Innovation Lessons from The Checklist Manifesto

How do we deal with complexity? A while ago I suggested that one strategy that we use to handle complexity is that we outsource some of the rote memorisation of facts and routines that we need regularly. This is essentially the strategy that Atul Gawande also advocates in his outstanding book The Checklist Manifesto: How to Get Things Right. The primary theme of the book is that one of the best tools we can use to handle complex situations is a very simple one – the checklist.

The key story in the book is the World Health Organization’s development of a Safe Surgery Checklist. The checklist consists of a series of items to confirm as part of the surgery process. The are all fairly basic things, and they are put into three groups that are asked at three natural pause points in the surgery – before the anaesthetic is administered, before the first cut is made, and before the patient is taken from the operating room. They address very basic issues that you would think wouldn’t be missed, but which often are: confirm that patient’s name, confirm which side of the body the surgery will take place, confirm the procedure, ensure that all surgery team members have introduced themselves by name and role, discuss key concerns for patient recovery, and several others.

After the checklist was developed, WHO tested in eight hosptials around the world – four were in developed countries, and four were in developing countries. They ran the gamut from well-funded hospitals with all mod cons to rural hospitals that had so few resources that they had to sterilize and re-use surgical gloves until they wore out. In the test study, they gathered data from about 4,000 surgery patients across all eight hospitals for three months, then they introduced the checklists into the surgical procedures, and gathered data from another 4,000 operations.

The results are astonishing. Major post-surgical complications fell 36% with the use of the checklist, deaths were down 47%. All eight hospitals saw major reductions in both categories, and from a statistics standpoint, the relationships are statistically significant. The outcomes were published in the New England Journal of Medicine at the start of 2009.

Gawande is a terrific writer, and I recommend the book highly (his earlier books Complications and Better are also great). I think there are several things that we can learn about innovation from this story, including:

  • Behavioural innovation is at least as important as product innovation – probably moreso. Drug companies make a pretty big deal out of new discoveries that have statistically significant impacts of 1 or 2% on their target – what would happen if they had a drug that reduced the incidence of an important problem by over 40%? It would be all over the news, and it would be hailed as one of the biggest breakthroughs in medical history. We’ve seen products with even bigger impacts – for example, the polio vaccine. However, the idea that we can reduce the incidence of several major categories of surgical complications simply by acting differently is mind-boggling.
  • So why haven’t we heard more about this? People often resist simple solutions to complex problems. Gawande believes that this is because many people think that relying on things like checklists reduces their autonomy, and their ability to act creatively. Gawande’s response:

    It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The work of medicine is too intricate and individual for that: good clinicians will not be able to dispense with expert audacity. Yet we should also be redy to accept the virtues of regimentation.

    Like I said at the start – checklists are great because they allow us to outsource some complexity. This means that we don’t have to think about the basic things, leaving more time and brain resources to deal with the things that genuinely require our skill and judgement.

  • We do not interrogate our failures very well. The first step in building an effective checklist is to find the ways that we commonly screw up, look for systematic patterns, and put steps in the checklist to address these common problems. Checklists have been most widely adopted so far in industries where failures are closely examined – flying and construction. When a plane crashes or a building collapses, a lot of effort goes into learning why, and how to prevent the problem in the future. Once we learn the cause of the failure, the checklist helps prevent its reoccurance.

The application of these ideas to innovation is fairly obvious. When you look at innovation as an evolutionary process, it quickly becomes apparent that a number of ideas need to be selected out before we invest too much into them. Most organisations do not spend too much time thinking about the ideas that didn’t work. One of the things that we need to get better at is learning from our ideas that fail. If we do this, then we can build a checklist.

Gawande has a couple of business examples in the book. He talks about three investment firms that have developed checklists to help them evaluate investment opportunities. And he talks about a study by Geoff Smart that looked at what made Venture Capitalists most effective:

Smart specifically studies how such people made their most difficult decision in judging whether to give an entrepreneur money or not. You would think that this would be whether the entrepreneur’s idea is actually a good one. But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is another matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and the setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.

Which VCs are most successful? According to Smart’s study, the ones that use a checklist. Checklists are simple tools that can help us filter ideas and opportunities. They help us outsource complexity, leaving us more mental capacity to connect up ideas in novel ways – which is the key to innovation.

Student and teacher of innovation - University of Queensland Business School - links to academic papers, twitter, and so on can be found here.

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10 thoughts on “Innovation Lessons from The Checklist Manifesto

  1. interesting and very useful information especially on the acknowledgement that people resist the simple for the more complex. I often see that as a psychological problem. People usually regard ‘complexity’ to ‘sophistication’. Its a strange thought. Simplicity is different from simplistic. Being simple has many virtues apart from its efficiency and productivity. Saves you the many resources without pulling one’s hair out… (reminds me of the many balding managers around…but that’s another story.)

  2. Thanks for the comment (and the RT) Karen! I agree that the preference for complex over simple is often a psychological one. I see it happen both in business, and within academia too – people prefer complexity because they think it makes them sound smarter. That’s often not the case though!

  3. Tim,

    One advantage of checklists and other such solutions is that they are sufficiently generic that they can be shared and replicated elsewhere. It is also easy and quick to test whether they are helpful or not.
    Now, fortunately, complex environment do not necessarily have complex problem. Most problems are the kind that can be solved using generic, easy to replicate, easy to test solutions. In fact, most environment are like that (complex environments with simple problems). I do not know of any environment that can plausibly be called simple without a certain amount of abstraction or simplification.
    It gets sticky when the problems themselves are complex; that is they cannot be solved in a systematic way or are too unique to test alternative solutions.
    But I wonder if there is a quick and easy way to distinguish between simple and complex problems. A checklist perhaps?

  4. Good question Marco :)

    I’ve seen some good check lists developed from Charles Perrow’s study of “Normal Accidents”*. In the book he suggests differentiating organisational problems related to technology by determining whether their components are tightly vs. loosely coupled and have complex vs. linear interactions. Proven Models has a general summary*.

    * *

  5. You’re right about the stickiness of complex problems Marco. Even if we can’t use a checklist to differentiate, the benefits of a checklist is that it can let us handle the simple parts of the problem more easily, leaving more cognitive capacity to tackle the complex problems. I think that is one of the big benefits of using them…

  6. you’re most welcome Tim! A sigh of relief that the Simpson’s avatar is ok… Its a vast difference between how business and designers would solve a simple/complex problems. In anyway, problems are supposed to be simplified into the simplest form wherever possible. I doubt there’s a better system for linear thinking. Linearity only gets more complex. Creative problem solving cuts the process short.

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