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.

3 thoughts on “Navigating complexity with checklists (a book review)

  1. Ah, checklists…one of the most bandied about things in medicine lately.

    Don’t get me wrong, I am mostly in favor of them. It’s just that, like all good things, many times people take things to an extreme when first implementing them.

    Your quote above references lists being “…swift, usable, and resolutely modest…”. When they fulfill these criteria, then they can be very useful, indeed. Sometimes people try to impose overarching lists to cover all possible situations, which results in experienced practitioners (who recognize the inherent relative waste of time of such lists) to not reference them at all.

    I favor a “sensible middle ground”. I think that lists should be introduced when they can be shown to be useful. This means that, like all interventions, they need to be studied.

    As to “getting past the culture of surgeons”, like most “commonly held beliefs” there is some truth there. But it is not a universal truth. And not a wholly unmanageable one.



  2. Ideas are great, but success is all in the execution. One of the things that most impressed me about the book was the amount of time he spent discussing the importance of checklist design. As you say, and they found, checklists that are more instruction or algorithm are next to useless in a complex environment.


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