Extreme complexity can harm expertise, but checklists can provide efficiency.
“Extreme complexity is the rule for almost everyone today,” writes Atul Gawande in The Checklist Manifesto. Too much complexity, he says, can be too high for the human brain to keep up. Some of us may like to think so, but we are not infinitely capable.
“There are degrees of complexity,” Gawande writes, “and medicine and other fields like it have grown so far beyond the usual kind that avoiding daily mistakes is proving impossible even for the most super specialized.”
Facing increasing complexity all around us, Gawande argues that following essential checklists can provide a cognitive safety net against inevitable human fallibility. He looks first at medicine—he’s a surgeon—and how checklists can benefit doctors, nurses, and other health care personnel. He sees the practice of taking a patient’s four vital signs as the original medical checklist.
Gawande also examines engineering and construction, noting similarities between the range of complexities involved in trying to save a human life and those involved in building skyscrapers.
In the chapter, “The End of the Master Builder,” he recalls coming upon a new wing of his medical center under construction:
“It was only a skeleton of steel beams at that point, but it stretched eleven stories high, occupied a full city block, and seemed to have arisen almost overnight from the empty lot that had been there. I stood at one corner watching a construction worker welding a joint as he balanced on a girder four stories above me. And I wondered: How did he and all his co-workers know that they were building this thing right? How could they be sure that it wouldn’t fall down?”
In search of answers, Gawande sought out Joe Salvia, a structural engineer at McNamara/Salvia, which had provided the structural engineering for many major hospital buildings in Boston over the last fifty years.
“A building is like a body,” Salvia tells him. “It has skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring.” Projects, Salvia notes, now involve at least some sixteen different trades.
It hasn’t always been this way, Gawande notes, as he traces the history of the building and how it’s evolved:
“For most of modern history, Salvia explained, going back to medieval times, the dominant way people put up buildings was going out and hiring Master Builders who designed them, engineered them, and oversaw construction from start to finish, portico to plumbing. Master Builders built Notre Dame, St. Peter’s Basilica, and the United States Capitol.
“But by the middle of the 20th century, the Master Builders were dead and gone. The variety and sophistication of advancement in every stage of the construction process had overwhelmed the abilities of any individual to master them.
“In the first division of labor, architectural and engineering design split off from construction. Then, piece by piece, each component became further specialized and split off, until there were architects on one side, often with their own areas of subspecialty, and engineers on another, with their various kinds of expertise; the builders, too, fragmented into their own multiple divisions, ranging from tower crane contractors to finish carpenters. The field looked, in other words, a lot like medicine, with all its specialists and super specialists.”
At the core of Gawande’s book are the questions, “What do you do when complexity is so great that expertise is not enough? When even super-specialists fail?”
Besides the use of checklists, Gawande finds another answer talking with Finn O’Sullivan, project executive for McNamara/Salvia: the power of communication.
“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.”
The AEC industry’s ability to foster constant communication among team members from a multiplicity of disparate fields makes for remarkable synchronicity. In surveying the industry for his manifesto, Gawande lauds AEC’s innovativeness and collaboration. He calls the industry’s willingness to apply its strategies to projects of any size and scope “striking.”
“What results is remarkable,” he writes. “A succession of day-by-day checks that guide how the building is constructed and ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way.”
As you can guess, LISA is a big fan of what Gawande has to say.
