A checklist for checklists

It’s easy to say, “Make a checklist for your complex process and use it”. It’s another thing altogether to actually make a checklist that is good and that works.

One of the things that I like most about The Checklist Manifesto is that it recognizes and addresses the challenges inherent in designing a good checklist. In fact, a good part of the story revolves around making the WHO surgical checklist a good one. In the acknowledgements section of the book, Gawande credits Boeing engineer Dan Boorman (who is also mentioned in the book) as an “essential partner” in the ongoing development of new checklists, and from the looks of it they’ve been hard at work.

Most relevant to my ongoing thread here is the Checklist for Checklists, pictured below. If you have decided that checklists can help you, this is an excellent place to start as you begin the process of developing your checklists.

Simplifying the execution of complexity

My review of Atul Gawande’s latest book The Checklist Manifesto focused, by design, on the broad scope of the book. Within that “big picture” lesson, though, are many smaller, more specific lessons to be learned.

For example:

No, the real lesson is that under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either – that is anarchy….

[U]nder conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided – and even enhanced – by procedure.

During this discussion, he refers back to what he had learned from the skyscraper-building industry, that they had figured out how to put an understanding of complexity into a series of checklists. That they had, in Gawande’s words, “made the reliable management of complexity a routine.”

What makes this even more fascinating is how the checklist, the lowly checklist that Steven Levitt had no interest in (until reading this book), can help simplify the execution of complexity even when the team members have never before worked together.

Just think what they could do for a team that works together all the time.

Navigating complexity with checklists (a book review)

Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right is an incredible book that I highly recommend to anyone that works in a complex environment, especially if that involves working with multi-discipline teams. And most especially if this involves frequently working with people you have never worked with before.

I picked the book up not really knowing what I was in for. Talking about checklists, I thought maybe it would be a discussion of how to document and implement best practices, or something similar. Boy was I wrong.

At the surface, the book is the story of how Gawande, as part of a World Health Organization initiative to reduce surgical complication rates around the world, discovered the power of checklists to help avoid “avoidable failures.” Looked at more closely, it is a study of the importance of team building, team work, and communications between team members as they tackle the complex problems we all face today.

The first chapter, titled “The Problem of Extreme Complexity”, sets the stage. Later chapters build on this problem statement and uses examples from many diverse fields including aviation, construction, ¬†and the operations of corporations and government. The common thread through each of these examples is the checklist – the lowly, simple checklist.

The challenges face by Gawande and the WHO team were (are) two fold: figuring out how to take what worked in these other industries and translating it into the needs of the surgical community; and getting past the culture of surgery and surgeons. The former was a relatively simple matter of trial and error, see what works and give it a try (in simulation first, where possible). The latter, on the other hand, remains a significant issue.

Part of the resistance is, according to Gawande, a misconception about what checklists are and the purpose they serve. This is a lesson he learned as he worked with engineers from Boeing in trying to understand what makes a good checklist:

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plan out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives.

As a systems engineer I recognize many of the issues, challenges, and solutions that Gawande discusses in the book. I was (am) quite appalled at how little of this systems type thinking seems to exist in the world of surgery and am quite hopeful that the idea of checklists catch on at all hospitals. If I ever have to go in for surgery, one of the first questions I ask the surgeon and his team is going to be, “Do you have a checklist prepared for this procedure?”

Perhaps the greatest insight about checklists in the book is that checklists – a lowly, simple, well crafted checklist – can take a group of individual experts and quickly turn them into an expert team.

All you have to do is use it.

Update: For more on the book, links to various media interviews, and some examples of effective checklists, visit Atul Gawande’s website.