The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.
Of all organizations, it was oddly enough Wal-Mart that best recognized the complex nature of the circumstances, according to a case study from Harvard’s Kennedy School of Government. Briefed on what was developing, the giant discount retailer’s chief executive officer, Lee Scott, issued a simple edict. “This company will respond to the level of this disaster,” he was remembered to have said in a meeting with his upper management. “A lot of you are going to have to make decisions above 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.”
No, the real lesson 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—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals.
When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). 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 checklist 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. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.
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. Boorman didn’t think one had to be religious on this point.
“It all depends on the context,” he said. “In some situations you have only twenty seconds. In others, you may have several minutes.”
But after about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things. People start “shortcutting.” Steps get missed. So you want to keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless. (Data establishing which steps are most critical and how frequently people miss them are highly coveted in aviation, though not always available.)
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. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)