First, Gawande describes the disparate organizational approaches to the Katrina crisis in New Orleans. He concludes that organizations are prone to break down in a crisis unless their management cedes control to the most far-flung workers. Rigid federal and state authorities froze up, as did many local authorities, but police and firefighters accepted and coordinated the help of hundreds of small boat owners to conduct unorthodox rescues of tens of thousands of residents. Many private businesses flailed in the complex aftermath of the disastrous storm, but WalMart shone. Its CEO announced:
This company will respond to the level of this disaster. 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.Wal-Mart had to close 126 stores; 20,000 employees and family members were displaced. But within 48 hours, more than half of the stores were open again and able to consider, "Oh, my God, what can we do to help these people?" On their own authority, managers began distributing diapers, water, baby formula, and ice to storm victims. They improvised crude paper-slip credit systems for first responders at a time when FEMA was still paralyzed. One assistant manager went through her badly damaged store with a bulldozer, salvaging what she could and giving it away in the parking lot. She also broke into the store's pharmacy in response to a local hospital's call for help. Senior Wal-Mart officials, rather than micromanaging or second-guessing these efforts, concentrated on coordinating with line employees and state agencies to meet needs as they arose. What has this got to do with checklists? I'm not sure. Gawande is struggling toward an approach to unpredictable complexity that avoids stultifying central control without accepting anarchy as its alternative. He approves of "a seemingly contradictory mix of freedom and expectation -- expectation to coordinate, for example, and also to measure progress toward common goals." He thinks this approach can be codified into simple checklists.
The second anecdote concerned a CDC worker in Karachi who tried an inexpensive, low-tech solution to infectious disease outbreaks. Procter + Gamble wanted to prove the value of a new antibacterial soap. The CDC worker got a grant to study three groups: one supplied with ordinary P+G soap, one with the new antibacterial soap, and one left to its own devices for soap. Test subjects were encouraged to use the soap in six specific situations, such as just before feeding an infant. After a year, various infectious diseases dropped by between 35% and 52% in both groups using the P+G soap. The study was a failure in P+G's eyes, because the new antibacterial soap conferred no noticeable advantage, but it showed the CDC how a simple routine could combat persistent public health problems. The soap, Gawande says, was a "behavior-change delivery vehicle." It came with instructions for its use in six separate situations. The households already were using soap at the rate of two bars per week on average, but the study apparently caused them to use it more systematically and, because it was pleasant-smelling and well-lathering, more enthusiastically. "Global multinational corporations," as the CDC worker noted, "are really focused on having a good consumer experience, which sometimes public health people are not." What's more, the people enjoyed receiving the soap: "The public health field-workers were bringing them a gift rather than wagging a finger."
Getting back somewhat more convincingly to the "checklist" theme, Gawande interviewed a successful investor who put his colleagues into six categories according to how they evaluated the entrepreneurs who were seeking their venture capital. "Art Critics" assess entrepreneurs at a glance on the basis of intuition and long experience. "Sponges" gather information exhaustively, then go with their gut. "Prosecutors" challenge entrepreneurs with hard questions about how they would handle hypothetical situations. "Suitors" woo entrepreneurs rather than evaluate them. "Terminators" make a superficial initial choice and plan to fire and replace incompetents ruthlessly later. Finally, "Airline Captains" take a methodical, checklist-driven approach, consciously overriding their intuition. Gawande reports that the final category outperformed the rest dramatically, though they made up a small minority of the whole, which was dominated by Art Critics and Sponges. Why were the Air Captains so rare? Gawande muses that something in us makes checklists seem like buzzkills, like an abandonment of romantic ideals of competence. When his own experimental surgical checklist project for the World Health Organization showed impressive gains in reducing complications from infection and errors, he nevertheless felt a personal reluctance to implement them for his own surgical team: "[I]f I told the truth -- did I think the checklist would make much of a difference in my cases? No. In my cases? Please." It did, though, and it strengthened his conviction that modern humans are engaging in complex cooperative tasks that require a new approach to discipline and focus than comes naturally to us.










