Complexity and Essence

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Atul Gawande is a surgeon and author. His bestselling book The Checklist Manifesto: How to Get Things Right describes his efforts to...

Atul Gawande is a surgeon and author.  His bestselling book The Checklist Manifesto: How to Get Things Right describes his efforts to enlist hospitals in using a standard checklist to reduce surgical errors and complications.  Research has shown that hospital checklists make a dramatic difference for patient health.  In addition to medicine, Gawande studies other fields, especially construction and aviation, that depend heavily on checklists.  These are all enterprises in which growing technological complexity eventually exceeded the ability of the traditional leader--the surgeon, the pilot, the master builder--to manage all the essential tasks and processes by keeping them in his head.  Documenting the flow of work and communicating well within a team became fundamental. 

An effective checklist is not easy to create.  A very long checklist is too cumbersome and won't be used effectively, if it's used at all.  It takes trial and error to name the simple but crucial steps in handling a crisis.  The dramatic story of Captain "Sully" Sullenberger, ditching his plane in the Hudson River, is given as an illustration of the power of a checklist.  The crew of that flight worked with maximum efficiency using a checklist in the two minutes or so that they had to respond to a life or death emergency. 

Some of the items on Gawande's surgery checklist are almost laughably simple.  The members of the surgical team are to introduce themselves by name to one another.  The patient's identity is confirmed.  The team checks what procedure is being performed that day, how long the procedure usually lasts, what the possible complications are.  For some operations, such as a hip replacement, they check whether it is the left or right hip.  These are the no-brainer details that medical professionals take most for granted.  But attending to them carefully at the start of an operation, and returning to them in the event of an emergency, is vital.

Perhaps the most important thing the checklist does is to improve collaboration.  The act of working through the checklist as a team opens the flow of communication and eases social barriers and inhibitions.  Making the formal introductions, learning one another's names, is surprisingly important.  Team members will speak up rather than smile silently and hope that a key task has been done.  If a nurse sees that a surgeon has skipped a step, the nurse will feel free, indeed compelled, to intervene and make a correction.

Here is Gawande's summary reflection on high-risk professions:

All learned occupations have a definition of professionalism, a code of conduct.  It is where they spell out their ideals and duties.  The codes are sometimes stated, sometimes just understood.  But they all have at least three common elements.

First is an expectation of selflessness: that we who accept responsibility for others--whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots--will place the needs and concerns of those who depend on us above our own.  Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise.  Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges.

Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others.  This is a concept almost entirely outside the lexicon of most professions, including my own.  In medicine, we hold up "autonomy" as a professional lodestar, a principle that stands in direct opposition to discipline... It has the ring more of protectionism than of excellence.  The closest our professional codes come to articulating the goal is an occasional plea for "collegiality."  What is needed, however, isn't just that people working together be nice to each other.  It is discipline.

Discipline is hard--harder than trustworthiness and skill and perhaps even than selflessness.  We are by nature flawed and inconstant creatures.  We can't even keep from snacking between meals.  We are not built for discipline.  We are built for novelty and excitement, not for careful attention to detail.  Discipline is something we have to work at.

The Checklist Manifesto, pp. 182-183

This book has been very timely for me: it has many direct applications for the Clergy Health pilot project, for managing a surprisingly complex and deeply interpersonal process.  Perhaps Gawande's work has lessons for local church ministry as well. 

Liturgy, the order of worship, can be seen as a checklist.  Reading the bulletin is no substitute for worshiping, of course, but the worship order is an important framework and support.  It has evolved over centuries as a guide to the bases that must be touched whenever two or more are gathered in God's name. 

Discipline is a term with deep resonance for pastors, especially United Methodist pastors.  Discipline requires us to accept limits on our autonomy.  Our individual gifts and character are not sufficient for us to meet every challenge.  We honor the collective wisdom laboriously set down and re-worked over many years in the Book of Discipline.  We honor the ministry of clergy peers and laypeople with collegiality but also mutual accountability.

In speaking of health and behavior change, our staff often uses the term agency.  Unlike autonomy, it does not imply freedom to act in isolation from others.  Mutuality and accountability are part of the formula.  Agency speaks to the power to make changes, a faith that our inputs into the world will make a difference.

Shalom y'all,


John James, M.A.
Research Coordinator
Clergy Health Initiative

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