Handling Complexity: The Checklist Manifesto for Professional Services

I just finished reading Atul Gawande’s The Checklist Manifesto – a book that has been sitting on my kindle for an embarrassing amount of time, but which I put off because I thought reading the New Yorker article was enough.  I was wrong: this is one of the most important books I’ve read for thinking about ways to improve professional practices.

Gawande tells the story of the WHO’s Safe Surgery Checklist, a tool that, among other things, reduced infection and patient mortality by half in its pilot phase.  If it was a drug or medical device, we’d be heralding it as a breakthrough, yet it costs almost nothing to implement.  But the real story of the checklist isn’t about the tool itself, it’s about the culture change that’s required of a profession when increasing complexity makes it too difficult for a single person to know everything required to succeed, and instead need to rely on process, communication, and coordination.  By looking at physicians, construction engineers, and most importantly, pilots, Gawande is able to show the way a simple checklist can help a profession adapt and eliminate error in the face of exponentially increasing complexity.

In a Complex World, Expertise And Talent Aren’t Enough

Many of today’s professions are already facing this transition.  Across a variety of fields, the professional body of knowledge has increased, leading to specialization where we used to rely on generalists.  PR firms now employ designers, web developers, digital marketing experts, and researchers.  Complex litigation requires attorneys, technologists, a variety of experts, administrative specialists, para-professionals, and some of role to tie them together.  We’re increasingly moving towards a world where the individual rock-star is less important than the system in which he or she operates.

Changing Our Professional Culture

This transition can be scary for the professionals involved.  It’s threatening to have your expertise reduced to a list of bullet points, or to formalize what many see as expertise they’ve developed through years of training and professional experience.  There are nuances a checklist can never capture.   There’s a great deal of prestige associated in professional work, in part because the practitioner is seen as so important.  And there’s also the threat to our livelihoods: if the process becomes more important than the professional, what happens to our high rates?

But these fears are misplaced.  Standardizing processes is liberating and empowering.  There’s an enormous cognitive burden associated with trying to keep everything in memory.  The checklist frees your mind to concentrate on the sort of complex problem solving that clients really value.  Further, by shifting the focus from people to process, the checklist neutralizes power dynamics that would otherwise hold teams back from functioning effectively.  In the book, Gawande uses the example that the checklist gave nurses permission to make sure doctors carried out important infection reducing steps.

Bottom Line: Checklists Work

I’ve seen the value of checklists first hand, often as a result of the practice optimization workshops I run for clients.  One of the most common root causes we find is that an infrequent missed step, taken over hundreds of projects, causes most errors or rework.  In other cases, important information isn’t communicated to the right people at the right time.  Developing, testing, and actually using a simple checklist not only reduces these issues, but the collaborative process used to develop the checklist improves communication and trust across the entire team.

As Gawande makes clear, implementing a checklist isn’t just about coming up with the right information and putting it on a piece of paper.  It’s about the culture shift that’s required for a profession to adapt to increasing complexity.  In most of the professions, that’s a tough sell.  Nearly a decade after the original article, most areas of medical practice lack basic checklists and controls.  But the practices that take it to heart will have an enormous advantage over those that still try to do things the old fashioned way.

Later this year, our Consummate Professional podcast will discuss the Checklist Manifesto with an emergency medicine physician and a commercial airline pilot to get insights into what these two professions can learn from each other.  If you’re interested, sign up for our newsletter and we’ll let you know as soon as the episode comes out: