine General, St. Stephen's Hospital (New Delhi), Ifakara Hospital (Tanzania)
• The results were very clear after the checklists were implemented. Statistics below.
• St. Mary's Hospital (London England) - Major complication 11% >>> down to 7% | Death Rate 1.5% >>> down to 0.8%
• University of Washington Medical Center (Seattle, USA)- Major complication 11% >>> down to 7% | Death Rate 1.9% >>> down to 1.4%
• Prince Hamzah Hospital (Amman, Jordan) - Major complication 7% >>> down to 4% | Death Rate 2.2% >>> down to 0.8%

Overall Results from All Hospitals - Major complication 11% >>> down to 7% | Death Rate 1.5% >>> down to 0.8%

• Given the total number of patients per year are over 200 million, each 1% represents 2 million people!!! This is a huge difference.
• Naturally surgeons were the "king of the operating rooms" and some were reluctant to use the checklists, but by empowering the nurses to hold all stake holders accountable, that provided enough checks and balances or second set of eyes to make a monumental difference in millions of patients world wide.

Hurricane Katrina

• The Levees: It is widely known how poorly the levees were maintained. Having a good checklist system and regular inspections could have identified weaknesses in the system and address the issues promptly.
• After the disaster: It took several days for government agencies and FEMA to respond due to poor communications that was a result of damage to cell towers. There was also bureaucratic challenges in the "Command and Control" model of the government that delayed help even more.
• Walmart, on the other hand, quickly responded to the disaster within hours of the hurricane making landfall. They were mobilized and it's logistics network were ready to respond. They had pre-existing disaster plans and had positioned supplies and trucks in strategic locations before the hurricane hit. Their decentralized decision-making structure also allowed local managers to act swiftly without waiting for corporate approval.
• Lee Scott, CEO of Walmart at that time said to his employees:

"A lot of you are going to have to make decisions above your level. They may not always be the right decisions, but make decisions, and above all, do the right thing.”

Concepts from the book

Types of problems in this world: the simple, the complicated and the complex.

1. Simple problems. These are problems that require a set of skills and techniques to be solved – but once you’ve acquired those skills and techniques, the process becomes automatic. A great example is any cooking recipe.
2. Complicated problems. There is no clear instruction to solve these; usually, they require a group of people. However, once you’ve figured a complicated problem out,? you can use the algorithm again. Example – sending a rocket to the moon.
3. Complex problems. These include problems the outcomes of which are very uncertain because there are too many factors you cannot control. Example – raising a child.

• Checklists give power to those who don't have it (ie: an admin may have the right to challenge a director if a checklist item has not been addressed.)

• Activation Phenomenon: “The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an ‘activation phenomenon.’ Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up

• Behavior change delivery vehicle: Van Halen famously required there to be a bowl of M&Ms backstage with all of the brown M&Ms removed. When asked later, this was a checklist item that strongly correlated with how well or poorly a venue would prepare for their shows. For example, if the M&Ms were not properly delivered, it was highly likely that the venue did not check if the stage could handle the weight of the equipment or other critical matters.

The Karachi Soap Study:

• Background: In Karachi, a team of researchers from Procter & Gamble was studying ways to reduce the spread of disease in poor, densely populated areas. They focused on diarrheal diseases, which were a significant health issue in the region, particularly among children.
• The Study: The researchers conducted a study where they provided households in Karachi with bars of soap and educated them on the importance of handwashing. The soap itself was a basic item, but the intervention included showing people when and how to wash their hands properly, such as before eating and after using the toilet.
• Results: The results were remarkable. The incidence of diarrheal diseases among the households that received soap and education dropped significantly—by over 50%. This simple intervention, which cost very little, had a massive impact on public health in the area.

Lesson from the Karachi Soap Story:

Gawande uses this story to emphasize how simple, low-tech solutions—like a bar of soap—can have profound effects when used correctly. Just as checklists can standardize practices and prevent errors in complex environments, basic hygiene practices can drastically improve health outcomes, especially in resource-limited settings.

The Karachi soap story illustrates that sometimes the simplest tools, when applied with consistency and understanding, can lead to significant improvements. It also underscores the importance of implementation—knowing when and how to apply simple solutions can be as crucial as the solutions themselves.

Conclusion by Hue Chen

For Saglo, who owns shopping centers across multiple states, for us to continue to grow and scale we will need to insure that the work being done at the properties have the quality of a master craftsman taking into consideration leasing, property management, accounting and capital markets all at the same time. With today's communication and checklist technology, we can bring multiple experts in their respective field in in order to obtain the results of a master craftsman. The creation of great checklists that address all of the critical tasks will be a strategic initiative that improves our company.