Since Fading importance and the utility of lists, I decided to re-read the Checklist Manifesto by Atwal Gawande, and while checklists are not exactly the same thing as jotting down various observations and happenings, they do both share a commonality, after all its in the name. 

I'm intrigued by the utility of lists mostly for their cognitive and psychological benefits, as I have previously described, and checklists help in this respect to, however, they also provide a rigorous means to enforce quality through consistency, particularly when following or responding to the need for a sequence of necessary actions to be taken.

What is clear is that the quality of simple solutions can be improved by reducing the flaws inherent in remembering the minimum necessary steps through this externalization, i.e by using checklists to combat the distractions that can lead to these flaws. By externalizing necessary information into checklists, the enforcement of thoroughness is also ensured. 

These flaws that we seem to have, appear to be centred around the difficulty in being always disciplined, always detailed and paying attention - forgetfulness, distractions and boredom are human nature. 

An interesting distinction made in the book is what constitutes types of complexity that cause us to have difficulty in maintaining the level of discipline and thoroughness required when interpreting them. 'Complicated' problems or solutions are deemed to be repeatable, i.e once they are defined, they do not fundamentally vary and are often built upon simpler well-defined problems. They may however manifest in varying circumstances however, but essentially they are based on well-defined principles. Complicated problems are complicated because they require the management of many well-defined ideas in new and novel ways. Building a robot that can skip or juggle, is complicated, and so are various math problems. They vary, but they are all well-defined never-the-less.

'Complex' problems or solutions however are unique and individualized and cannot be repeated verbatim and require improvisation and experience to deal with. The example given in the book is that of raising children, no one child is the same as another and the complexity of an individual scenario is specific to that individual. I guess some examples would include overcoming one's own fears or reasoning about the unknown, possibly even devising a strategy to run faster, despite having been involved in a running accident. Overcoming and devising a strategy that's variable and specific to you, is not likely repeatable and general enough for others. If it is, then it is likely more in the realm of being a 'complicated' problem. This was quite interesting.

The coordination of seemingly large complicated work, correctly applied can be found in the execution and coordination of checklists at the basis of such work, to provide the core discipline required to manage and verify that the work is carried out thoroughly and without missing vital components required for producing quality, consistent results.

It appears that when checklists are used to ensure consistency and rigour, they improve quality. 

In these complicated work scenarios, an approach that seems to yield success is the stacking up of checklists upon checklists that define the execution of a series of fields of disciplines or work, that are then used to bring together a final aggregate or composite result - much like the building industry is composed of structural engineering, safety, building, design, materials etc. Put all these fields together using checklists to ensure they are rigorous in their quality and execution appears to help produce a coherent outcome in the face of multiple fields of combined complexities. However, it also appears that there are usually occasions, perhaps inevitably, where conflicts result, despite each field being rigorous and producing quality isolated results.

Modelling these situations and testing can be useful in reviewing conflicts. More interesting is that communication about the conflicts is presented as the means by which problems that inevitably result, are resolved through expert collaboration of the various fields. The example in the book is that of a 'submittal schedule' which upon detecting conflicts (by modelling the combination of incoming fields of work), coordinates which experts from the various fields that are part of the resulting conflict need to discuss the reasons and the possible resolutions in order to move forward with the next piece of scheduled work.

This collaboration in the face of complexity is an essential idea because it allows problems to be offloaded to various minds that can come up with a resolution. In A software engineering process for delivering software, I spoke about the burden that individuals have to solve problems, which are relieved by the spreading out of the problem across experts. Indeed, it appears that this is how many complicated processes that is engineered today are being rationalized in the face of complexity. The construction industry is one case in point. Possibly there is the application of these ideas in both Medicine and Software Engineering. 

In summary, the humble checklist provides a means to:

  • simplify complicated situations by ensuring necessary but crucial and critical steps are not missed or not considered.
  • combat human cognitive flaws such as forgetfulness, distraction, boredom and lack of discipline
  • enforce rigour and thoroughness, thereby improving quality and consistency
  • allows seeing problems/conflicts as you design checklists to address them
  • ensure work is applied correctly

There are some other interesting ideas that pertain to the utility of checklists too. Spreading the complexity of discovered problems (when combining checklists with submittal schedules) reduces the burden that individual has to make correct judgements and avoids mistakes in any one individual judgement when coming up with new solutions. This shows that collaboration is key in dealing with complexity.

Another important message is that measuring progress is important and setting a unified goal among many and then allowing multiple individuals to act autonomously to bring about achieving this goal, spreads the cognitive load and empowers people to do what they feel they can, i.e bring their own individualized expertise to the problem. 

So while individual autonomy is important, having it within a group of like minded-goal-oriented experts, is likely to reduce the cognitive load on any one individual. Embracing a culture of teamwork and discipline is also likely to produce quality results including increased communication and it is vital to clear any confusion throughout the team, regardless of how long it takes. 

Furthermore, checklists can be seen as an instrument that makes reliable management of complexity a routine exercise.  The complexity that is routinely managed is arguably simplified. 

A useful and effective mechanism is a change-of-behaviour delivery vehicle. This was shown in the distribution of soap in India in combination with a checklist that describes the minimal necessary steps to wash effectively. Making people like the product such that they prefer to use it, can very much help your cause, particularly if it's related to your cause. This is vital perhaps in establishing effective and useful research outcomes, for example.

Anything that makes something systematic improves its rigour and quality. Checklists are an example of this idea, but they are also a useful means to make priorities clear and explicit.  

When constructing a checklist, it should be brief and focus only on the 'killer items' in such a way that if the item was removed, it might be as critical as potentially killing someone - in relation to the criticality of the subject matter that the checklist pertains to. In this way, is recommended that they be between 5 to 9 items and hold only the minimum necessary but critical items. Detail is not required, fundamental, broad, non-difficult but killer items are, and these are often obvious but deviously elusive at times - and this is what makes checklists difficult to construct or appreciate but these are what make checklists effective, not only in emergencies or under dire distractions but when human senses are dulled perhaps by boredom etc.

Equally important is that the difficult concepts aren't usually good candidates for inclusion in a checklist, but more often it is the simpler, fundamental ideas that cannot be skipped that are. The difficult or hard things, or indeed the detailed things are likely to be what is expected by the expert to deal with or improvise at the time it occurs. In this way, unlikely, variable or non-consistent items should be considered as likely adding more items that are strictly necessary for the checklist. 

Another interesting concept is that simulation provides the needed practical testing for checklists, as checklists are expected to evolve over time and require frequent revisits and tuning. In testing a checklist, the effectiveness needs to be measured, such as asking or determining what will constitute a failure, for which the checklist is trying to reduce/prevent. This can help tailor the checklist when evaluating its performance against this measure.

General or the genericity of checklist items are favoured over specific, variable and ambiguous items. 

Checklists are likely useful in situations where 'process' is largely inconsistent, likely due to routine improvisation by experts. This is arguable a burden to experts and can be what they might perceive as negative to experts who feel it diminishes their utility to assess and deal with circumstances as they arise - i.e it affects their ego.  

Equally, adding a checklist to facilitate one's own expertise and experience is likely to be useful, however, one needs to overcome the idea that checklists are uninteresting, obvious and boring and more importantly impinge on our sense of capability and ego to require them. However, checklists are a tool to enforce quality, consistence and discipline - they do not provide experience or improvisation as experts do.








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