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Using checklists to deal with the unexpected
January 2nd, 2012 by Joca

I mentioned earlier about “The Checklist Manifesto” book. The post was originally written in Portuguese but you can find a Google translation here. In this post I mentioned about the use of checklist in surgeries and other medical procedures and how we could use checklists in the IT environment.

I was reviewing my Kindle highlights for this book and found this highlight:

Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures — perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them.

But the fourth killer — the unexpected — is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together — to be ready as a team to identify and address each patient’s unique, potentially critical dangers.

Dr. Gawande found out that in order to address the unexpected, checklists should not only include task checks but also communication checks. Dr. Gawande got to that conclusion visiting a 700,000-square-foot office and apartment complex construction site with between two to five hundred workers on-site on any give day managed by a man called Finn O’Sullivan. The volume of knowledge and degree of complexity O’Sullivan manages is impressive and it was as monstrous as anything Dr. Gawande had encountered in medicine. Here’s the explanation:

It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another — on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction — who had to share (or “submit”) particular kinds of information before the next steps could proceed.

The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.

So next time you design a checklist, remember to include not only task checks but also communication checks.

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