Last night, I went to hear Atul Gawande give a talk promoting his new book, The Checklist Manifesto: How to Get Things Right. The book’s premise is a simple one: In an increasingly complex world, even experts benefit from a routine checklist that requires them to focus on the essentials necessary to their task. The best checklists are not too detailed, and leave room for individual or team autonomy. Gawande, a surgeon, came up with the idea when the World Health Organization asked him to investigate how to decrease unnecessary deaths associated with surgery. After investigating similar complex situations (building tall buildings or airplanes), Gawande concluded that checklists that force people to remember what should be obvious (but nevertheless gets forgotten or overlooked), and that enable teams actually to function as teams, were the way to go. Boeing was a huge inspiration for this.
I came away from the talk convinced that Gawande has a point (perhaps because I’m a checklist and outline person myself). I was also impressed much less favorably by his devotion to the notion of government controlled health care (he’s all for the Frankenstein monstrosity wending its way through Congress). Aside from my own prejudices, his manifest delight in the health care bill made no sense as he told anecdote after anecdote demonstrating that it’s the business sector, not the government, that is best able to adapt to his recommendations. This became most clear when he talked about Hurricane Katrina.
Gawande noted that, in the wake of Hurricane Katrina, FEMA descended on New Orleans with the Checklists from Hell. They were overly detailed, denied any personal responsibility, and prevented FEMA employees from adapting to the situation on the ground. These government generated checklists, rather than heightening efficiency, rendered government employees ineffectual.
Gawande paused after this description. Around me, all the people in this liberal, elite San Francisco audience nodded their heads wisely. “That dumb Bush and his corrupt administration,” you could practically see them thinking.
By contrast, said Gawande, you could see the effective use of checklists from . . . long pause . . . “Wal-Mart, of all things.” He paused for the obvious laugh line, and the audience obliged. What a joke that the fascist Wal-Mart commercial dictatorship would function better than government. Gawande clearly agreed, yet he went on to describe a Walmart behaving efficiently and humanely during the disaster.
Because its checklists weren’t rigid or overly long, Wal-Mart employees had a certain degree of latitude in the face of an enormous crisis. Ultimately, Wal-Mart asked only that the managers check in with headquarters daily so that they could pool information and exchange ideas. Within one day, while FEMA was still turning away supplies because they weren’t on a given employee’s checklist, Wal-Mart had arranged for free medicine to be handed out to be people who were dependent on their medicine (diabetics, for example). They were also providing essential supplies to FEMA, which was incapable of accessing its own resources.
What neither Gawande nor the audience seemed to comprehend was that this outcome wasn’t surprising, it was obvious. Government is a bureaucratic entity ultimately responsible only for more government. It is driven by fear, not by outcome. The fear each employee has that he or she might get downgraded on the civil service list, the collective entity’s fear of a funding cut, its leadership’s fear that each member will fail to ascend in the government ranks, and so on. It has no responsibility beyond its own bureaucratic survival. If it goes through the motions, and sort of gets the job done, it will continue to exist.
Business, however, must be infinitely adaptable in the Darwinian world of the marketplace. It cannot afford complacency or rigidity. It cannot afford the risk of litigation for failure. It can react with incredible speed, since management doesn’t have to go through a bureaucratic or legislative process in order to change a checklist or procedure. If Gawande really believes in his lists, the last thing he’ll want is for them to be government controlled, because they will never improve. Instead, they will stagnate in bureaucratic limbo, good enough, but never better.
Gawande’s talk left me more certain than ever that, while our health care system needs reform, handing the details over to the government is a sure recipe for a FEMA-level disaster.