• Introduction: (a) The author refers to an essay by Samuel Gorovitz and Alasdair MacIntyre on the nature of human fallibility and they mention that there are only two reasons why we fail at things which are in our control- one, ignorance and two, ineptitude-i.e. we possess the knowledge, but apply it incorrectly. Ineptitude remains common because know-how and complexity expanded exponentially over the years and has exceeded our individual ability to deliver its benefits correctly. The strategy that the author puts forward to solve for this issue is use of checklists.

  • Chapter 1: The problem of Extreme Complexity: (a) The field of medicine has become the art of managing extreme complexity- WHO has classified more than 13,000 types of diseases, syndromes and injuries; clinicians rely on 6,000 drugs and 4,000 medical and surgical procedures. (b) He gives another example of Harvard Vanguard hospital- an average doctor annually evaluated around 250 different primary conditions and their patients had 900 other active medical problems that needed to be factored in and they prescribed ~300 medications, ordered more than 100 different types of laboratory tests and performed 40 different kinds of office procedures; (c) The field responded to this complexity by having specialisations and when even those became inadequate, the profession further responded with super specialisations; (d) The superspecialisation has substantially improved the surgical capability and success and yet the number of failures in surgical operations remain substantially high.

  • Chapter 2: The Checklist: (a) In 1935, U.S. army bought massive Model 299 bombers (B-17) from Boeing despite it crashing in the initial ‘flight competition’ held by the Army. The crash was attributed to pilot error; these planes were substantially more complex. The solution army came up with was not to require the pilots to undergo training; but to come up with a checklist and requiring the pilots to follow it. The planes completed 1.8 million miles without any incident. (b) In 2001, critical care specialist at John Hopkins Hospital, Peter Pronovost came up with a doctor checklist for avoiding nfections when putting in a central line. The checklist had simple five steps like wash hands with soap, put sterile drapes over entire patient, wear mask etc. In Michigan’s ICUs where this checklist was adopted on a project basis, infection rate decreased by 66%. (c) The author talks of another success story in the use of checklist in surgery for reviving patients from cardiac arrest after hyperthermia.

  • Chapter 3: The End of the Master Builder:

    (a) The common theme in each of the three examples in the earlier chapter is that the problem in each case was a simple one (focus attention on rudder and elevator controls, maintain sterility, be prepared for cardiac bypass). Much of the critical jobs that professionals do are complex. Brenda Zimmerman and Sholom Glouberman who study the science of complexity have proposed three different kinds of problems- simple (eg. following a recipe); complicated (eg. launching a rocket-multiple people, specialised expertise etc; but once done, repeating and perfecting it is doable); and complex (eg. raising a child-each case is unique, outcomes remain highly uncertain). The question therefore is whether checklist can help with complex problems. (b) The author draws inspiration from the construction industry- each building is unique and complex. In the earlier days, there was a master builder who oversaw the architectural design, engineering, construction of buidlings. However, the complexities became overwhelming beyond the capabilities of any single individual that there are now sixteen different trades involved in completing a building. For each building a new checklist is made by coordinating with all major trades involved and any unforeseen development is dealt with by ensuring that the people from relevant fields communicate with each other and sign off on proposed action. Thus there is a separate communication checklist called ‘submittal schedule’ which ensured experts spoke to one another- on X date regarding Y process.The checklist detailed who had to talk to whom, by which date and about what aspect of construction- who had to share (submit) particular kinds of information before the next steps could proceed. Interestingly, the construction industry uses a program called ‘ProjectCenter’ that allows anyone who has found a problem- even a frontline worker- to email all relevant parties, track progress and make sure a check is added to the schedule to confirm that everyone has talked and resolbed the matter. (c) While buildings are increasingly complex, the annual avoidable rate is less than 0.00002%; the major advance in the science of construction over the last few decades has been perfection of tracking and communication. While medicine, despite the complexities, continue to dominated by individual ‘master builders’.

  • Chapter 4: The Idea: (a) The building industry’s strategy for getting things right in complex situations is to give people power. Usually when one talks about checklist, it’s about dictating instructions to the workers to the tiniest details. This centralization of power is often dangerous when dealing with complex and non routine problems. The philosophy should be that you should push the power of decision making out to the periphery and away from the center; you should give people the room to adapt based on their experience and expertise. All that you ask, is they talk to one another, and take responsibility. (b) When New Orleans was flooded, Walmart, issued an edict, which empowered, the people at the store level; The CEO issued a simple instruction.~“This company will respond to the level of this disaster. A lot of you are going to have to make decisions about your level, make the best decision that you can with the information that’s available to you at the time, and above all, do the right thing”~. And this empowered the store managers who began distributing diapers, water and other essentials to the residents. Thus the senior Walmart officials concentrated on setting goals, measuring progress and maintaining communication lines with employees at the front lines. They did not issue instructions to handle the complex situations. All they did was to ensure that people communicated. (c) The real lesson from this is that under conditions of true complexity, where the knowledge required exceeds that of any individual, and unpredictability reigns, efforts to dictate every step from the center will fail. People need room to act, and adapt. Yet, they cannot succeed as isolated individuals either. Instead what is required is a mix of freedom and expectation-expectation to coordinate, for example, and also to measure progress towards common goals. This was the understanding people in the building industry learnt to codify into the checklist.