The Checklist Manifesto_ How to Get Things Right - Atul Gawande [75]
We have most readily turned to the computer as our aid. Computers hold out the prospect of automation as our bulwark against failure. Indeed, they can take huge numbers of tasks off our hands, and thankfully already have—tasks of calculation, processing, storage, transmission. Without question, technology can increase our capabilities. But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building, perform a lifesaving operation. In many ways, technology has complicated these matters. It has added yet another element of complexity to the systems we depend on and given us entirely new kinds of failure to contend with.
One essential characteristic of modern life is that we all depend on systems—on assemblages of people or technologies or both—and among our most profound difficulties is making them work. In medicine, for instance, if I want my patients to receive the best care possible, not only must I do a good job but a whole collection of diverse components have to somehow mesh together effectively. Health care is like a car that way, points out Donald Berwick, president of the Institute for Healthcare Improvement in Boston and one of our deepest thinkers about systems in medicine. In both cases, having great components is not enough.
We’re obsessed in medicine with having great components—the best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well. Berwick notes how wrongheaded this approach is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment of trying to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”
Nonetheless, in medicine that’s exactly what we have done. We have a thirty-billion-dollar-a-year National Institutes of Health, which has been a remarkable power house of medical discoveries. But we have no National Institute of Health Systems Innovation alongside it studying how best to incorporate these discoveries into daily practice—no NTSB equivalent swooping in to study failures the way crash investigators do, no Boeing mapping out the checklists, no agency tracking the month-to-month results.
The same can be said in numerous other fields. We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.
But we could, and that is the ultimate point. We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber—a machine so complex no one was sure human beings could fly it. They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist.
And so can we. Indeed, against the complexity of the world, we must. There is no other choice. When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It’s time to try something else.
Try a checklist.