The Power of Checklists

by Ahmed Humayun

71CwWiCJhuLIn The Checklist Manifesto – How to Get Things Right (2009), Atul Gawande – surgeon, Harvard professor, and New Yorker staff writer – recommends the strategic use of checklists to manage complexity. Gawande notes that while most domains of human activity in the modern era have witnessed a striking expansion in knowledge, it has become more and more difficult to apply this knowledge effectively. Through carefully chosen case studies and anecdotes, and a bevy of facts and statistics, Gawande persuasively demonstrates how an ostensibly simple tool like the checklist has substantially reduced avoidable errors and increased successful outcomes across any number of critical industries, including surgery, construction, aviation, disaster management, and investment management.

Today, highly complex projects straddle multiple specialized disciplines and involve many different individuals and teams. We inevitably miss key steps in addressing difficult challenges, due to limited memory, faltering attention, poor communication, unforseen events, or other factors. In effect, while we know a lot more today, we often don't apply our knowledge effectively. Therefore, we are constantly faced with avoidable errors in fields such as surgery, disaster management, software design, intelligence failures, and finance – indeed, in any area of human endeavor that requires the quick application of enormous knowledge to challenging problems with uncertain outcomes.

Checklists provide an effective method for avoiding error. They trigger the right action by the right person at the right time. Effective checklists activate the specialized knowledge most applicable at a particular point in time, and optimize communication between different sets of specialists. In this way, checklists help avoid one of the principal challenges of modern organizations: the ‘silent disengagement' that results when specialists only keep their narrow tasks in mind instead of focusing on broader team or organizational outcomes.

In advocating for the checklist, Gawande is not minimizing the importance of human discretion. On the contrary: in conditions of uncertainty – when a surgeon is operating on a patient, or a building is being constructed, or a venture capitalist is picking an entrepreneur to back – human judgment is vital. The goal of the checklist is not to eliminate discretion but to help ensure the optimal mix of procedure and discretion. Gawande notes that good checklists help balance competing principles: freedom and discipline, craft and protocol, specialized ability and group collaboration.

Some industries excel at using checklists to execute highly complex projects. For example, in the construction industry, a construction schedule contains a detailed, daily list of all the tasks that need to be executed including any dependencies. A second checklist, called a ‘submittal schedule', specifies communication tasks. This list ensures that different specialists speak to each other at critical stages and factor in any unforeseen events that have arisen. Specialists from 16 different fields, each dealing with some aspect of architecture, engineering or building, come together to build these two lists, which have an excellent record in achieving construction objectives.

In a riveting account, Gawande discusses his experience helping the World Health Organization develop a surgery checklist that has led to drastic improvements in high and low-income countries. A wide range of metrics improved after the implementation of painstakingly devised checklists, including decreases in infections, deaths, and major surgical complications.

Gawande has much to say about decision making in the modern organization. A key theme is that in conditions of extreme uncertainty, there tends to be information overload and an overwhelming number of decisions need to be made. In such conditions, a centralized command-and-control approach is ineffective. Organizations should therefore decentralize power, empowering agents and employees on the front lines to make decisions and generate solutions.

For example, Gawande shows how FEMA's failures in the aftermath of Hurricane Katrina stemmed from an overly centralized system in which key tasks, from the delivery of water and food to the requisition of buses, were not executed due to decision making bottlenecks. By contrast, Walmart was able to successfully respond to the crisis through its nimble, decentralized decision-making structure. Senior Walmart executives issued limited instructions, focusing instead on establishing goals, evaluating progress, and instituting checks to ensure constant communications across the team and with applicable agencies. This simple approach led to early and significant successes in the provision of water and emergency supplies, the setting up of mobile pharmacies, and the opening of temporary clinics.

Through his own experiences and other insightful case studies, Gawande identifies the core principles of an effective checklist. A good checklist is precise, to the point, and easy to use. Instead of spelling out everything that needs to get done – an impossible and counterproductive objective – a checklist contains reminders of the most important steps. Ideally, it will consist of somewhere between 5 and 9 items, live on a single page, and pertain to a discrete topic. Checklists cannot simply be copied and pasted from one situation to another. An effective checklist codifies empirically derived knowledge, while accounting for the distinct circumstances of the immediate use case and unforeseen events.

If the wisdom of using the checklist seems obvious, Gawande makes clear that it is far less prevalent than we might imagine. Historically, as a culture we have venerated the lone genius, the master of the domain, who designs, plans, and oversees all aspects of a great project from start to finish. But this is an increasingly impossible model to implement today. Few individuals, no matter how talented or experienced, can master all the intricacies involved in executing a life-saving surgery or constructing a skyscraper.

Devising effective checklists requires recognition that the collective wisdom of specialized teams closest to the problem, communicating closely and responding dynamically to fast-changing events, is superior to dictates from a centralized authority. It requires iterative work by many people dispersed across multiple disciplines to identify the most significant task and communication checks across hundreds or thousands of individual actions. Gawande's book is a powerful wakeup call for the modern organization to systematically use the checklist in addressing complex problems.

Ahmed Humayun is a nonresident senior fellow at the Atlantic Council in Washington, D.C.

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