The Checklist Manifesto_ How to Get Things Right - Atul Gawande [26]
Back down in the field office, I asked Finn O’Sullivan how he and his team dealt with such a circumstance. After all, skyscraper builders must run into thousands like it—difficulties they could never have predicted or addressed in a checklist designed in advance. The medical way of dealing with such problems—with the inevitable nuances of an individual patient case—is to leave them to the expert’s individual judgment. You give the specialist autonomy. In this instance, Rouillard was the specialist. Had the building site been a hospital ward, his personal judgment would hold sway.
This approach has a flaw, however, O’Sullivan pointed out. Like a patient, a building involves multiple specialists—the sixteen trades. In the absence of a true Master Builder—a supreme, all-knowing expert with command of all existing knowledge—autonomy is a disaster. It produces only a cacophony of incompatible decisions and overlooked errors. You get a building that doesn’t stand up straight. This sounded to me like medicine at its worst.
So what do you do? I asked.
That was when O’Sullivan showed me a different piece of paper hanging in his conference room. Pinned to the left-hand wall opposite the construction schedule was another butcher-block-size sheet almost identical in form, except this one, O’Sullivan said, was called a “submittal schedule.” It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another—on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction—who had to share (or “submit”) particular kinds of information before the next steps could proceed.
The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.
So the submittal schedule made them talk. The contractors had to talk with the installers and elevator engineers by the thirty-first. They had to talk about fire protection with the fireproofers by the twenty-fifth. And two weeks earlier, they had been required to talk about the condition of the core wall and flooring on the upper floors, where the water had pooled, with the structural engineers, a consultant, and the owners.
I saw that the box had been checked. The task was done. I asked Rouillard how the discussion had gone.
Very well, he said. Everyone met and reviewed the possibilities. The owners and the contractors were persuaded that it was reasonable to expect the floor to level out. Cleanup was arranged, the schedule was adjusted, and everyone signed off.
In the face of the unknown—the always nagging uncertainty about whether, under complex circumstances, things will really be okay—the builders trusted in the power of communication. They didn’t believe in the wisdom