A checklist is more powerful than an org chart?

Most of us so-called ‘knowledge workers’ don’t particularly fancy the term ‘checklist’. It smacks of an antiquated top-down command-and-control Dilbert-style bureaucracy where someone sitting on 42nd floor of corporate headquarters hands down a piece of paper for you to blindly follow and to make you feel dumb and outright humble – for it dilutes your role and underplays your intelligence as if anyone else in your position could have done it! In short, it seems to trivialize the knowledge, skills and expertize required for the job into a mechanical routine requiring no human intelligence, and places the decision-making into hands of people irrespective of their competence levels. And we hate it!

Wikipedia defines a checklist as:

“A checklist is a type of informational job aid used to reduce failure by compensating for potential limits of human memory and attention. It helps to ensure consistency and completeness in carrying out a task. A basic example is the “to do list.” A more advanced checklist would be a schedule, which lays out tasks to be done according to time of day or other factors.”

From the definition above, it seems like an innocuous tool that just helps you keep focus on the most critical things – things that you might skip rather unintentionally or lose track of during one of the numerous hand-offs, or mix-up their sequence when there is time pressure. Obviously, there is no way a checklist could enlighten a dummy into being an expert overnight!

Atul Gawande has done a wonderful job of elevating the good old checklist in his pathbreaking “The Checklist Manifesto” to a modern management tool that can be used to prevent unintentional human mistakes and improve collaboration and decision-making in emergency situations – even in the areas that require utmost brainpower. He cites real-life examples from some of the most complex endeavors – complex human surgeries, constructing tall building and flying jet planes, among others, that no doubt require very high

A short pencil is better than a long memory…

amount of individual cognitive skill in respective functional areas, but also require a high precision in the steps to be followed – both during meticulous planning and preparation, and in making split-second decisions during an emergency, be it flying at ten miles above ground or a complex brain surgery on operation table. One after other, he repeatedly presents compelling data from such hi-intelligence professions that reinforce his assertion that something as rudimentary as a checklist could have such dramatic impact in complex human endeavors.

In this article, I have taken some teasers from this book that I liked and made a lot of sense to me. I have also included my own commentary and perspective for each of these.

Knowledge continues to grow at an astounding pace. No one person can hope to ever keep pace with all latest advances in any one single field, let alone build a body of knowledge around core specialization area and adjacent knowledge areas. And yet, in many cases, we have no option but to rely on the individual judgment by a supposed ‘expert’. What if that ‘expert’ was not good enough, or as good as we make out of them? What if that one single source of true knowledge, the true ‘Master Builder’ was more like someone who was a mediocre talent as best, and could not live up to the high expectations of infallibility, and yet we place almost entire decision-making into their independent charge? That would be a true disaster. Gawande calls out such challenge:

“…in the absence of a true Master Builder – a supreme, all-knowing expert with command of all existing knowledge – autonomy is a disaster. It produced only a cacophony of incompatible decisions and overlooked errors.”

So, while autonomy is the desired end-state, we need to be cognizant that perhaps there is no such single person in real life who deserves to be the undisputed knight of all things worldly! At best it is an urban myth and at worst, it is a nightmare played out multiple times in each field! A cacophony of incompatible decisions and overlooked errors! Sounds outrageous, but apparently not so rare.

Let’s walk a bit with the fact (?) that there is no one single person supremely capable of mastering all the knowledge so as to be the single source of truth. What would then be the second-best way to manage complex human endeavors? Perhaps assign it to teams who are then chartered to figure out the solution? A group of perhaps regular people who individually posses a bit of knowledge each, and collectively represent whatever it takes to address the problem at hand? That does seem like a logical way, because we believe more heads are better than one. However, it is difficult enough to get a collocated team perform in top gear, imagine distributed teams in multiple time zones, contractors from different companies with different and often incompatible cultures and processes working together, employees coming from various departments for whom local departmental gains are more important than the global organizational goals. Can checklists provide some guidance?

Here again, Gawande has some interesting viewpoint:

“in the face of the unknown – the always nagging uncertainty about whether, under complex circumstances, thing will really be okay – the builders trusted in the power of communication. They didn’t believe in the wisdom of the single individual, of even an experienced engineer. They believed in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem and then letting the watchers decide what to do.

Man is fallible, but maybe men are less so.”

However, we often believe that by simply crowdsourcing, we can fix the problem. We expect a reasonably sized group to eventually gravitate towards one common solution. While this might be true for simple party games like ‘guess the weight of the cake’, how do we extend and apply this to more real-life problems that entail tangible risks, such as do we need an additional overhead beam to distribute the load on the 37th floor of a highrise building, or whether we need to give more anesthesia to a 63-year old patient of severe diabetes and hypertension on the table for his bypass? In traditional management, a manager would be supremely empowered to make such decisions – his knowledge and experience was ‘supposed’ to mitigate any risks associated with such centralized decision-making, because, well, the ‘workers’ in that quintessential industrial age were after all dumb. In such one-sided match, the worker participation was almost always zero, and the decision-making was the elite preserve of the management class. We can’t say if that was effective or not (though we do know that was not the most motivational way), but apparently that’s the only thing that was! However, the advent of knowledge-economy brought with it three important changes : rapid pace of creation of new knowledge, new means and mechanisms to rapidly mass proliferate the newfound knowledge and a faster obsolescence rate of old knowledge have all collectively led to a more balanced play at work. No longer is ‘manager’ the Mr. Know-all, but is increasingly dependent on the critical inputs from her team member – most of whom have much more current knowledge and also hate a centralized hoarding of decision-making.

In such workplaces, it’s time the decision-making was made more democratic. What would be the risk of democratizing decision-making? Would it be akin to the inmates running the asylum? How can we ensure that best decisions will be made, and who will be accountable for those decisions? Can checklists help in this regard?

“In response to risk, most authorities tend to centralize power and decision making. That’s usually what checklists are about – dictating instructions to the workers below to ensure they do things the way we want. ….it spelled out to the tiniest details every critical step the tradesmen were expected to follow and when – which is logical if you’re confronted with simple and routine problems; you want the forcing function.”

So, apparently, the checklists ‘decentralized’ the decision-making but more as a forcing function. In a way, we can say that since Managers couldn’t be everywhere, Management created Checklists! Clearly, that’s not the best reason to justify or support checklists, even though we might have succeeded in our nefarious designs.

However, history has repeated shown us that every new invention has two sides – the good and the bad. While a checklist might have succeeded in its ‘forcing function’, it also has a positive side. This is the aspect that helps pilots and brain surgeons achieve better planning and performance. This allows for teams to create better bonding as much as making life-or-death calls in a split second. You have the read Gawande’s book to believe that.

So, why is that people hate checklist? Do they fear loss of individuality, respect, authority? Gawande offers some perspective and the counterintuitive wisdom:

“The fear people have about the idea of adherence to protocol is rigidity. They imagine automatons, leads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with.”

As an example, he cites an interesting anecdote about what makes a team high performing by a simple act of just making sure that people follow the simple checklist of introducing themselves to the team by just telling their names:

“People who don’t know one another’s names don’t work together nearly as well as those who do.

The investigators at John Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon”. Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.”

Imagine if the simple act of sharing names could accomplish so much, what else lies unexplored? However, in the absence of a checklist that ‘mandated’ such ‘routine’ we were potentially wasting this opportunity. Surely we could do away (and perhaps should do away) with checklists if only we could do such ‘common sensical’ stuff without them!

So, if checklists are an important management tool, how best to operationalize them? Should the manager ‘own’ the checklisting process? Here is an interesting take from the field of aviation, where, as we all know, once you take-off, you are literally hanging in the mid-air, and hence must do everything right to land safely:

“In aviation, there is a reason the “pilot not flying” starts the checklist. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility send the message that everyone – not just the captain – is responsible for the overall well-being of the flight and should have the power to question the process.”

So, there we are. It seems that there is a significant body of work to support the conjecture that checklists can be beneficial in more ways than one. They are not simply a forcing function, nor do they impede empowerment not stifle creativity. On the contrary, they help facilitate conversations during unexpected non-trivial situations. They also make the decision-making more decentralized and often democratic. To that end, a checklist is more powerful than an org chart. Too bad if that scares you!

Use checklist for all reasons and all seasons. As they say, a short pencil is better than a long memory…

3 thoughts on “A checklist is more powerful than an org chart?


    Great work.Its my habit to make checklist .Before reading this post it was a little hard for me to making lists now it can be very easy to do this.Thanks for sharing.


  2. Adam Searcy

    Sometimes I make checklist of items just to feel some satisfaction of checking items off. It can be very motivating to see my perceived to-do list shrinking.

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