Complexity and The Checklist Manifesto (book)

I heartily recommend reading Atul Gawande’s new book, “The Checkbook Manifesto.” I’m not alone

In it, Dr. Gawande recounts the birth of the modern formal checklist, developed by the US Army Air Corps (now the Air Force) after the crash of a new four engine Boeing bomber on a test flight in 1935. Flying a four engine plane was so much more complicated than flying a two engine plane that the pilot, the Air Corps’ chief of flight testing, left something out. Like releasing a locking mechanism on the elevator and rudder controls…

Dr. Gawande ascribes the safe landing of US Airways Flight 1549 on the Hudson to the crew’s following their checklists. (BTW, Captain “Sully” Sullenberger does too.) The “hero” was the checklist!

He goes on to describe the checklists used by construction companies in building our enormous shopping centers, hospitals, and the like. No longer do they rely on “Master Builders” keeping everything straight in their heads.

He recounts a study in which Intensive Care Unit patients required an average of 178 individual actions per day, and by and large the doctors and nurses missed only about 1 percent. But that’s two a day…

He then describes in detail how he and a team developed surgical checklists for the World Health Organization, testing them in a handful of hospitals of varying sizes in countries ranging from Canada to Tanzania. The health benefits were enormous across all hospitals.

Dr. Gawande points out that the senior surgeons generally rejected the idea that THEY needed to follow checklists – why, they’d been trained by experts and had years of experience! Yet, shown the results, they admitted that if THEY were the patients, they’d like their surgeons to use checklists, certainly.

The book is hard to put down, and I’m about to write up two checklists showing what to do at our house when we lose internet access. I already use a checklist for closing up our house in West Virginia – but it needs updating. I am sold!

The book has lessons for the design of government as well. Here are the last two paragraphs of his introduction (page 13):

“Here then is our situation at the start of the twenty-first century. We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable errors are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

“That means we need a different strategy for overcoming failure; one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.

“It is a checklist.”

So if complexity is a part of our problem in designing governmental interventions that work, then Dr. Atul Gawande would argue that checklists are part of the solution.

But it is here, as he winds up the book, that he makes the point most relevant to the design of government (page 185):

“We have a thirty-billion-dollar-a-year National Institutes of Health, which has been a remarkable powerhouse of medical discoveries. But we have no National Institute of Health Systems Innovation alongside it studying how best to incorporate these discoveries into daily practice – no NTSB equivalent swooping in to study failures the way crash investigators do, no Boeing mapping out the checklists, no agency tracking the month-to-month results.

“The same can be said in numerous other fields. We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.”

Sounds like he also thinks that the lack of feedback mechanisms is also a problem, doesn’t it?

We can no longer afford the Congressional legislative process described some years ago by then Indiana Congressman (and later President of New York University) John Brademas: “Congress never gets anything right the first time – after five or six years, we have to revisit our ‘solutions’ and correct them.”

In an era of increasingly complex, critical, and urgent problems, that’s simply UNSAT.

I’m starting to think about checklists as part of any “Legislative Impact Statements.” Not rocket surgery, is it?

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