A compelling exploration of a simple—and well-proven—solution to complex problems
The modern world has given us stupendous know-how. Yet avoidable failures continue to plague us in health care, government, the law, the financial industry—in almost every realm of organized activity. And the reason is simple: The volume and complexity of knowledge today has exceeded our ability as individuals to prop- erly deliver it to people—consistently, correctly, safely.We train longer, specialize more, use more advanced technologies, and still we fail. Acclaimed writer and surgeon Atul Gawande
makes a compelling argument that we can do better, and finds a solution in the most humble of places: the lowly checklist. Four generations after the first aviation
checklists went into use, a lesson is emerging: Checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cog- nitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities. But they have limits, as well. So a key step is
to identify which kinds of situations checklists can help with and which ones they can’t. Twoprofessors who study the science of com-
plexity—Brenda Zimmerman of York Univer- sity and Sholom Glouberman of the University ofToronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex. Simple problems, they note, are ones like baking a cake from a mix. There is a recipe. Sometimes there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success. Complicated problems are ones like sending a
rocket to the moon. They can sometimes be bro- ken down into a series of simple problems. But there is no straightforward recipe. Success fre-
quently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent.Timing and coordination become serious concerns. Complex problems are ones like raising a
child. Once you learnhowto send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the profes- sors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expert- ise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely dif- ferent approach from the previous one. And this brings up another feature of complex problems: Their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all. We are besieged by simple problems.Muchof
the most critical work people do, however, is not so simple. Plus, people are individual in ways that rockets are not—they are complex. The quest of when to follow one’s judgment
and when to follow protocol is central to doing the job well—or to doing anything else that is hard. You want people to make sure to get the stupid stuff right.Yet you alsowant to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along theway. The value of checklists for simple problems seems self-evident. But can they help avert failure when the problems combine everything from the sim- ple to the complex? I came across an answer as I was just strolling down the street one day.
ON_THE_WEB: Atul Gawande is a MacArthur Fellow, a general and endocrine surgeon at the Brigham andWomen’s Hospital in Boston, and an associate professor at Harvard Medical School and the Harvard School of Public Health, as well as a staff writer for The NewYorker. Read his articles at http://gawande.com.
Metropolitan Books Henry Holt and Company LLC, 2009
MORE FROM THE BOOK: Surgery has, essential- ly, four big killers wherever it is done in the world: infection, bleeding, unsafe anes- thesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightfor- ward and valuable pre- ventative measures we think we consistently follow but don’t. These misses are simple fail- ures — perfect for a classic checklist.