Using Checklists

“History Is Just One Damn Thing after Another.” Winston Churchill

Ralph Stacey , an organizational theorist, adapts Churchill’s quote by saying “An organization’s life is just one damn thing after another”.

In the presence of complexity, failure can happen because of myriad of variables that unpredictably interact in an unimagined way. There is no guarantee that the measures of failure prevention can always work. Because failure is a function of environment variables and circumstances that are ever-changing unpredictably. Hence, in-addition to addressing failure prevention through quality standards, we need to plan for the sure to happen failures.

In studying system failure, Atul Gawande suggests that higher performing teams do not fail less, but they rescue more. These teams have plans for what to do when failures happen. While high technical skills are important, in face of failure what counts more are:
– Being humble enough to acknowledge that something goes wrong
– Judgement
– Team work
– Discipline

“Under conditions of complexity, not only are checklists a help, they are required for success.” Atul Gawande ,The Checklist Manifesto

In the Checklist Manifesto, Atul argues that highly trained people make errors because of complexity rather than lack of skills. A checklist acts as a forcing function helping highly trained people to remember basic tasks that often cause failures. Also, a checklist can show what to do when a failure happens.

Teams in complex systems are often at odds with the process , project and management practices of their organization. Their organization achieves its goals by running projects, which need sense of predictability that is not congruent with the team aspects shown in the above diagram. Also, these management practices often are disconnected from how teams create value to the customer.

Instead of top-down reinventing organizations to create meaningful improvement, front-line teams design their own checklists. Then, they experiment to reach a target-condition representing a future state that is shaped by incorporating the checklist in their value-stream.

During Grasping the Current Condition, teams do process analysis to design a checklist to address:
– the root causes of defects and delays
– what to do when a failure happens
– how to make right design decisions, and more.

Operationalizing a checklist describes the ‘desired operating pattern’ of target-condition.

Implementing a checklist can involve obstacles, including:
– Disengaged stakeholders
– Technical inability for providing needed information
– A step takes longer time


Rather than implementation, introducing a checklist involves experimentation; a checklist represents a future-state that teams experiment towards it. Checklist requires new level of interactions when doing the work, because it makes assumptions explicit. The benefits however to the teams are discipline, team-work, and humility to change their mind in face of errors. These behaviors are needed in face of complexity and inevitable failure.

Published by Sameh

I coach teams and their managers on Scientific Thinking, Lean, and Product Innovation. I have realized that the real coaches for teams are their managers, because they model the desired behaviors and actions. Furthermore, I shifted my focus to coach managers to champion experimentation in their teams, which has created a lasting impact.

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