CHECKLIST

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. Some-
times 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
broken down into a series of sim- ple problems. But there is no straightforward recipe. Success
frequently requires multiple people, often multiple teams, and specialized expertise.
Unanticipated difficulties are frequent. Tim- ing and coordination become serious concerns.

Complex problems are ones like raising a child. Once you learn how to send a rocket to the
moon, you can repeat the pro- cess with other rockets and perfect it. One rocket is like another
rocket. But not so with raising a child, the professors point out. Every child is unique. Although
raising one child may provide experience, it does not guarantee success with the next child.
Expertise is valuable but most certainly not sufficient. nd 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.

You want people to make sure to get the stupid stuff right. Yet you also want to leave room for
craft and judgment and the ability to respond to unexpected difficulties that arise along the way.
The value of checklists for simple problems seems self- evident. But can they help avert failure
when the problems com- bine everything from the simple to the complex?

The philos- ophy 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 one another and take responsibility. That is what works.

The strategy is unexpectedly democratic, and it has become standard nowadays

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol,
specialized ability and group collaboration.

And for checklists to help achieve that balance, they have to take two almost opposing forms.
They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they
supply another set of checks to ensure people talk and coordinate and accept responsibility while
nonetheless being left the power to manage the nuances and unpredictabilities the best they know
how.

EJEMPLO: the experience of Columbus Children’s Hos- pital, which had developed a checklist
to reduce surgical infec- tions. Infection is one of the most common complications of surgery in
children. And the most effective way to prevent it, aside from using proper antiseptic technique,
is to make sure you give an appropriate antibiotic during the sixty-minute window before the
incision is made.

he hospital’s director of surgical administration, who hap- pened to be not only a pediatric
cardiac surgeon but also a pilot, decided to take the aviation approach. He designed a preincision
“Cleared for Takeoff” checklist that he put on a whiteboard in each of the operating rooms. It
was really simple. There was a check box for the nurse to verbally confirm with the team that
they had the correct patient and the correct side of the body planned for surgery—something
teams are supposed to verify in any case.

Some time after that first miserable try, I did what I should have done to

begin with. I went to the library and pulled out a few articles on how flight checklists are made.
As great as the construction- world checklists seemed to be, they were employed in projects that
routinely take months to complete. In surgery, minutes mat- ter. The problem of time seemed a
serious limitation. But aviation had this challenge, too, and somehow pilots’ checklists met it.

Good checklists, on the other hand, are precise. They are effi- cient, to the point, and easy to use
even in the most difficult situ- ations. They do not try to spell out everything—a checklist cannot
fly a plane. Instead, they provide reminders of only the most crit- ical and important steps—the
ones that even the highly skilled professionals using them could miss. Good checklists are, above
all, practical.

The power of checklists is limited, Boorman emphasized. They can help experts remember how
to manage a complex pro- cess or configure a complex machine. They can make priorities clearer
and prompt people to function better as a team. By them- selves, however, checklists cannot
make anyone follow them.

Pilots nonetheless turn to their checklists for two reasons. First, they are trained to do so. They
learn from the beginning of flight school that their memory and judgment are unreliable and that
lives depend on their recognizing that fact. Second, the check- lists have proved their worth—
they work. However much pilots are taught to trust their procedures more than their instincts,
that doesn’t mean they will do so blindly. Aviation checklists are by no means perfect. Some
have been found confusing or unclear or flawed. Nonetheless, they have earned pilots’ faith.
Face-to-face with catastrophe, they are astonishingly willing to turn to their checklists.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a
DO-CONFIRM checklist, he said, team members perform their jobs from memory and
experience, often separately. But then they stop. They pause to run the check- list and confirm
that everything that was supposed to be done was done. With a READ-DO checklist, on the other
hand, people carry out the tasks as they check them off—it’s more like a recipe.
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine
items, which is the limit of working memory.

The wording should be simple and exact, Boorman went on, and use the familiar language of the
profession. Even the look of the checklist matters. Ideally, it should fit on one page.

We made it speedier. We adopted mainly a DO-CONFIRM rather than a READ-DO format, to

give people greater flexibility in performing their tasks while nonethe- less having them stop at
key points to confirm that critical steps have not been overlooked. The checklist emerged vastly
improved.

We made it speedier. We adopted mainly a DO-CONFIRM rather than a READ-DO format, to

give people greater flexibility in performing their tasks while nonethe- less having them stop at
key points to confirm that critical steps have not been overlooked. The checklist emerged vastly
improved.

This proved the most difficult part of the exercise. An inher- ent tension exists between brevity
and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too
much in and the list becomes too long to use. Furthermore, an item critical to one expert might
not be critical to another.