nancylebov (nancylebov) wrote,

A sense of process-- The Checklist Manifesto

In my previous post, I was complaining about people who expect things to go right just because they have an idea that things going right ought to happen. by Atul Gawande was a real pleasure to read because he doesn't have that delusion.

He talks about the complexity of medical care, and the disasters which result or nearly result because obvious, standard methods aren't used to prevent them. The problem is that obvious is in the mind of the beholder, and there's a limit-- a fairly low limit-- of how much people can remember to do in complex, urgent situations.

Instead of going at it with the idea that the medical profession is just awful, he looks at the power of checklists to function as an external memory. He then discovers that you can't just make up a checklist and have it work because checklists are good.

Developing a usable checklist for a group of people doing something complex can't be done off the top of your head or entirely by theory. It takes hard thought and meticulous testing and judgement calls.

And once he had a promising checklist, he didn't say checklists are good, and hospitals are bad for not using his lovely checklist. It was a non-trivial chunk of work to carefully introduce his checklist to 8 assorted hospitals (all over the world, and in situations ranging from wealthy to very poor) for testing.

Checklists for groups require social engineering-- it's essential for low status people to be able to tell high status people that something was missed, and be heard and obeyed. Surprisingly, it turns out that just having people introduce themselves to each other at the beginning is very helpful.

The checklist caused a substantial drop in complications in all the hospitals-- a double-digit drop in 7 out of 8.

Checklists are pervasive in the building trades, not just to make sure all the usual things are done, but to make sure that if modifications are needed (this is very common), all the relevant people sign off on them.
The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to each other and take responsibility. That is what works.

The result is unexpectedly democratic, and it has become standard nowadays, even in building inspections. The inspectors do not recompute the windforce calculations, or whether the joints in a given building should be bolted or welded, he said. Determining whether a building like the Russian Wharf or my hospital's new wing is built to code and fit for occupancy involves more knowledge and complexity than any one inspector could possibly have. [Note: this is just about the plans, it doesn't cover actually looking at the physical construction.] So although inspectors do what they can to oversee a building's construction, mostly they make certain the builders have the proper checks in place and then have them sign affidavits that they themselves have ensure that the building is up to code.

Gawande goes on to explain that the best rescue work after Katrina was done by organization which permitted people on the ground to make decisions, and the worst was done by those which retained centralized control, with examples from business and government on both sides.

This may be an oversimplification-- iirc, there were some very bad localized decisions made by police.

However, it's very tempting for some people to say that all of business is wicked because it's profit-driven, and only tight regulations will lead to decent treatment of employees and customers. There are others (more like me than the first batch) who will say that government is wicked because it's all arbitrary authority.

The truth as far as I can tell is that quite a high proportion of people want to do good work if they're in an environment which permits it, and what creates that environment isn't obvious. You can't make people want to do well through rewards and punishments, and to much emphasis on reward and punishment just distracts them.

Oh, well, back to Gawande-- he's also got a detailed description of the cooperation needed to land that plane safely on the Hudson, and how the media tried to make it into a one-hero story, and somewhat about how a few successful high-end investors make good use of checklists.

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